Our Health Policy Matters

Mental Health Cuts Will Lead to Increased Health Costs

2012-02-29T00:01:00.000-05:00

On December 8, 2010, Jack Dalrymple, a Republican Governorin the safely Republican state of North Dakota, sent a budget to the state LegislativeAssembly calling for an $8 million increase in funding for mental healthservices.

His transmittal message accompanying his FY2011-2013proposed budget was simple. “We… need to make investments that help takecare of people. We have all been alarmedrecently about teen suicide rates, especially on our Native Americanreservations. These highlight the needto make more resources available for critical mental health services for ourcitizens.”

So, in a $3.3 billion general fund budget, he proposed over$6 million for new inpatient services, community crisis stabilization, and drugdependency treatment. He also proposed$1 million for suicide prevention, another million dollars for mental healthservices on college and high school campuses, and a rate increase for mentalhealth providers.

He summed up theserequests by saying that “the physical and mental health of our citizens isalways a top priority.”

The North Dakota Legislature apparently agrees. According to a recentreport of the National Alliance on Mental Illness, the state has made upfor historically low spending on mental health services over the past threeyears by topping the nation in increasing spending for mental health.

As overall state mental health spending in the nationdeclined by $1.6 billion, North Dakota increased spending for mental health by48.1%.

In the same time frame, South Carolina, Alabama, Alaska, andIllinois all cut mental health spending by over 30%, and Nevada, the Districtof Columbia, and California all cut it by over 20%. In fact, most of the rest of the country isclearly out of step with North Dakota.

A BloombergNews article headline this past week made clear what cuts to mental health mean:“Mental Health Cuts by U.S. States Risk Boosting Health Costs.” The reason, as one Illinois emergency room physicianpointed out, is that sick patients don’t just disappear when they are deniedone set of services. They seek outanother, often more costly, alternative.

In the case of people denied mental health care, it isusually the hospital.

According to the Centers for Disease Control and Prevention(CDC), there were 2.4million primary diagnoses of mental illness in general hospitals in 2006. Inthe same year, state mental health spending totaled $104 per capita, accordingto Kaiser Family Foundation State Health Facts data.

CDC recently releasednew data for 2009. In that year, thenumber of primary mental illness diagnoses decreased to under 1.6 million. But the State Health facts data reported thatstate mental health spending had increased by then to $123 per capita.

In other words,during a time frame when state mental health agency funding increased by 18%, mental healthdiagnoses in general hospitals decreasedby 35%.

These are the facts, and there is an association here, at least for the most recent three-year period for which we have data. Whenstates spend more on mental health as they did in 2009, fewer people withmental illness need hospitals for care. And when states spend less on mental health, asthey did in 2006, hospital use goes up.

Now that they have the facts, what are states proposingthis year?

The Florida Senate has proposed to reduce adult mental health services funding by 34%. The House saved Florida from such a spendingdisaster last year; it will have to do so again this year.
Connecticut’s Governor has proposeda $12 million cut to the Departmentof Mental Health and Addiction Services from the state’s already-approvedFY2013 budget.
Alabama last week announced plans to close 4 psychiatric hospitals.
Illinois has proposed cuttingtwo psychiatric hospitals and a host of community health centers throughoutChicago.
Mississippi is proposing a 5% cut to mental health thatcould result in the closing of sixmental health facilities throughout the state.
The Pennsylvania Governor’s newly proposed budget will cut Philadelphia by $42 million in mostly mental health andaddiction services funding, according to information provided by the MentalHealth Association in Pennsylvania.

Do you detect a pattern here?

Proponents argue that these cuts are being made in thename of fiscal responsibility, but they don't have the vision to see the forest beyond the trees. Every one of them will make people sicker,state costs higher, and an already bad situation worse.

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The 13,386 Lives Congress Sacrificed Last Week

2012-02-22T00:01:00.000-05:00

“I will keep them fromharm and injustice.”

“I will preventdisease whenever I can, for prevention is preferable to cure.”

-Classic andmodern versions of the Hippocratic Oath, from MedicineNet.Com

Senator Tom Coburn of Oklahoma is a physician. He’s familiar with the Hippocratic Oath, andhas used it to explain his opposition to health care reform.

Last November, Senator Coburnfamously termed a $15 billion appropriation for public health and prevention a“slush fund.” That’s because it waspaying for community tobacco control programs, immunization activities, andaddiction disorder prevention and treatment services around the country.

For information on sources, see note below

“Prevention is about focusing on an individual patient,” hecommented, apparently forgetting everything he learned about epidemiology atthe University of Oklahoma’s College of Medicine and at least some of the wordsof the Hippocratic Oath.

Public health is thebasis of health promotion and disease prevention.

It focuses on the well-being of entire populations andcommunities. It gets only3% of our total health funding according to CMS data. It has been responsible for at least half ofthe increase in life expectancy in America in the last century.

Now it is going to get even less funding, because SenatorCoburn’s view has prevailed.

Last week, his Congressional colleagues – in approving whatwas described as the last significant piece of legislation like to pass thisyear – agreed to cut $5 billion from the public health fund. (Senator Coburn voted against the final bill,but not because it cut public health funding.)

We now know how many lives that $5 billion cut to public health will cost.

This is because of an article written by Glen Mays andSharla Smith and publishedlast July in Health Affairs. In that article, theauthors showed that increasing spending on public health reduces infant deathsand deaths from cancers, heart disease, diabetes, and other chronic illnesses.

