Archive for the ‘Healthcare’ Category
I doubt that any for-profit hospital can long withstand the constant pressure to grow profits. Julie Creswell and Reed Abelson write in the NY Times:
Every day the scorecards went up, where they could be seen by all of the hospital’s emergency room doctors.
Physicians hitting the target to admit at least half of the patients over 65 years old who entered the emergency department were color-coded green. The names of doctors who were close were yellow. Failing physicians were red.
The scorecards, according to one whistle-blower lawsuit, were just one of the many ways that Health Management Associates, a for-profit hospital chain based in Naples, Fla., kept tabs on an internal strategy that regulators and others say was intended to increase admissions, regardless of whether a patient needed hospital care, and pressure the doctors who worked at the hospital.
This month, the Justice Department said it had joined eight separate whistle-blower lawsuits against H.M.A. in six states. The lawsuits describe a wide-ranging strategy that is said to have relied on a mix of sophisticated software systems, financial incentives and threats in an attempt to inflate the company’s payments from Medicare and Medicaid by admitting patients like an infant whose temperature was a normal 98.7 degrees for a “fever.”
The accusations reach all the way to the former chief executive’s office, whom many of the whistle-blowers point to as driving the strategy.
For H.M.A., the timing could not be worse. Shareholders recently approved the planned$7.6 billion acquisition of the company by Community Health Systems, which will create the nation’s second-largest for-profit hospital chain by revenue, with more than 200 facilities. The deal is expected to be completed by the end of the month.
While the lawsuits against H.M.A. provide a stark look at the pressure being put on doctors and hospital executives to emphasize profits over their patients, similar accusations are being raised at other hospital and medical groups as health care in the United States undergoes sweeping changes.
Federal regulators have multiple investigations into questionable hospital admissions, procedures and billings at many hospital systems, including the country’s largest, HCA. Community Health Systems, the Franklin, Tenn., company from which H.M.A. hired its former chief executive in 2008, faces similar accusations that it inappropriately increased admissions. Community is in discussions with federal regulators over a settlement regarding some of the accusations.
The practice of medicine is moving more rapidly than ever from decision-making by individual doctors toward control by corporate interests. The transformation is being fueled by the emergence of large hospital systems that include groups of physicians employed by hospitals and others, and new technologies that closely monitor care. While the new medicine offers significant benefits, like better coordination of a patient’s treatment and measurements of quality, critics say the same technology, size and power can be used against physicians who do not meet the measures established by companies trying to maximize profits.
“It’s not a doctor in there watching those statistics — it’s the finance people,” said Janet Goldstein, a lawyer representing whistle-blowers in one of the suits, of a type known as qui tam litigation, against H.M.A.
What’s more, like their Wall Street bank counterparts, the mega-hospital systems, with billions of dollars in revenue, are more challenging to regulate, according to experts.
Still, when H.M.A. announced the Justice Department’s involvement in the lawsuits, investors and analysts shrugged, and the stocks for both companies involved in the merger barely budged.
Sheryl R. Skolnick, who follows health care for CRT Capital, recently wrote in a note to investors, “Investors seem to think that D.O.J. investigations, qui tam suits and allegations of serious Medicare fraud are simply a cost of doing business.” Many settlements run only into the tens of millions of dollars. That’s a corporate slap on the wrist for companies whose stocks typically soar when executives push the profit envelope. Only if the penalty is at least $500 million, Ms. Skolnick said, are corporations likely to find the cost a deterrent.
H.M.A. also faces shareholder lawsuits and a federal securities investigation. A former executive was indicted late last year on an obstruction charge related to these investigations.
The company said it could not comment on pending litigation, but was cooperating with the Justice Department investigation. In a statement, the company defended the quality of its medical care. “H.M.A. associates and physicians who practice at our facilities are focused on providing the highest-quality patient care in all of our hospitals,” it said.
The architect of the strategy to raise admissions, according to several of the lawsuits, brought by an array of physicians, individual hospital administrators and compliance officers, was the company’s former chief executive, Gary D. Newsome.
“Gary vigorously denies the allegations,” according to an email from his lawyer, Barry Sabin of Latham & Watkins.
Mr. Newsome joined H.M.A. in September 2008 from a high-ranking post at Community Health. He left H.M.A. last summer to head a religious mission in Uruguay. His compensation in the three years before his departure totaled $22 million.
Shortly after joining H.M.A., Mr. Newsome traveled to North Carolina to meet with local hospital officials. He informed them he was putting in place new protocols, using customized software, meant to “drive admissions” at hospitals, according to allegations in a federal suit filed by Michael Cowling, a former division vice president and chief executive of an H.M.A.-owned hospital in Mooresville, N.C.
To reach admission goals, administrators were directed to monitor on a daily basis the percentage of patients being admitted, using a customized software program called Pro-Med. The progress of the physicians in meeting their goals was updated daily on the scorecards.
When Mr. Cowling confronted Mr. Newsome with physician concerns that the new protocols were clinically inappropriate and would result in unnecessary tests and admissions, and said that his doctors “won’t do it,” Mr. Newsome responded: “Do it anyway,” according to the lawsuit.
As a result, according to a former physician who cited multiple examples, patients who did not need inpatient treatment often were admitted, which allowed the hospital to bill Medicare and Medicaid more for the care.
In Georgia, a baby whose temperature was 98.7 degrees was admitted to the hospital with “fever,” according to a lawsuit filed in federal court by Dr. Craig Brummer, a former medical director of emergency departments at two H.M.A. hospitals.
In one case, an 18-year-old Medicaid patient with a right-knee laceration was admitted, though he could have been treated and discharged, Dr. Brummer said in his lawsuit.
Executives who raised questions about H.M.A.’s policies and procedures were often fired.
When Jacqueline Meyer, a regional administrator for EmCare, a company that provided emergency room physicians to a number of H.M.A. hospitals, refused to follow H.M.A.’s directives and fire doctors who admitted fewer patients than H.M.A. wanted, she was fired, according to the lawsuit she filed with Mr. Cowling. The Justice Department has not yet decided whether to join her lawsuit against EmCare, which declined to comment.
Likewise, shortly after Ralph D. Williams, an accountant with 30 years’ experience in hospital management, was hired as the chief financial officer for an H.M.A. hospital in Monroe, Ga., he asked an outside consulting firm to review the hospital’s inpatient admission rate.
When Mr. Williams showed the report, which confirmed a higher admission rate, to a higher-level division executive, he was told to “burn it.” Mr. Williams was soon fired, according to a qui tam lawsuit Mr. Williams filed in federal court in Georgia.
The last year has been particularly tumultuous for H.M.A., starting with . . .