They found that a 10% difference in public health funding isassociated with a 6.9% difference in infant deaths, a 3.2% difference in heartdisease deaths, a 1.4% difference in diabetes-related deaths, and a 1.1%difference in cancer deaths.

The CMS tally of U.S. spending on public health in 2010 was$78 billion. A $5 billion dollar cutrepresents 6% of that total.

So that 6% cut this year will be associated with thefollowing:

1,077additional infant deaths;
7,831additional deaths from heart disease;
617additional deaths attributed directly to diabetes;
3,861additional deaths from cancer.

Let’s be clear. Maysand Smith were careful to point out that we can’t say that lower public healthspending causes more deaths – but theassociation is real. The amount of disease and death go up as publichealth spending goes down.

There are two levels of irony in the vote.

The first is that, before this happened, Mays and Smithcited the public health fund as evidence of Congress’s increasing awareness ofthe value of public health. So much forawareness.

The second is thatCongress decided to use the $5 billion to pay physicians to see Medicare patientswho suffer from conditions like heart disease, cancer, and diabetes.

Physicians needed that so-called “doc fix.” Congress caused theproblem way back in 1997 when it adopted a Medicare reimbursement formula witha flaw.

Ever since the flaw became apparent a decade ago, Congresshas plugged the reimbursement hole it created one year at a time, kicking thesolution another year down the road. After ten years of kicking, the hole is so large that doctors’reimbursements would have been cut by 27% without the plug.

Kaiser Health News has an excellent summary of the docfix dilemma on its web site for those who want to read more about it. Because Congress won’t fix it for good,doctors are forced to waste their time and money lobbying for a fix every year.

Physicians are undoubtedly relieved that they came out okayagain this year, but I seriously doubt that most of them would have wanted themoney to be taken from public health. After all, they’ve all sworn the same Oath as Senator Coburn.

But here’s the importantquestion. When Congress is able toafford $40 billion in oil and gas tax subsidies over the next ten years for hugely profitable companies, how come,when our health and well-being is concerned, it has to be either/or – and atthe expense of thousands of lives?

Note on Source Data for Lives Lost Calculations: Sources for numbers of deaths attributable to cancer, diabetes, heart disease, and infant mortality were websites of national chronic disease advocacy organizations and U.S. Government (CDC). Death calculations were made by OHPM using the one-year death total for the most recent year available (usually 2010) and applying a 6% change factor. The implicit assumptions is that if the 6% cut were to become annualized, so too would the annual number of increased deaths.

If you have any questions about this column, or would like to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

The Contraception Exception

2012-02-15T00:01:00.000-05:00

In arguing last week for the “contraception exception,” did CatholicBishops – whose compassion for human beings is generally second to no one’s –really mean to open the door to those who would deny people access to other neededprevention services?

To recap, the Obama Administration announced that birthcontrol had to be a part of employer-based health insurance plans. Contraception is considered preventivehealth, and the Affordable Care Act mandates this and many other preventionservices be offered free of charge.

The Catholic Bishops objected strongly. They are morally opposed to birth control,and argued that, as an employer, the Church should not be compelled to pay for preventionservices it deems immoral.

The Obama Administration then announced a compromise. No religious institution would be required topay for contraception services in its health insurance plan, but insurers wouldstill have to cover the services for women who wanted them.

On Friday, it appeared that Catholic leaders would acceptthe compromise.

Cardinal-designate Timothy M. Dolan, who heads the U.S.Conference of Bishops, called the Administration’s announcement “afirst step in the right direction” of “preserving the principle ofreligious freedom.”

But by Saturday theU.S. Conference had issued astrong statement declaring that “the only complete solution to thisreligious liberty problem” was “to rescind the mandate of these objectionableservices.”

Some commentators have taken a cynical view about theBishops’ statement, arguing that they’re out of touch with the 99% of U.S.women who have used birth control.

In the past, governments have preserved access to ethicallycontroversial services, including contraception, abortion, and capitalpunishment, while assuring that no one with an objection had to pay or participate.

As KaiserHealth News pointed out in a February 8^th blog, over half thestates required coverage of contraception services before the passage of the AffordableCare Act, and twenty of those had some form of exemption for religiousinstitution employers.

The Bishops’ Saturdaystatement breaks new ground in demanding that a prevention “mandate” berescinded.

It has the potential to change the way we make public policyregarding both prevention and health care services in ways the Bishopsthemselves would not support.

Historically, we have protected most religious objections tohealth care treatment. But we haven’t alloweda religious organization to run roughshod over nonbelievers. Jehovah’s Witnesses, for example, can refuseblood transfusions, but they can’t deny them to a non-believer.

But it is a prevention service to which the Bishops seek to deny access, not a health care treatment service.

The Bishops argue that this is just about their rights underthe first Amendment to the Constitution, which reads in part “Congressshall make no law respecting an establishment of religion, or prohibiting thefree exercise thereof.”

However, we also have a Ninth Amendment which reads: “The enumeration in the Constitution, ofcertain rights, shall not be construed to deny or disparage others retained bythe people.” In other words, the Church’sFirst Amendment rights don’t come at the expense of someone else’s NinthAmendment rights.

So then everyone mustbe given the opportunity to maintain their health by accessing whateverprevention services they need, consistent with their own religious and secularbeliefs – unless we do not have a Constitutionalright to health.

That last part is the door the Bishops – who also supportuniversal health care – have now cracked open.

By creating a Constitutional objection to some preventionservices under the Affordable Care Act, they are inviting others with less life-affirminggoals to make theology-based Constitutional objections to other preventionservices, too.

There are policy leaders in this country who don’t believethat people have a “right” to health. Theysee health care as a commodity, subject to the whims of the free market. They don’t support insurance mandates – for contraception,prenatal care, child health, or anything else. You can already see them piously wrapping themselves in theBishops’ cloaks.

It is a slipperyslope for Bishops – who on Saturday also reiterated their support for “access to life-affirming healthcarefor all” – to cast their lot with these“unchristian” people.

If the Bishops are true to their beliefs, they will speakout in the coming days as forcefully to these policy leaders as they did to thePresident – about why they supported health care for all in the first place.

If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Is Medicare for All on the Horizon?

2012-02-08T00:01:00.000-05:00

We’re now just a little more than a month away from the day theSupreme Court will hear the arguments that determine the fate of the AffordableCare Act.

The fight will be narrow – about the constitutionality ofthe individual mandate and Medicaid expansions.

The consequences for health care financing, however, will be widespread.

And, ironically, both states rights conservatives andpro-national health insurance progressives may end up rooting against their ownpositions.

To understand why, consider the four ACA Supreme Courtissues that will be argued.

The first is the constitutionalityof the individual mandate under the Commerce Clause of the Constitution.

To be constitutional under the Commerce Clause, a law has toregulate economic activity that “hasa substantial effect” on interstate commerce.

While it may seem that all the activity under ACA will havea substantial effect on interstate commerce, Judge Vinson in Florida disagreed. In considering the individual mandate, hefound that the failure to purchase insurance by an individual is economic “inactivity,”not “activity.” For Judge Vinson, there’s no distinction between economicinactivity and non-economic activity. (I’m not so sure.)

Two times – in 1995 and again in 2000 – the Supreme Courtheld that non-economic activity wasn’t covered under the Commerce Clause. So if the Supreme Court agrees with JudgeVinson, then the individual mandate won’t be constitutional under the CommerceClause, and the Court will have to consider the second issue.

Is the individual mandateconstitutional under the taxing authority of Congress?

If the Commerce Clause doesn’t make the mandateconstitutional, then the Anti-Injunction Act might. It prevents anyone from challenging the rightof Congress to collect taxes.

But even though ACA forces people who don’t buy insurance topay higher income taxes, Congress specifically referred to these as “regulatorypenalties.” So is a tax by another namestill a tax? If it is – as the FourthCircuit Court ruled – then the individual mandate is probablyconstitutional.

But let’s say it isn’t.

Then the third issue becomesimportant – whether the individual mandate can be “severed” from the rest ofthe law.

Some laws state explicitly that if one section of the law falls,the rest still stand. But ACAdoesn’t. So it’s up to the Court todecide what happens to ACA as a whole if it finds the individual mandateunconstitutional.

So far judges who have ruled the mandate unconstitutional havedisagreed about its severability.

One judge (Hudson) said it was severable, citing a 2010 SupremeCourt ruling. When portions of a law are unconstitutional, all that should bethrown out were “problematic portions while leaving the remainder intact.”

Another judge (Connor) also found it severable, but not fromthe entire law. He said that thesections of the law that prevent insurance companies from denying coveragebased on pre-existing conditions and prevent higher rates based on healthcondition, geography, or gender are intertwined with it. So he found these unconstitutional, too.

A third judge (Vinson) ruled that the individual mandatewasn’t severable, but essential to ACA’s overarching goal. He therefore decided that the whole law wasunconstitutional.

The individualmandate was originally developed as an alternative to single-payer, government-funded,universal health care coverage. But thefourth issue – whether ACA’s Medicaid expansion is constitutional – may now gluethe two together.

The 26 states opposing the Medicaid expansion aren’t arguingagainst it per se, but against the federal government “coercing” them intoimplementing it. In other words, governmenthealth care is fine, but not if states have to pay.

This year, these and other states are proposing disturbingcuts to safety net health services. Florida is considering aproposal to turn most state health services over to counties . The Governor of Maine wants to remove65,000 adults from the Medicaid program. Louisiana just announced a new round of cutsto local mental health providers. AndConnecticut has begun denyingsome Medicaid coverage to kids with disabilities.

It’s as if they collectively believe that any problem can besolved by taking money away from it.

Here’s what they’re ignoring. When you oppose requiring either individuals orstates to pay for health care, you’re left with only one viable future option –federally-financed Medicare-for-all.

On the other hand, when you defend ACA as it is, you’rearguing that a two-tiered system of government-subsidized private healthinsurance for those who can afford it and public insurance for the poor andelderly is the solution to our health care financing crisis.

So when the Supreme Court decides, who wins?

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, contact gionfriddopaul@gmail.com.

California Screaming

2012-02-01T00:01:00.000-05:00

I first heard about James McGillivray, Lloyd“Jim” Middaugh, and Paulus “Dutch” Smit about a month ago, though not by name.

A tiny news crawler reported that three men werevictims of a serial killer in southern California.

James McGillivray’s body was found near aPlacentia, CA, shopping mall on December 21^st. 53 year-old McGillivray hung out almost everyday at the mall. Regulars there calledhim humble, unobtrusive, and a “nice guy.” A 17 year-old commented “I don’t know whysomeone would kill him.” McGillivray wassleeping when he was attacked and stabbed to death.