Jaw-dropping: Mitch McConnell is campaigning on his “support” for free preventive healthcare services for Ketuckians
Mitch McConnell seems to lack any shred of integrity. Igor Volsky writes at ThinkProgress:
Sen. Mitch McConnell (R-KY) is out with a new campaign ad touting his success in securing free preventive health care services for Kentuckians. The spot, titled “Cares,” tries to paint the Senate Minority Leader as a compassionate Republican who carries a moral obligation to provide sick people with access to government-sponsored health care.
It’s a message you wouldn’t expect from a Republican senate leader who has voted to repeal the Affordable Care Act and continues to oppose its implementation in Kentucky. But the minute-long ad, featuring Robert Pierce, an energy worker and throat cancer survivor, highlights the Republican Senate leader’s effort to secure “cancer screening programs” for Kentuckians and provide them with government compensation. Watch the spot:
The aid is the result of an entitlement McConnell secured for former employees of a plant in Paducah, Kentucky who were exposed to high levels of uranium throughout the 1950s and 1960s, and who now suffer from cancer or other ailments. As the Huffington Post’s Zach Carter and Jason Cherkis catalogue in their exhaustive report on the crisis, McConnell had initially “kept the plant’s doors open” to guarantee jobs for his constitutes, even as “the plant’s toxins had spread through the air and into the ground, slowly killing its own workers and tainting the surrounding area.” Though McConnell had toured the facility, “knew about the contaminated water supply and the mountain of leaking storage containers,” and had been in regular consultation with the Department of Energy about the crisis, he ultimately voted against an amendment that would have held nuclear subcontractors liable for negligence or misconduct at nuclear plants — and didn’t take legislative action to help the plant’s sick workers until 1999.
Almost two decades after employees began dying from cancer, and five years after the Paducah plant was declared a Superfund site by the Environmental Protection Agency, McConnell pushed through a new entitlement “that allowed plant workers over age 50 access to free body scans and free health care.” The program also “provided $150,000 lump sum payments to workers who developed cancers or other illnesses from radiation exposures, and up to $250,000 in compensation for medical problems caused by other toxins.” Once the benefit started flowing in 2001, McConnell and his wife, then-energy secretary Elaine Chao, even “flew to Paducah and awarded the first $150,000 check.”
McConnell has long used his influence to direct federal funds to other health care programs that closely resemble the preventive goals outlined in the Affordable Care Act. The Kentucky senator secured an earmark that ultimately provided pregnant women with sonograms and routine care. He also “directed money to everything from mobile health screenings to lab upgrades for stem cell research into heart failure” and “earmarked close to $3 million to fund heart health classes that would educate residents in the state’s rural areas about how to eat better and exercise.”
Yet ultimately, McConnell’s piecemeal approaches to Kentucky’s health care problems — it’s a state where 17 percent of residents are uninsured, 69.1 percent of adults are overweight or obese, and 30 percent have high blood pressure — won’t solve the state’s public health care crisis. Obamacare, which has provided more than 116,000 Kentuckians with health care coverage, could. But McConnell still opposes the law. Responding to the state’s success in implementing the measure, McConnell said he doesn’t believe in “free” benefits, telling reporters, “That’s free health care. If you want to give out free health care you’re going to have a lot of interest. Just like free anything else.”
Interesting post at Daily Kos by Egberto Willies:
Common knowledge to those who follow the ins and outs of Obamacare is that there is an industry out there to destroy it at all cost. The traditional media has been the major conduit of the lies and misinformation.
It isn’t only the smaller media outlets that are generating the barrage of misinformation. CBS News whose ‘60 Minutes’ has been compromised with Benghazi and NSA misleading stories has been a major culprit. After-all CBS’s Jan Crawford reported a story about a woman losing the insurance she loved and could afford. It turned out had CBS made one telephone call or just checked healthcare.gov they could have informed the woman that she could get much better and reliable insurance for a comparable price.
It is a new day in media. Corporate owned major media that sometimes seem to purposely allow themselves to be a conduit to lies and misinformation are being challenged. Bloggers and other independent media that previously had little reach are now fact checking. They are using the power of the internet to inform with fact based information and not hit pieces that is now endemic in the traditional media.
Maggie Mahar, a prolific blogger at HealthBeat Blog and author of ‘Money-Driven Medicine: The Real Reason Health Care Costs So’ wrote the blog post Anatomy of an Obamacare ‘horror story’ detailing yet another misinforming story. It turns out the story in the Fort Worth Star Telegram was not only biased, it was simply not true. Maher writes.
For months, health reform’s opponents have been feasting on tales of Obamacare’s innocent victims – Americans who lost their insurance because it doesn’t comply with the ACA’s regulations, and now have to shell out more than they can afford – or go without coverage. Trouble is, many of those stories just aren’t true.
Yesterday I posted about a Fort Worth Star Telegram article that leads with the tale of Whitney Johnson, a 26-year-old new mother who suffers from multiple sclerosis (MS). Her insurer just cancelled her policy, and according to Johnson, new insurance would cost her over $1,000 a month.
That claim stopped me in my tracks. Under the ACA, no 26-year-old could be charged $1,000 monthly – even if she has MS.
Obamacare prohibits insurers from charging more because a customer suffers from apre-existing condition. This rule applies to all new policies, whether they are sold inside or outside the exchanges.
At that point, I knew that something was wrong.
Maggie Mahar did not just read the story, discount it, and go off to something else. She did something about it. She got involved. She checked healthcare.gov and found out that a comparable policy with much better and secure coverage would cost Whitney Johnson $7 more than she was currently paying.
Maggie Mahar went further. She called the Fort Worth Star Telegrram. After calls not being returned, she finally got a callback. She was informed that the newspaper received an email stating Whitney Johnson did find insurance at a similar price. The newspaper would not confirm that they would correct the story. It is evident the newspaper either has an agenda or is scared of revealing the truth for reasons that can be assumed. They came out with a defense of the story as well as a mea culpa for a less than complete story.
Maggie Mahar discovered that Whitney Johnson was a member of the Tea Party. The newspaper did not attempt to do any background checks. She finally reached the reporter of the story. The reporter told her that she had no experience covering healthcare. Moreover her assignment was to find people who were having problems with Obamacare. When she suggested doing a story on people helped by Obamacare she was not given a green light to do so from her editor.
The Fort Worth Star Telegram has over 200,000 readers. They chose to misinform these users maybe negligently, maybe willfully. What is sure is that so far they have chosen to willfully keep them misinformed.
If this isn’t yet another reason to disregard most of corporate and traditional media, what is? The consequences of misinforming the public are grave. It can even be fatal. The public must be informed constantly that the media that use to be the source of unbiased information that could be depended on is no more.
The conservative wind machine really, really wants Obamacare to be bad, and lately they’ve been harping away at the death spiral: not enough healthy young people sign up, so that the unhealthy and the elderly predominate in the insured population, which raises rates, which drives away more of the young and healthy, leading to more rate increases,… A vicious circle termed the “death spiral.”