Jim Middaugh’s body was found along a riverbed trail in Anaheim on December 28^th. He was also stabbed to death as he slept. After his death, his mother – to whom Middaughwas exceptionally close – described her six foot, four inch son as a “gentlegiant.”

Dutch Smit was 57 years old when his body wasfound outside a Yorba Linda public library on December 30^th. He left three children and 10 grandchildren. He was described by his daughter as “an honest and sincere soul.” He enjoyed the library, often sitting and reading quietly for hours onend.

McGillivray, Middaugh, and Smit had one thing in common.

They were targeted for death because they were homeless.

The police considered McGillivray a “loiterer,”but his homelessness may have been tied to his drinking. According to the National Coalition for theHomeless (NCH), a 2008 survey identified substance use as the leading cause of homelessness among single adults.

Smit, who called himself a wanderer, not atransient, was a hoarder who left his home when it became too unsafe to livein. Hoarding is a symptom of mentalillness. Mental illness is the third leading cause of homelessness among singleadults.

Middaugh lost his transitional living apartmentfor sex offenders after he had lunch with a friend at a Chinese restaurant thatwas too close to a public park where children might be playing. He had been convicted for “lewd andlascivious acts on a minor under the age of 14.” But the crime for which the 42 year old was still being punished had occurredmore than twenty years in the past.

80% ofcrimes of violence against homeless people are committed by people under theage of 30.

The suspect in the executions of McGillivray,Middaugh, and Smit is 23 years old. ItzcoatlOcampo, of Yorba Linda, CA, is a former Marine who served in Iraq. As a Marine, Ocampo was reported to have earned at least four medals and commendations.

Ocampo was caught with blood on his hands on January13^th, while executing a fourth homeless man, John Berry, a 64year-old Vietnam Veteran. Ocampo targetedthe others simply because they were homeless,but apparently attacked Berry as retaliation after Berry spoke out in the mediaabout the murders. During the assault, aGood Samaritan intervened and chased Ocampo down.

Police and prosecutors seem certain that Ocampodoes not suffer from PTSD or other mental illness, but his attorney is not sosure.

There is no doubt that the Good Samaritan, 32year old Donald Hopkins, now does. He isreceiving counseling after witnessing the violence because the scene keeps playing over and over again in his head.

This story – and the relative lack of national news attention it hasreceived – bothers me a lot.

Perhaps it is because of the way we treat homelessadults. Of 235 cities surveyed by NCH, 33% prohibit “camping,” 30% prohibit “sitting or lying,” and 47%prohibit “loitering,” all of which are often selectively enforced against homeless people. Of the ten "meanest cities" toward people who are homeless, three are in California, but my home state of Florida is home to four – St. Petersburg, Orlando,Bradenton, and Gainesville.

Or maybe it is because we ostracize even childrenwith behavioral health conditions, setting many of them on their path towardisolation and homelessness as adults. The school district in myold Connecticut home town of Middletown madenews last week for forcing such children into cell-like “scream rooms.” The federal government is now investigating.

Or maybe it is because my son also happens to live in California, andis homeless, has mental illness, and self-medicates. He has been beaten up, cited for “sitting orlying” on a sidewalk, and been in jail, but he also loves reading in libraries,has an honest and sincere soul, and has been described as a gentle giant.

But I think what screams out most to me is that these executionscall attention to our deeply flawed views about homelessness, behavioral healthdiseases, and the victims of violence in America.

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

The Curse of the Super Bowl Chargers

2012-01-25T00:01:00.000-05:00

Are the 1994 AFC Champion San Diego Chargers a cursed team,or just a reflection of a growing trend toward chronic disease and early deathin America?

Led by running back Natrone Means and linebacker Junior Seau,the1994 Chargers won the AFC West with a record of 11 wins and 5 losses, and beatthe Miami Dolphins and Pittsburgh Steelers to reach the Super Bowl. The 53 players on the active roster averaged26 years of age.

According to 1995 lifeexpectancy tables, a 26 year old male could expect to live to the age 75.

But when 42 year old LewBush – a linebacker on that Super Bowl team – died on December 9, 2011, he wasthe 7^th member of the team to die more than 30 years prematurely.

Source: ESPN Official 2011 Roster Information

There is talk that these 1994 Chargers are cursed. The first player to die, linebacker DavidGriggs, was 28 when his car slid off an expressway ramp in Ft. Lauderdaleand crashed into a pole in June, 1995. Thesecond, running back Rodney Culver, died in a plane crash in 1996. He was 26.

Young people most often die of injuries. So those two deaths, while untimely andtragic, didn’t make anyone think “curse.”

The third one did. In 1998, linebacker Doug Miller, alsojust 28, died when he was struck twice by lightning while on a campingvacation.

For the next decade, “curse”talk faded as the surviving 50 players went about their lives and careers.

Then, in 2008, two more Chargers died. Center Curtis Whitley was 39 when he died ofa reported drug overdose, and defensive lineman Chris Mims was 38 when he diedof heart failure. Mims – a relativelysvelt 288 pounds for a six foot, five inch lineman in 1994 – was reported toweigh 456 pounds when he died.

Defensive lineman Shaun Lee was the sixth to die, on March 1^stof last year. He was 44 when he lost abattle with pneumonia. He was reportedto weigh over 300 pounds and suffer from diabetes at the time of his death.

And when Lew Bush died of a heart attack in December, theseseven men together had lost 280 years from their expected life spans when theyplayed in their Super Bowl – the equivalent of nearly four full lifetimes.