Only it’s not happening. Not at all. If you look at the facts (difficult for conservatives), you see that. Ezra Klein lists the ways in which there is no death spiral.
The chart is from a post by Kevin Drum, which you should read in its entirety. Regarding the chart, he states:
Recently a team of authors did just that in JAMA and produced the chart [above]. It shows Years of Potential Life Lost (YPLL) as multiples of the median for other rich countries. A number greater than one means we’re losing more years than the rest of our peers. Here’s the chart.
The dramatic thing about this chart is that the United States does worse than other rich countries in every single area. Sure, it’s possible that there are 16 different reasons that we’re doing worse in 16 different categories, but it doesn’t seem likely, does it? When something is this widespread, the cause is a lot more likely to be something broadly based, like health care delivery. This isn’t smoking gun proof that our Rube Goldberg health care system is responsible for our lousy life expectancy, but it sure ought to make you sit up and take notice. There’s a pretty good chance that you, your friends, and your family are going to live three or four years less than you should, solely because you live in America.
Sarah Kliff has a good comment on the chart in the Washington Post.
David Super is a professor of law at Georgetown University. On Friday, he wrote a New York Times op-ed arguing that, as bad as Obamacare’s launch has been, “food stamp and Medicaid recipients can only look on in envy.” In it, he offered examples of the terrible service the government often offers to the poor, including a Colorado program that “refused food stamps to anyone who did not have a driver’s license from Guam” and a Georgia disaster that failed “to send renewal notices to the homes of some 66,000 food stamp recipients and about half that number of Medicaid beneficiaries: and terminated their coverage on November 1st.”
We spoke by phone on Monday. A lightly edited transcript follows.
Ezra Klein: How does the launch and subsequent trajectory of HealthCare.gov compare to what you typically see in programs for the poor?
David Super: The early months were very typical of what we see whenever a new system is implemented that affects low-income people. But the recovery has been startlingly fast.
EK: So what happens in these programs typically? They launch, fail, and then what?
DS: They just thunder on ahead. The system that’s broken down spectacularly for food stamps and Medicaid in Georgia began as a pilot in a few counties a year-and-a-half ago. It was a miserable failure there. Federal administrators tried calling the toll-free number to get help themselves and couldn’t get through. But they rolled it out anyway.
EK: What’s the decision chain that ends up justifying scaling up a failing pilot?
DS: There’s this idea, “we’ve gone this far, we should keep on going.” You hear people say that this has to be done sooner or later and we might as well do it now. Or they say, “we should take our lumps.” It always makes my blood boil because it’s not the administrators taking the lumps.
EK: There’s an old line that goes, “programs for the poor are poor programs.” When you compare programs that are used by the poor, like food stamps, to programs used by Americans of all income brackets, like the IRS or the DMV, do you think the old adage holds true?
DS: It’s night and day. I hear people complain about the IRS and I’m just astounded. Its level of customer service is radically better than what we see in even fairly well-run poverty programs. There’s all sorts of things the IRS would never dream of doing that are absolutely routine in these other programs. They actually give people a chance to explain things.
EK: These programs are designed with good intentions. The people behind them care. So how do you end up in a situation like Georgia, where many of the people can’t even get through the phone tree? What goes wrong?
DS: There are many reasons. But the reason there are a lot of problems right now is we’ve had so many consecutive years of state budget cuts and hiring freezes. Many states pay very, very low wages for people administering these programs, and so there’s a lot of turnover. So when the state has a hiring freeze, the better-paid agencies don’t shrink very much, but these programs shrink enormously. So they just don’t have enough bodies.
EK: I think someone reading this interview could say, “this is just more evidence that government can’t manage these things well and should stop trying. Give the money to the private sector and let them invest it, or give the programs to private contractors and let them manage them.” Do you agree?
DS: I don’t think that matches up with the evidence. . .
The entire article by Nina Martin at Pacific Standard is interesting and worth reading. It includes an interesting graph:
This is ominous. As has been reported, Catholic hospitals will allow a mother to die rather than take action to abort a fetus, even a non-viable fetus. Moreover, Catholic hospitals require all staff to follow religious dictates, not simply those who are Catholics.
Equally disturbing is the growth in for-profit hospitals. When profits become the goal, the quality of service drops and prices rise (better profits). This has been repeatedly demonstrated.
Interesting interview in Pacific Standard by Charles Ornstein of Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, a nonprofit think tank (and not related to Kaiser Permanente, an HMO).
Few groups have tracked the Affordable Care Act as closely as the Kaiser Family Foundation, a non-profit, non-partisan think tank (not affiliated with Kaiser Permanente). Integral to those efforts has been Larry Levitt, senior vice president for special initiatives at the foundation.
Back in February, Levitt wrote a commentary for the Journal of the American Medical Association about what he expected to happen in the early going of the health insurance exchanges. He predicted: “It is very likely that it will be less than perfect.”
That’s certainly been the case. He continued:
“There also will undoubtedly be technical glitches in the eligibility and enrollment systems that are being created from scratch on a tight schedule. Some people will see their premiums increase, and anecdotes about those cases will undoubtedly be highlighted in the media. The fact that others will see their costs decrease or will have insurance that offers better benefits and more secure coverage may be overlooked. Although personal out-of-pocket costs for health care should decrease for most people, some may nonetheless perceive their deductibles and co-pays as unaffordable.”
With the impending Dec. 23 deadline to sign up for Obamacare coverage that begins on January 1, I checked in with Levitt to see if his thoughts had changed. The email interview has been edited for length and clarity.
As we approach the December 23 enrollment deadline, how do you feel?
I’d say we’re pretty much where I anticipated we’d be with implementation—two months ago. I always expected, as did many others, that things wouldn’t be perfect at the start. In fact, I wrote about that back in February in JAMA. My expectation was that there would be some glitches in the systems, things wouldn’t necessarily work smoothly for people with more complex family and financial circumstances, there would some mix-ups on the back end transmitting enrollment information to plans (as in the Medicare Part D program at first), and things would be working better in some states than others. That’s essentially where we are now. That’s not ideal, but there is still time to get things back on track. January 1 is important, but March 31—the end of open enrollment—is even more important.
It looks like there’s going to be a last-minute crush of applications (online and on paper). Are they going to be processed on time?
Well, my crystal ball is a bit blurry today, so there’s no way to say for sure whether all the last-minute applications will be processed on time. The good news is that data from the states, which have generally been reporting enrollment information faster than the federal marketplace, are showing a December surge. That suggests people have not necessarily been discouraged by the early problems.
I’d say the highest priority is avoiding coverage gaps for people who were buying their own insurance before. That’s folks who had their policies cancelled because they didn’t meet the new requirements of the ACA, as well as some people with serious health conditions in high-risk pools. There are also still a lot of people in the system who have been determined eligible but have not yet picked a plan. I know the federal marketplace has been reaching out to those people, and hopefully they can be converted into actual enrollees.