Are the untimelydeaths of these young men a curse or a reflection of what causespremature death in America?

According to the NFL Players Association, the average lifeexpectancy for an NFL football player is under 60 years. Traumatic football injuries, such asconcussions, are blamed for this. They area factor, but the common conditions of life in America today – including obesity,chronic disease, and non-football injuries – have been the “curse” of theChargers.

Even if all 46 remaining members of the team now live totheir normal life expectancy, the team as a whole will still have lost 5.3years of life per player to premature death.

NFL football players don’thave a life expectancy that is approximately 20 years less than the norm justbecause they played football.

Like many other young people in our society, their lives arebeing claimed before their time by the cardiovascular diseases, behavioralillnesses, and other chronic conditions that result from poor diets, stress,and unhealthy habits.

This problem is real, and isn’t going to go away on its own.

The average weight of the 44 linemen, excluding tight ends,on the 2011-2012AFC Champion New England Patriots and the 2011-2012NFC Champion New York Giants is 306 pounds. They are a year older than the 1994 Chargers were. But they also weigh an average of 17 poundsmore than the twenty Chargers who played the same positions in 1994.

To what do they have to look forward as they age? If you believe the NFL Players Association,they will be walking advertisements for premature death.

They are not the onlyones.

According to AHRQ data, 60% of all Americans have at leastone chronic condition, 38% have two or more, and 16% have at least three. In this one way, we are all just like theChargers.

Like most Americans, I enjoy watching the Super Bowl and celebratingthis unique American holiday. But weshould embrace not just the game, but the light it can shed on the real cursethat affects us all. That is the curseof both men and women dying young for reasons we could have, and should have,prevented.

If you have questions or suggestions about this column, or would like to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

The Medicaid Elephant in the Supreme Court Room

2012-01-18T00:01:00.000-05:00

States’ Medicaid elephants are being dragged into the courtsthis year. States had better be careful,or they just might get trampled under the weight of people they’ve failed toenroll.

Last week, CTNews Junkie reported the story of a class action lawsuit filed on behalf ofalmost 7,000 potential Medicaid recipients in Connecticut as of November 2011 whoseapplications were not processed within the 45 days mandated by federal law.

And Health NewsFlorida, among others, reported that Florida’s Attorney General Pam Bondi fileda brief with the Supreme Court on behalf of twenty-six states (Connecticutis not one of them) alleging that Congress exceeds its authority when it“coerces states into accepting onerous conditions” of participation in theMedicaid program –even when it pays 90-100% of the costs of thoseprovisions.

The two battles raisesimilar questions about how states avoid Medicaid costs today.

The Supreme Court brief is supposed to be an argument againstthe Affordable Care Act-mandated Medicaid expansion to cover everyone up to133% of poverty beginning in 2014.

Bondi builds her argument around a simple point. States depend so heavily on Medicaid moneyfrom the federal government that they can’t afford to drop out of the program.

And the ACA-mandated expansion, she argues, will costFlorida almost $1 billion.

But then there’s astunning revelation in her brief.

Most of the costs she cites have nothing to do withACA. They represent the cost of enrollingcurrently eligible people in theMedicaid program, not those who will become eligible as a result of theAffordable Care Act.

On page 17 of thebrief, she writes that “Florida anticipates spending approximately $351 millionon its share of the cost for newly eligible program participants who arepresently uninsured and $574 million on the currently eligible but unenrolled.”

In other words, 62% of the costs she’s claiming will resultfrom ACA are actually costs the state should be paying today, but avoids by failingto enroll Medicaid-eligible residents.

The Connecticut classaction suit attacks essentially the same issue – failure to enroll currently eligiblepeople.

In paragraph 25 of the complaint,the plaintiffs allege that Connecticut “has set up a system to circumvent thefederal timeliness requirements by making it appear that the applicant hasfailed to provide required documentation.”

Throughout the nation, these practices result in theavoidance of billions of dollars of costs at the expense of elders, low incomechildren, and people with chronic diseases and conditions – and the health andmental health providers who serve them.

Bondi’s brief suggests that new Medicaid enrollments couldcost Indiana about $2 billion over ten years, Arizona and Louisiana over $7billion, and Texas close to $25 billion. But these numbers all appear to include the currently eligiblepopulations.

States understandably and justifiably want to contain theirMedicaid costs. But they cross the linewhen they do it by turning away literally millions of people who already belongon the program.

Bondi works hard to makethe currently eligible group relevant to the Affordable Care Act by stretchinga silken thread of the individual mandate around them.

She writes that “the considerable cost for the [currentlyeligible group] reflects the fact that, unlike for the newly eligible, Congresshas not increased federal funding for those newly enrolled (but previouslyeligible) by virtue of the ACA’s individual mandate. As a result, the States will continue to payfor up to half of the costs generated by the latter group’s now mandatoryenrollment.”

But she stretches thethread to the breaking point. Theindividual mandate doesn’t apply to the group of people currently eligible forMedicaid. Their Medicaid enrollmentis “mandatory” by virtue of existing state and federal laws that pre-date ACA.

So what happens when the Supreme Court makes its ruling thisspring?

If the Court finds the Medicaid expansion constitutional,then the states will have to implement it in 2014 – and also enroll thosecurrently eligible without further delay.

But even if it doesn’t, the currently eligible group isn’tgoing away – and we now know what they will cost. Florida will still owe at least $574 millionand Connecticut will still have to enroll up to 7,000 more eligible people.