There have been a number of reports about well-known hospitals not being included in many health plans. Are you concerned that consumers will discover this after it’s too late? . . .
Reporters seem unable to learn from experience, not a good sign. Yet again they ran with a story leaked by Darrell Issa—big problem found in Healthcare.gov security!!!—only to learn that the bug was trivial and fixed before the system went live. Michael Hiltzik reports in the LA Times:
Bingo! We have not one but two “investigative” news reports, from CBS and ABC, based on the same partial transcript. And both, consequently, have the same level of credibility: none. CBS News even offers a dividend — a thoroughly dishonest and discreditable interview with Issa himself. We’ll get to that in a moment.
The topic of the latest leak is the purported security flaws in healthcare.gov, the federal health enrollment website. The raw meat is a partial transcript of an interview conducted by the staff of Issa’s House Committee on Oversight and Government Reform with Teresa Fryer, chief information security officer at the Centers for Medicare and Medicaid Services, which is handling the healthcare.gov rollout.
Cue Sharyl Attkisson of CBS: “A top HealthCare.gov security officer told Congress there have been two, serious high-risk findings since the website’s launch, including one on Monday of this week.”
Well, yes. But not exactly. Fryer said more, which you’d know if you read the parts of the transcript left out of the Issa leak but distributed by the committee’s Democratic minority. There you discover that Fryer also said that the system’s security measures exceed industry standards, that there haven’t been any security breaches of the website, and the parts of the system affected by the high-risk findings were promptly shut down and quarantined.
That brings us to Issa, who went before the CBS cameras to charge that Fryer’s recommendation that the website launch be delayed was overruled by mysterious “individuals” who, he said, “were looking at a broader array of risk.” His tone of voice put air quotes around that “broader.” He continued, “I took that to mean the risks such as risk to the president of embarrassment, the risk to people who were counting on being able to sign up for these plans.”
See what he did there? He suggested that CMS was pressured by the White House to launch a website with security holes.
But there’s absolutely no basis in Fryer’s transcript — zero — to support that. What she said was that it’s standard operating procedure to place security assessments like hers in a broader context. In fact, the process is set forth by NIST, the National Institute of Standards and Technology, which is the government’s technology assessment agency. And of course that makes sense: You weigh the security aspects of a technical system against numerous other factors, including the importance of the program, and decide from the totality whether to launch.
There’s nothing in Fryer’s words even remotely hinting at an effort to spare the president “embarrassment.” Issa appears to have made that up out of whole cloth.
But he didn’t stop there. He suggested to CBS that the healthcare.gov website exposed virtually the entire government to hacking. “Remember, Sharyl, this is not about your application being compromised. This is a system, exchange and portal, that lets me go into the Department of Homeland Security, lets me go into the IRS … Social Security. Think about what’s at Social Security, what’s at IRS, what’s at Department of Homeland Security. That’s the vulnerability.”
Is that so? A flaw in a healthcare enrollment website that could let hackers in on our most precious government secrets? Let’s agree that if this were true, it would be huge. But once again, Issa has absolutely no evidence that it’s remotely true. If he had it, he would shout it from the rooftops, and he’d be right to do so. He wouldn’t slink around in the dark to a news show and slip it into the conversation with a credulous reporter.
CBS plainly knows Issa was blowing smoke. . .
Aha! So reporters are not fooled! They just don’t give a shit.
Very interesting report in the Washington Post by Ezra Klein.
Junk often costs less than quality. Tony Pugh has an interesting piece for McClatchy:
April Capil has mixed feelings about the national outcry over canceled health insurance policies.
Five years free of the stage III breast cancer that nearly claimed her life, the Boulder, Colo., resident is once again healthy, but she’s still struggling to put her life back together.
Like millions of Americans, Capil thought she had solid individual health insurance. Then she got sick and found that her coverage was woefully inadequate.
The financial problems that followed would aggravate Capil’s health struggles, force her into bankruptcy and trigger a fraud lawsuit over $230,000 in unpaid medical bills against HealthMarkets Inc., the parent company of her former insurer.
The litigation is nothing new for HealthMarkets. The North Richland Hills, Texas, insurer, formerly known as UICI, has a long history of battles with state regulators trying to root out “junk insurance” in the individual market. But numerous sanctions and a host of consumer protections in the Affordable Care Act have put a financial squeeze on the company and forced it to change its business model.
Beginning in January 2014, the health care law prohibits the kind of limitations, exclusions and benefit spending caps that made Capil’s coverage so problematic.
But after falsely promising that Americans could keep their health insurance if they liked it, President Barack Obama bowed to political pressure in November and OK’d a one-year extension on 2013 individual policies – even those facing cancellation next year because they don’t meet the health law’s new minimum standards.
Now Capil, a software project manager, wonders how many Americans will use the president’s canceled-policy “fix” to unwittingly renew another year of “junk insurance” like she used to have.
“It’s sad that there are people who have this insurance who don’t know that they’re going to end up like me if they ever get sick,” she said. “I feel like people are upset that they’re losing these plans and they’re upset because they think their plans are comprehensive. But they aren’t. These insurance companies have been selling Americans coverage that will bankrupt them if they ever have a serious illness.”
It’s a concern others share as well.
“As those policies are grandfathered in, people have to be aware they may be exposed,” said Mark Rukavina, a health care consultant in Massachusetts and an expert on medical debt. “It’s something to think about as these people stay with these plans that seem like a good deal.”
Capil thought her plan was a good deal. She said her insurance agent told her it was full, comprehensive coverage and if she ever got cancer, Capil would never pay more than a deductible or co-insurance.
What she got instead was a “limited benefit plan,” which is “commonly seen as inadequate because it tends to pay for routine care and leave you without coverage fairly soon if something major costing tens of thousands of dollars kicks in,” said Ed Haislmaier, a senior research fellow for health policy at the Heritage Foundation, a conservative Washington think tank.
Donna Ledbetter, HealthMarkets’ director of external communications, declined an interview request for this story, citing Capil’s pending lawsuit. She also declined to answer questions not involving that litigation. . .
Now that Healthcare.gov is (more or less) working, and the various exchanges in those states that decided to implement them are running, we’re starting to find out the effects of Obamacare. The National Journal has an interesting article by Lucia Graves about the “unlikely winners” in finding new healthcare, a puzzling title: the whole purpose of the Affordable Care Act was to help people with health insurance, so calling it “unlikely” that people would find good healthcare insurance via the ACA is very strange: that “unlikely” thing is the whole point of the ACA.
At any rate, the article begins:
Sue Spanke of Missoula, Mont., was highly displeased this fall when she learned her health insurance had been canceled.