That’s the best case scenario. The worst is that such a ruling could inducethe federal government to reduce its role in the Medicaid program to avoid the“coercion” argument in the future. Thenstates might have to provide coverage and care to the poor and elderly all bythemselves.

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

What the New Mitt RomneyCare Would Mean for Health Care Costs

2012-01-11T00:01:00.000-05:00

“States and private markets, not the federal government,hold the key to improving our health care system.”

Those are the words of Presidential candidate Mitt Romney, as hearticulates his health reform vision on his campaign web site.

U.S. health care costs are around $2.5 trillion. This money buys alot of care, and pays a lot of salaries. One out of every six workers in America relies on the health careindustry for a paycheck.

Romney thinks that’s too big a cost for care.

“At its core of this debate,” he writes (jarringly inarticulatelyfor an official campaign web site), “is the question of what creates betterpatient outcomes and more efficiency: free enterprise and consumer-drivenmarkets, or government management and regulation?”

I realize that he wants us to answer “free enterprise and consumer-drivenmarkets.” But in this case, that doesn’t happen to be true.

Thereasons why we have even a semblance of an affordable health care system inAmerica are government management and government regulation. Relying on free enterprise andconsumer-driven markets in their place would lead to an unmitigated (sorryabout the pun) health care financing disaster.

It is the salaries of professional athletes that may bestillustrate why.

In a free enterprise system akin to what Mitt Romney proposes, thesalaries of the most highly skilled health care professionals might be similarto the salaries of the most highly skilled professional athletes. In fact, they once were. In 1950, family physicians earned anaverage annual salary of $12,480. Thatwas before Medicare, Medicaid, and a whole lot of governmental regulation.

In 1950, theaverage salary of a major league baseball player was comparable - $13,300. That was before television advertising.

Let’s look at what has happened to health care salariessince then.

Today, the average salary for a registered nurse is just over$67,000. Pediatricians make almost $166,000. Psychiatrists make $168,000, andanesthesiologists make $336,000 a year to ensure that we undergo surgerywithout pain and without losing our lives to a drug overdose.

Governmentalmanagement and regulation have a great deal to do with those salaries, becausethe Medicare system drives the prices providers can charge to patients andprivate insurers.

Are they too high? Whenvalued public sector employees such as police officers are making $55,000 andfirefighters only $47,000, it may seem so.

And in the private service sector a house painter who makes$37,000, a janitor who makes $24,000, and a child care worker making $21,000 maywonder if health care professionals would really be ten times more valuable in afree enterprise system than they are.

The answer is yes, they probably would be. We demand highly-skilled, highly trainedprofessionals to tend to our health. Wecan’t perform surgery on ourselves, but if we had no alternative most of us woulddo our own painting, clean up our own messes, and give up school and work to raiseour own children.

So in afree enterprise system, how highly might we value health care professionals?

There are only 4,600 neurosurgeons in the entire country. It just so happens that there are also justover 4,600 elite professional athletes playing in the National Football League,Major League Baseball, the National Basketball Association, and the NationalHockey League combined.

Neurosurgeons are at least as highly trained and as elite a group ofprofessionals as major league athletes. Neurosurgeonsmake, on average, around $220,000 a year, though in some areas of the countrythe number is higher and the best can earn upwards of three-quarters of amillion dollars annually.

However, majorleague professional athletes, who sixty years ago earned what doctors earned, nowmake, on average, $2.7million dollars each, more than ten times what neurosurgeons make. That’s the effect of free enterprise.

If we turned our health care system into more of a free enterprisesystem, would a professional athlete still be worth ten times as much to us as ahighly-skilled surgeon and forty times as much as a nurse?

Probably not. The salariesof health care professionals would undoubtedly go up.

Mitt Romney’s new health care vision for America is far differentfrom the one he envisioned as Governor of Massachusetts. In a consumer-driven, less-regulated market,the high demand for health care would increase, not decrease, health care costs. There isn’t really any question about this.

In fact, the only question is why is Mitt Romney pretendingotherwise?

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

A Dime's Worth of Difference in 2012

2012-01-04T00:01:00.000-05:00

With the Iowa caucuses finally behind us, the Presidentialcampaign of 2012 now begins in earnest, and will dominate our news and livesfor the next year. I predict we willhear words like "Obamacare," “Romneycare,” “government takeover,” and“individual mandate” (usually in sentences following the word “repeal”) untilwe can’t stand it anymore.

If this is to be our fate in the New Year, then perhaps wecan take some comfort in knowing that the debate probably won’t make a dime’sworth of difference about where most of us get our health care over the nextfew years or how we pay for it.

This is because the 2010 Affordable Care Act and theindividual mandate were not really health reform. They were efforts to preserve health insurance as we know it, by getting morepeople who can afford it to purchase private insurance, and more who cannotonto the Medicaid public insurance program.

So maybe we shouldtake a minute between caucuses, primaries, and the general election to imaginewhat real health reform in America would look like in 2012.

It isn’t hard. Wejust have to keep in mind a few facts.

First, governments already pay approximately $1.8 trillionof our roughly $2.5 trillion annual national health care bill. Individuals pay another $300 billionout-of-pocket. These numbers aren’tgoing down, whether the Affordable Care Act is upheld or repealed by theSupreme Court in June.

Second, there is plenty of money in our health system todelivery high quality health care to everyone who needs it. We just need to target it to prevention aswell as treatment.

Third, for the relatively small amount of money they putinto the system, insurance companies have been given an outsized role indetermining when, where, and how our health care is delivered.