“I got so mad that I went to my phone and started calling all the political people and giving them what for,” Spanke told The Billings Gazette. That was before she learned she was eligible for a policy at a much lower cost.
After angrily calling her state auditor’s office, Spanke, a self-employed artist in her 50s, found she was eligible for a federal subsidy. Her new insurance will cover her for a mere $30 to $40 a month with a deductible of only $500. She had been paying $350 a month for a Blue Cross policy with a $5,000 deductible. “I went from a horrible policy that didn’t cover anything, that was breaking me, to the best policy at the best price I’ve had since I was in my 20s,” she said.
With the website largely fixed, one of the last lines of attack against Obamacare is that the president lied when he said if people like their insurance plans, they can keep them. The White House is hoping stories like Spanke’s will inoculate them against those arguments. And the positive stories abound.
Another man interviewed by The Billings Gazette, Gary Mermel, said he received cancellation notices for his family’s Blue Cross policies only to find later that he and his family were eligible for much more affordable insurance. Mermel, a retired physician with apreexisting health condition, had been paying almost $1,700 a month to cover his family, and last month Blue Cross informed him his rates would go up to nearly $2,100 a month for the remainder of the year. Under the Affordable Care Act he was able to find insurance covering his entire family for just $1,200 a month with comparable benefits and a lower deductible than he’d had previously.
He also won’t have to worry about being denied coverage or getting charged more for preexisting conditions. “Before, the insurance companies had full control,” he said. “They were allowed to place people at risk [of financial ruin] and they no longer can do that.”
Other local outlets have documented the success post-insurance cancellation stories as well.
In Lancaster, Pa., Lori Lapman, 58, learned her health plan was being canceled in September—by October things were looking up. Per The Sunday News: “Sitting at a laptop with a certified health law helper, Lapman went to HealthCare.gov, found it running smoothly, and bought a subsidized Highmark plan that allows her to keep her doctors while saving her money. Her canceled plan cost her $520 a month. Her new coverage? Only $111.73.”
In Harrisburg, Pa., The Patriot News documented the case of Lynn Keltz, one of the hundreds of thousands nationwide who received a cancellation notice. Keitz, who happens to be one of the federally funded navigators helping state residents find new coverage under the Affordable Care Act, said her new policy provides her better coverage and costs $80 per month less.
In a letter to the editor in The Santa Maria Times, Allan Pacela told the story of how after his wife lost her insurance this fall, she found much better coverage under Obamacare. The couple is now saving $8,000 per year for a “much better plan.”
These stories can be found in national media outlets as well. The Huffington Post relayed the story of an HIV patient from . . .
Ezra Klein is puzzled (or at least says he is; I suspect he understands it perfectly) by Republican hypocrisy on health care. For many years the GOP has advocated things that are supposed to bring the magic of the marketplace and individual incentives to health care: higher deductibles to give people “skin in the game”, competition among private insurers via exchanges — competition that would include reducing costs by limiting networks — and, of course, for cuts in Medicare. Now the GOP complains bitterly that some Obamacare policies have high deductibles, that it relies on the horror of exchanges, that some networks are limited, and that there are cuts in Medicare.
Klein suggests that Republicans are really upset by other aspects of Obamacare, but are going after the easy targets even though they’re attacking their own ideas. In a sense he’s right, but as I said, I suspect that he knows that the issue is both bigger and simpler than he says.
What underlies what Jonathan Chait calls the Heritage uncertainty principle? He describes it thus:
Conservative health-care-policy ideas reside in an uncertain state of quasi-existence. You can describe the policies in the abstract, sometimes even in detail, but any attempt to reproduce them in physical form will cause such proposals to disappear instantly. It’s not so much an issue of “hypocrisy,” as Klein frames it, as a deeper metaphysical question of whether conservative health-care policies actually exist.
The question should be posed to better-trained philosophical minds than my own. I would posit that conservative health-care policies do not exist in any real form. Call it the “Heritage Uncertainty Principle.”
Well, actually it’s pretty simple. The purpose of most health care reform is to help the unfortunate — people with pre-existing conditions, people who don’t get insurance through their jobs, people who just don’t earn enough to afford insurance. Cost control is also part of the picture, but not the dominant part. And what we’re seeing right now, in any case, seems to confirm a point some of us have been making for a long time: controlling costs and expanding access are complementary targets, because you can’t sell things like cost-saving measures for Medicaid and limits on deductibility of premiums unless they’re part of a larger scheme to make the system fairer and more comprehensive.
And here’s the thing: Republicans don’t want to help the unfortunate. They’ll propound health-care ideas that will, they claim, help those with preexisting conditions and so on — but those aren’t really proposals, they’re diversionary tactics designed to stall real health reform. Chait finds Newt Gingrich more or less explicitly admitting this.
Hence the rage of the right. Here they were, with a whole raft of ideas they could throw out, like chaff thrown out to confuse enemy radar, to divert and confuse any attempt to actually provide insurance to the uninsured. And those dastardly Democrats have gone ahead and actually incorporated those ideas into real reform.
Once you realize this, you also realize that people who warn that by opposing Obamacare Republicans are undermining their own proposals are missing the point. Yes, the Ryan plan to privatize Medicare looks a lot like Obamacare — but Ryan comes to Medicare not to save it, but to bury it, so the question of whether his plan could work is irrelevant.
There’s no mystery here; it’s just top-down class warfare as usual.
The GOP is in sort of a bind on healthcare. First, Obamacare is based on their own ideas. Second, though they are eager to repeal the program, they have yet to come up with (another) alternative. (Their first idea was Obamacare, but since that’s been implemented, they need now to come up with something else.) Ezra Klein points out some aspects of the bind they’re in:
Now that HealthCare.Gov is on a clear path to functionality, Republicans are having to come to terms with the fact that Obamacare will not conveniently collapse before anyone can purchase insurance. If the law is going to fulfill its promise of destroying Barack Obama’s presidency and giving Republicans their long-awaited chance to repeal-and-replace, it will have to be because people actually hate the insurance they get through Obamacare.
Republicans have zeroed in on two things that people really will hate about insurance under Obamacare: The high deductibles and the limited networks. Brendan Buck, press secretary for House Speaker John Boehner, tweets:
“As consumers dig into the details,” Robert Pear reports in the linked article, “they are finding that the deductibles and other out-of-pocket costs are often much higher than what is typical in employer-sponsored health plans.”
What’s confusing about this line of attack is that high-deductible health-care plans — more commonly known as “health savings accounts” — were, before Obamacare, a core tenet of Republican health-care policy thinking. In fact, one of the major criticisms of Obamacare was that it would somehow kill those plans off. “Obamacare may be fatal for your HSA,” warned the Heritage Foundation on 2010. “Health Savings Accounts Under Attack” blared Red State.