Fourth, we woefully underfund our most important healthservices. Public health and preventionactivities have accounted for half of the gains in life expectancy during thelast century, but receivefar less than 5% of health care funding.

And fifth, we criminalize instead of preventing and treatingmuch of mental illness, and have made jails our nation’s largest mental healthinstitutions.

With those facts inmind, we should acknowledge what real health reform isn’t.

It is not Romney’s or Obama’s “individual mandate” to buyprivate health insurance people don’t want and won’t trust.

It is also not Ron Paul’s notion of leaving people to fendfor themselves in some non-existent “health care marketplace.” No civilized nation does this and we are notgoing to be the first.

Here’s what a true Americanhealth reform – one that would result in healthier citizens, better access tocare when it is needed, lower long term costs of care, and better quality –would look like.

1. We would rebuild our health care delivery systemaround the federalized funding that already dominates health financing. Medicare would be our basic national healthinsurance program, and be available to everyone.

2. Medicaid would become a federal program likeMedicare, and cover only long term care needs including chronic mentalillnesses. There would be nomeans-tested eligibility. States would not have to pay for it or administer it,so they could lower their state taxes accordingly.

3. Private insurers, which are already such a smallpart of the overall health financing market, would play a role to which theyare more suited. They could offer supplementalinsurance products covering first-dollar deductibles, co-pays, and additional, discretionaryconsumer services (like private hospital rooms and gourmet meals) at whateverprices they could get, for whatever profit they could make.

4. The Medicaid program could still require thatpeople spend down a considerable portion of their own resources before itcovered the remainder of long term care costs. But we should allow everyone to set up tax-deferred long term caresavings accounts to use for themselves, members of their families, or anyoneelse they designate.

5. We would double the percentage of health dollarsin public health and prevention over the next ten years.

How could we financesuch as system of care? The reality isthat this system probably wouldn’t cost us any more than the current one does,and would probably cost less.

Of course, we won’t get this reform, but we can dream. And I’d much prefer such a real policy debateabout health reform in 2012 to the one we’re scheduled to receive – Mitt Romneyattacking the individual mandate he invented and Barack Obama defending theindividual mandate he opposed.

If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

The Top Health Policy Stories of 2011, Part Two

2011-12-28T00:01:00.000-05:00

Last week, I shared four of the top policy stories of theyear that told us something about how health policy has been trending over thepast decade or more. This week, I’moffering four more to close out the year that tell us a little about where healthpolicy is going in the future.

4. ConnecticutEmployees Choose Health. Back in theearly days of managed care, when HMOs were not yet a four-letter word and they emphasizedwellness as much as health care cost containment, they proved to be popularwith members. In August, the State ofConnecticut revived the concept, giving its employees the choice of a lowercost health insurance plan that emphasized wellness or their traditional comprehensiveplan. It expected 50% to choose the new wellnessplan. But the state got a big surprise. When the dust settled in October, 97% hadopted for the wellness plan. This willcost the state much more in the first year, but will also produce more than the$100 million in health care cost savings the state originally projected for thefuture.

The implication for futurepolicy – people want do more for their health, and will if they see a direct financialbenefit.

3. The Florida Legislature Puts the NRA In Charge ofMedicine. During its 2011legislative session, the Florida legislature attracted some national attentionwhen it decided to include the National Rifle Association (NRA) in the doctor/patientrelationship. The NRA asked the legislatureto prohibit pediatricians from even asking parents if there were firearms inthe house so they could counsel them about firearm safety – despite well-knownevidence that children are more likely to die from unintentional injury thanany other cause. The bill passed, andthe pediatricians were eventually forced to go to court to stall itsenforcement. With big lobbyingorganizations being allowed to sit in the doctor’s office with us, is it anywonder that people wonder whose side government is on?

The implication for futurepolicy – Patient privacy protections will erode if “smaller government” cedesmore power to private entities.

2. The Attack onPublic Health. After the loss ofalmost 30,000 public health jobs nationwide between 2008 and 2010, theAssociation of State and Territorial Health Officials (ASTHO) headlined an April press releasewith the words “Cuts to Essential Public Health Services Jeopardize Americans’Health.” The proof came in an article publishedin Health Affairs in August, whichshowed that a 10% change in public health funding changed infant death rates,as well as death rates from cancer, diabetes, and heart disease.

The implication for future– we and our children will be less healthy tomorrow because of the cuts ourpolicy leaders have made today.

1. The Implementation of the Affordable Care Act. The implementation of the Affordable Care Act(ACA) was once again the health story of the year. The public is still divided. A plurality supports it, but the combinednumbers of those opposing it either because they believe it did too little ortoo much comprise the majority. Meanwhile,the law has begun to affect significant numbers of Americans. For example, in September, CMS announcedthat 1.3 million Medicare recipients had received drug discounts averaging over$500 per person, and another 1.3 million had gotten a free wellness visit as aresult of ACA. And this month, the NationalCenter for Health Statistics reported that 2.5 million young adults hadinsurance because of ACA provisions enabling them to stay on parents’policies. Theelection campaign and the expected May or June Supreme Court ruling on itsconstitutionality guarantee that this will be the story of 2012, too.

The implication forthe future – government’s role in determining our health care future is goingto grow, not diminish. Policymakers willcontinue to struggle with our expanding $2.5 trillion health care economy andthe public will continue to try to figure out whose side they’re on.