When Republicans were forced to come up with alternatives for Obamacare, high-deductible plans were core to those proposals. “Conservatives have suggested deregulating Obamacare’s exchanges to make it easier to provide policies with high deductibles,” wrote Ramesh Ponnuru. One of those conservatives was right-wing darling Dr. Ben Carson. “In order to right the ship, we need to return the responsibility for good health care to the patient and the health care provider,” he said. “One of the best ways to do this is through health savings accounts, which patients can control.”
This always baffled Obamacare’s supporters. “The minimal, or bronze, insurance option allows out-of-pocket spending of up to $12,500 for a family of four,” wrote Jonathan Cohn. “Those are some pretty high deductibles!”
Now that those high deductibles are here, Republicans have decided that they are, if anything, too high. Just one more broken promise.
Obama’s pledge that “if you like your doctor, you can keep your doctor” is also under fire. The issue here is that insurers entering the competitive health marketplaces are tightening their networks in order to cut costs and improve quality. It’s worked: Premiums in the marketplaces are far lower than was expected when Obamacare passed.
This, too, is a success for a longtime conservative health-policy idea. Insurance exchanges have been in every major Republican health-care bill since the early 1990s. They were in Paul Ryan’s 2009 health-care proposal. They’re the basis of the GOP’s plan for Medicare reform.
Conservatives believe that a huge problem with the health-care status quo is that most people get insurance through their employer or the government. In both cases, they don’t directly pay the full cost of the plan, and so they have every reason to demand more generous care rather than more cost-effective care. If they were paying and shopping for plans themselves, they would care about price, and insurers would have an incentive to cut costs by carefully choosing the doctors and hospitals that can do the best job for the least money.
“Narrow networks are not some cruel attempt to limit patient choice foisted upon us by the insurance industry,” write economists David Dranove and Craig Garthwaite. “Instead, these plans may provide our best opportunity for harnessing market forces to lower prices.”
But Republicans don’t seem pleased to see their ideas in action. “As I travel across Kentucky, I hear from many constituents who are seeing premiums increase along with higher co-pays and higher deductibles as a result of Obamacare,” wrote Mitch McConnell in an op-ed for the New Democrat Leader. “Adding insult to injury, these constituents are discovering that despite these higher costs, they have no guarantee that they will be able to continue using the hospital of their choice.”
The Republican turnaround on high-deductible plans and tighter networks has puzzled many longtime health-care observers. “Conservatives are winning at least as much as they are losing in health care, even if they don’t know it or won’t say it,” wrote Drew Altman, president of the Kaiser Family Foundation.
I asked some of the GOP’s most influential health-care voices about the tension between the criticisms Republicans are launching against Obamacare and their longstanding commitment to these ideas. . .
Continue reading. The whole column is interesting and mordantly entertaining.
Good news, which should be cheer to Congress, which was complaining mightily when the exchange wasn’t working. I expect to see some guarded praise from the Right… well, no, not really. Lizette Alvarez and Jennifer Preston report in the NY Times:
After two months of false starts, error messages and pleas for patience from the once-hobbled federal online health care exchange, Karen Egozi, the chief executive of the Epilepsy Foundation of Florida, watched on Monday as counselors navigated the website’s pages with relative ease.
Click. Next page. Click. Next page. The website, HealthCare.gov, was working so well that Ms. Egozi, who oversees the 45 navigators in eight locations who help consumers enroll in health plans, said her team gave the system an 8 on a scale of 1 to 10, meaning that most people got as far as selecting a plan or taking home information to select a plan. It felt like a champagne moment.
“I’m 80 percent satisfied,” Ms. Egozi said. “I think it will be great when it’s 100 percent.”
A little over a week after the deadline that President Obama gave for fixing the federal health care exchange, the system is definitely working better, according to consumers and navigators interviewed in several states. The technical errors that had bedeviled visitors to the site for weeks seemed to have been tamed by the patchwork of hardware and software fixes ordered by the administration, and applicants were finally selecting health care plans under the president’s new law, the Affordable Care Act. By last week, the number of applicants who dropped a plan into their virtual grocery carts was climbing at a rapid clip.
Still, the interviews indicated, some technical obstacles persist. After shoppers clicked all the way to the plans, for example, the system was not letting some people actually choose one. In other cases, people were asked to try again later.
Improved entry into the online marketplace has also exposed a new layer of problems and confusion for applicants who are suddenly finding their efforts to buy insurance delayed by requirements that they provide proof of identity or citizenship or that they wait for determinations on Medicaid eligibility.
For the most part, though, the news for the beleaguered online exchange, which serves 36 states, is improving. Since early December, the federal exchange website has run without crashing, officials said. In the first week of December, about 112,000 people selected plans — compared with about 100,000 in all of November and only 27,000 in October. Last week, more than half a million people created accounts on the federal website, according to people familiar with the health care project.
Technical experts involved with the exchange said they are now preparing for a surge of applications before Dec. 23, the enrollment deadline to receive coverage by the first of the year. Although those preparations will require some significant changes to the system, the work will be easier now that the site seems stable during heavy use, the experts said.
In offices spread across the country, from Florida and Pennsylvania to Wyoming and Wisconsin, all of them states that rely on the federal government’s insurance exchange, navigators and applicants reported far fewer problems.
“I was hearing so much about the glitches in the system that I was worried that it wouldn’t work,” said Caroline Moseley, 54, who lost her job as a housing program analyst for the City of Philadelphia. After asking a navigator from the nonprofit Resources for Human Development for help in finding a plan, Ms. Moseley chose one that costs $27 a month with a $6,000 deductible. “It was a great experience,” she said. “The site was running very smoothly. It took about 30 minutes tops.”
Stephanie Lincoln, 60, of Lansdowne, Pa., also had quick success with the exchange — after a frustrating experience trying to submit an application online in October and November. With the help of a navigator, Caroline Picher, working at the local library, Ms. Lincoln signed up in just one hour on Friday for a policy that will cost $113 a month, with no deductible.
“I am one of the people whose plans were canceled,” Ms. Lincoln said. “It was just the easiest thing in the world.” . . .
Brian Beutler discusses the improved performance and links to other reports of progress; from his article:
. . . Here’s one from the State in South Carolina:
An elbow-injuring fall in March proved nearly as painful financially as physically for Carolyn Gates, who was uninsured and ended up with an $8,000 bill for her emergency room visit.
She felt much better Wednesday after a visit to the S.C. Progressive Network’s Columbia office, where she worked with Navigator Tim Liszewski to sign up on the Health Insurance Marketplace under the Affordable Care Act. While Gates and her husband slowly pay off that emergency room debt, she’ll also be paying a $107-per-month health insurance premium next year.
“As far as I’m concerned, it was the best thing ever,” Gates said. “I told my Bible study about it, and three said they’re going to sign up.”
And here are several more from the St. Louis Post Dispatch:
At the Columbia location of Primaris Healthcare Business Solutions, an enrollment event Monday proved successful for all of its visitors. Jeremy Milarsky, navigator program manager, said he didn’t experience any website glitches and all of his appointments with consumers ended in successful plan selections.
“Today was, I would say, an enrollment event with a capital ‘E,’” he said.
The St. Louis Area Agency on Aging, another nonprofit group assisting consumers with health insurance enrollment, held several outreach events this week. Mark Smith, case management coordinator, said navigators are still seeing some website problems, but also significant improvement. The new feature that allows users to delete their applications and begin again has helped, he said, and the majority of people at the events have been able to select a plan. . . .
Progress is good, right? Things are looking up (except for those in states that refused to expand Medicare for their citizens).
Becky Bach reports in Pacific Standard:
Thousands of veterans suffering from post-traumatic stress disorder rely on the Department of Veterans Affairs for relief. They might be better served, however, if they tapped the hard-won wisdom of incarcerated Vietnam veteran Michael “Doc” Piper.
Piper knows, though the VA has yet to acknowledge, that community service could be the most effective treatment available for PTSD, a debilitating condition marked by nightmares, anxiety, flashbacks, pain, anger, self-blame, alienation, and depression.
Despite his confinement in Soledad Correctional Training Facility, a California state prison, 67-year-old Piper is a professional volunteer. From a 106-square-foot former broom closet with no Internet access, Piper helps fellow incarcerated veterans access VA benefits. By helping others, Piper says he’s been able to cope with his anger, nightmares, and flashbacks. But he’s not the only one who understands the power of community service.
Mission Continues, a St. Louis-based organization, is generating national attention, including a June 2013 Time cover story, for its success helping veterans who served in Iraq and Afghanistan integrate into society. It’s a dire need: The VA has treated nearly 300,000 veterans from those conflicts for PTSD symptoms, according to a November report. Mission Continues, which was founded in 2007 by a group of veterans, places veterans in six-month service fellowships in community organizations across the country.
Fellows paint hospital walls, collect food donations, and plant gardens, developing career and life skills in the process. And although in-depth studies are lacking, an investigation (PDF) by Washington University in St. Louis social scientist Monica Matthieu, found that Mission Continues helps.
Matthieu and her team surveyed 27 Mission Continues fellows, many of whom have been diagnosed with PTSD. Following their fellowship, 71 percent continued their education and 86 percent were able to find employment.
The VA currently assaults PTSD with a grab bag of treatments. It recommends (PDF) a combination of drugs, most commonly anti-depressants, and therapies including individual and group psychotherapy, hypnosis, and meditation. The department’s 2010 guidelines also recommend social and family skills training, job training, education, and spiritual support. VA therapists even teach stress-tolerance techniques.
For example, . . .
Now this is good legislation, whatever the motive: in 2009 the GOP votes to require that Congress be covered under Obamacare. While the intent was political theater and punitive, the effects are likely to be salutary and good for the country. One has to recognize positive legislative action when it occurs, whatever brings it about. Ryan Cooper writes in the Washington Post:
Right now, one of the primary ways Congressional Republicans are attacking Obamacare is to cite the sob stories of Congressional staffers — and lawmakers themselves — who are having a bad experience with the law. Thanks to a bit of Republican legislative trolling that forced Members and their staffs onto the exchanges to make a political point, some are discovering that premiums are higher than they would have expected, having previously enjoyed the protection of government benefits that essentially shielded them from reality.
But if anything, the fact that Members of Congress are now having an unpleasant brush with the American health care system is a good thing. These Members are experiencing the same American health care system that the uninsured and people with preexisting conditions have been experiencing for many years. They are being forced to face the fact that American health care costs a lot, which, of course, is one of the reasons reform is so hard.
The health care system is already deeply unjust. A good article in the New York Times sheds light on this, and on how Obamacare is changing things for the better:
More than 243,000 have signed up for private coverage through the exchanges…and more than 567,000 have been determined eligible for Medicaid…For many, particularly people with existing medical conditions… the coverage is proving less expensive than what they had. Many others are getting health insurance for the first time in years, giving them alternatives to seeking care through free clinics or emergency rooms — or putting it off indefinitely.
Kevin Drum adds a related note about how hospitals routinely gouge uninsured people for everything they’ve got:
A heart attack that gets billed—profitably!—to Blue Cross at $50,000, can end up costing you $200,000 if you’re unlucky enough to suffer that heart attack while you’re uninsured. Think about that: for decades, the health care industry has deliberately taken ruthless advantage of the very people who are the weakest and most vulnerable—those who are poor or unemployed… It’s shameless and obscene. It’s like kicking a beggar and stealing his coat just because you know the cops will never do anything about it.
Obamacare, by slowing bringing everyone into the insurance system, will eventually stop this. Compare that to Rep. Michael McCaul (who with at least $114 million is the second-richest member of congress) complaining that the new plans on the DC health exchange are expensive.
This sort of experience is unvarnished good news. Finally, wealthy members of congress are getting a tiny, tiny taste of how the healthcare sector actually works. Five decades of skyrocketing health price inflation didn’t inspire so much as a peep when Republicans held all three branches of government. But now that Republicans have derped themselves onto the exchanges, they’re shocked, shocked at how expensive things have gotten. . .
The NY Times has an excellent editorial:
Beyond new state efforts to restrict women’s access to proper reproductive health care, another, if quieter, threat is posed by mergers between secular hospitals and Catholic hospitals operating under religious directives from the nation’s Roman Catholic bishops. These directives, which oppose abortions, inevitably collide with a hospital’s duty to provide care to pregnant women in medical distress. This tension lies at the heart of a federal lawsuit filed last week by the American Civil Liberties Union.
The suit was brought on behalf of a Michigan woman, Tamesha Means, who says she was subjected to substandard care at a Catholic hospital — the only hospital in her county — after her water broke at 18 weeks of pregnancy. Doctors in such circumstances typically induce labor or surgically remove the fetus to reduce the woman’s chances of infection. But according to the complaint, doctors acting in accordance with the bishops’ directives did not inform Ms. Means that her fetus had virtually no chance of surviving or that terminating her pregnancy was the safest treatment option.
Despite acute pain and bleeding, Ms. Means was sent home twice, and when she returned a third time with a fever from her untreated infection, she miscarried even as the paperwork was being prepared to discharge her again. The fetus died soon after.
The case has gained attention because Ms. Means is not suing the hospital for medical negligence but the United States Conference of Catholic Bishops. The A.C.L.U. is arguing, on her behalf, that having issued the mandates and made them conditions of hospital affiliation, the conference is responsible for “the unnecessary trauma and harm” that Ms. Means and “other pregnant women in similar situations have experienced at Catholic-sponsored hospitals.”
How the suit will play out is unclear, but it showcases an important issue. Catholic hospitals account for about 15 percent of the nation’s hospital beds and, in many communities, are the only hospital facilities available. Allowing religious doctrine to prevail over the need for competent emergency care and a woman’s right to complete and accurate information about her condition and treatment choices violates medical ethics and existing law.
The problem Ms. Means encountered is not unique or limited to her particular medical needs. In 2010, the Diocese of Phoenix punished a nun and stripped a hospital of its affiliation after doctors there performed an abortion to save a mother’s life.
In a statement last Friday, the president of the bishops’ group, Archbishop Joseph Kurtz, said that the religious directives did not encourage or require substandard medical treatment. He also portrayed the case as an attack on religious freedom — the same unpersuasive argument the bishops are making against the new federal health care law’s requirement that all plans include contraception coverage.
The bishops are free to worship as they choose and advocate for their beliefs. But those beliefs should not shield the bishops from legal accountability when church-affiliated hospitals following their rules cause patients harm.
Harold Pollack has an interesting column in the Washington Post:
Healthcare.gov’s troubled rollout brings new attention to competing proposals to alter health coverage for low-income Americans. One group of Republican analysts would largely replace Medicaid with some combination of primary care supports and catastrophic coverage. Others wouldn’t go that far but would make greater use of patient cost-sharing to provide incentives for disciplined use of medical services.
Ross Douthat has put the argument well in some thoughtful columns.
[C]omprehensive health insurance is, at its heart, a deeply wasteful use of resources: Modern people, and especially modern Americans, are much more likely to overconsume health care than to underconsume it… This doesn’t mean that social insurance shouldn’t protect people against adverse medical outcomes and unaffordable medical bills, but it suggests that there are better ways to allocate our resources than comprehensive coverage, and that most people would be better off if public policy didn’t push so much money into that direction.
Economic intuition suggests that Harold Pollack and Ross Douthat alike would use care more efficiently if we had more skin in the game, if we were less comprehensively insured. Sure enough, non-poor participants in the RAND Health Insurance Experimentused roughly one-third less care when they were enrolled in something akin to a catastrophic plan than did their counterparts who were enrolled in more generous plans. Despite their reduced service use, participants in the catastrophic plan also appeared, on average, to be just as healthy. Such findings provide a powerful argument for catastrophic plans. (Recent results from the Oregon Medicaid experiment are another matter.)
The cracks in this argument become more noticeable when one shifts attention from the typical insured person to the typical insurance dollar spent for patient care, particularly when one considers the vulnerable populations overrepresented among public insurance recipients.
Most people are light users of medical care. As Aaron Carroll regularly emphasizes, expenditures are concentrated within a group of costly patients with complex conditions, many of whom would hit any reasonable catastrophic coverage cap and who are poorly placed to manage the practicalities and financial risks associated with their medical care.
Although I’m curious to see how healthy, affluent professionals would purchase (say) knee and hip replacements if they faced the full costs, this won’t save much money. Most people in a position to make such choices don’t consume much health care. The real money is spent on patients like my relative who is recovering from a nasty stroke. For all sorts of reasons, giving him something other than comprehensive coverage seems unwise.
These distributional realities hold especially true among poor people. Figure 1 shows 2012 data for Illinois’s 3.2 million Medicaid recipients, ranked by percentile from lowest to highest expenditure. The top line shows cumulative Medicaid spending. The bottom bars show average annual expenditures in dollars. (If you look closely, you’ll notice straight lines where I interpolated between available data points.)
The bottom 72 percent of Illinois Medicaid recipients account for 10 percent of total program spending. Average annual expenditures in this group were about $564, virtually invisible on the chart. We can’t save much money through any incentive system aimed at the typical Medicaid recipient. We spend too little on the bottom 80 percent to get much back from that. We probably spend too little on most of these people, anyway. For the bulk of Medicaid beneficiaries, cost control is less important than improved prevention, health maintenance and access to basic medical and dental services.
The real financial action unfolds on the right side of the graph, where expenditures are concentrated within a small and incredibly complicated patient group. The top 3.2 percent of recipients account for half of total Medicaid spending, with average expenditures exceeding $30,000 annually.
Many of these men and women face life-ending or life-threatening illnesses, as well as cognitive or psychiatric limitations. These patients cannot cover co-payments or assume financial risk. In theory, one might impose patient cost-sharing with some complicated risk-adjustment system. In practice, that is far beyond current technologies and administrative capabilities. Even if such a system were available, we couldn’t push the burden of medical case management onto these patients or their families.
The Affordable Care Act’s Medicaid-expansion population won’t include traditional dual-eligible and nursing home patients who make up much of that 3.2 percent. The new group will still include a mix of basically healthy adults alongside more costly recipients with complicated problems who will account for the bulk of actual spending.
In my view, the best way to improve Medicaid is to tackle three inter-related challenges.
First, . . .
Kevin Drum calls it like it is. Some Republican states seem desperate to prevent the poor from getting any help whatsoever. A friend in a red state who is a rabid Republican (and former Methodist minister) explained that they don’t want the poor to get such help because it will foster “dependency”. By preventing the poor from getting (for example) healthcare, they are actually helping the poor. Jesus wept.
And do read the article linked in Drum’s post:
Under Obamacare, if your income is less than 100 percent of the poverty line, you don’t qualify to buy subsidized insurance on the exchanges but you do qualify for Medicaid. Unless, that is, your state has refused to participate in Obamacare’s Medicaid expansion. In that case you don’t qualify for anything.
Dylan Scott has a piece at TPM about health care navigators who have to break this news to people. Here’s the saddest passage:
In some cases, those being left out seem to understand, having been left out of the health insurance complex for a while, said Cynthia Rahming, who is heading the Houston, Texas, navigator program. She did agree, though, that her team is “often” coming across people who are part of the Medicaid gap in that state.
“They were excited. They were trying to see what’s available to them,” she said. “But they’re still okay. They know it’s just a chance.”
These are poor people. They mostly represent families making less than $20,000 per year. And yet in many cases, they greet the news that they’re completely excluded from access to health care with weary acceptance. They probably never really believed that anything good might come their way in the first place. In the meantime, multi-millionaires can virtually bring the government of the United States to a screeching halt over the prospect of a 2 percent increase in the marginal rate they pay in income taxes.
The refusal of Republican states to accept Obamacare’s Medicaid expansion surely ranks as one of the most sordid acts in recent American history. The cost to the states is tiny, and the help it would bring to the poor is immense. It’s paid for by taxes that residents of these states are going to pay regardless of whether they receive any of the benefits. And yet, merely because it has Obama’s name attached to it, they’ve decided that immiserating millions of poor people is worth it. It’s hard to imagine a decision more depraved.
Conservatives hate it when you accuse them of simply not caring about the poor. Sometimes they have point. This is not one of those times.