In early December, OurHealth Policy Matters was averaging over 2,500 readers per month, and had recordedits 20,000^th reader – not too bad for the first year of a once-a-weekcolumn focused entirely on health and mental health policy. I appreciate you all, especially those of youwho printed and shared columns with your friends, used them with your students,and offered them to readers of your own electronic journals and web sites.

I’m always interested in your ideas about how to improve thecolumn, and how to get it in front of more people. Please let me know (gionfriddopaul@gmail.com) if youhave any suggestions for me.

And thank you all for engaging in the health policy debate,and my best wishes for a happy, healthy, and prosperous 2012!

The Top Health Policy Stories of 2011, Part One

2011-12-21T00:01:00.000-05:00

Public policy attacks on public health and mental health, intrusionsin doctor/patient privacy, the continuing fight over the Affordable Care Act, andour collective loss of faith in private health insurance were among the tophealth policy story lines of 2011.

This year, eight stories make my short list. Not all of these stories made big headlinesduring the year. But they have had, orwill have, an outsized impact on our lives.

I’ll begin the countdown this week with four that capture andcontinue some of the major trends of the recent past. Nextweek, I’ll offer four more that hint at where health policy may go in thefuture.

8. The Shooting ofa Congresswoman. In January, thefirst big health policy story of the year was about violence and mental illness– the horrible wounding of a member of Congress, and the murder of severalpeople around her. As the media struggledto make sense of this, it raised once again the relationship between mentalillness and violence. What it failed todo was to report that, while this particular shooter seemed mentallyimbalanced, most perpetrators of violence are not, and many victims of violenceeither already have mental illness, or will develop it as a result.

The continuing trend –Our jails are our nation’s largest mental health institutions, and will remainso until we invest more in prevention and treatment of mental illness.

7. The End of theIraq War. The War in Iraq may haveended this month, but its health effects will be with us and our veterans formany years to come. A GAO report released in Octobergot little mainstream media attention, but was blunt in its description of theeffects of this war and others on veterans’ mental health. The 2.1 million unique veterans who receivedmental health treatment in the five year period between 2006 and 2010 representedover 30% of the veterans who received any type of health care. The fastest-growing groups of veteransreceiving mental health treatment during this period were the 213,000 Iraq andAfghanistan veterans with mental health needs. And 38% of all Iraq/Afghanistan veterans who received health care duringthat time required mental health care.

The continuing trend –So long as we remain at war, veterans’ health and mental health services willneed to be expanded significantly throughout the foreseeable future, and, astaxpayers, we will need to pay for them.

6. The Death ofthe CLASS Act. What does it say whenthe first major provision of health reform to be killed off in a bipartisan waywas the one provision that had enjoyed bipartisan support for ageneration? There are at least twothings about long term care most of us don’t want to face. The first is that most of us will need itsomeday. The second is that practicallynone of us can afford it on our own. Rather than coming up with a meaningfulpublic/private partnership to pay for it after almost thirty years of trying, theAdministration and Congress quietly killed CLASS in October, choosing onceagain to keep the current, broken system in place. This is the one where we first impoverishpeople when they get old and sick, and then let government pay the whole bill.

The continuing trend –Medicaid will remain the default payer for long term care. Costs will continue to skyrocket, we’ll allcontinue to complain, and long term care insurance won’t gain a greaterfoothold in the market any time soon.

5. Low PCIPEnrollment Numbers. The mostcompelling evidence in 2011 that we may have finally lost our faith in privateinsurance was found in the late summer reports of the low enrollment in thePre-Existing Condition Insurance Program (PCIP). This is a program that eligible uninsuredpeople were supposed to embrace, because it pretty much guaranteed that itwould pay out far more for their health care than it collected in premiums,saving each of them lots of money. Butwhen only30,000 of the 4 million eligible people enrolled as of July, most of therest seemed to be saying that they would rather take their chances on permanentfinancial ruin than insurance. Or that theywere already so impoverished by illness that they no longer had anything tolose.

The continuing trend –If the health insurance industry cannot restore our trust, even the people whoneed it most will opt out, relying only on safety net government funding.

Next week: The final Our HealthPolicy Matters column of the year looks at four more big stories of the year,and their implications for the future.

Echoes of Scrooge

2011-12-14T00:01:00.000-05:00

Except for summertime humidity, the Florida and Connecticut “climates”don’t have a lot in common.

For example, Connecticut has one of the best climates forhealth and health care, while Florida’s is in the bottom half. On the other hand, Florida has one of thebest business tax climates, while Connecticut’s is near the rear.

Their political climates are also polar opposites. Florida’s governor is a Republican, and its Legislatureis overwhelmingly Republican. Connecticut’s governor is a Democrat, and its legislature isoverwhelmingly Democratic.

And the difference in their policy climates is reflected inthe way they handled their 2011 budget crises. Connecticut raised taxes and cut spending, while Florida just cutspending. As a result, Connecticut’sbudget now balanced. Florida, meanwhile,extended its crisis by another year. Andits Governor has just proposed cutting $2 billion from health services alone inhis proposed new budget.

But for two stateswith so little in common, their emerging 2012 Medicaid cost containmentstrategies are remarkably similar echoes of the ghost of Ebenezer Scrooge.

They both want to “decrease the surplus population” of needypeople on the program. Florida istargeting kids; Connecticut young adults.

In Florida, HealthNews Florida reported last week that nearly 800,000 Florida residents could beforced off of Medicaid because of a new co-pay Florida has asked theFederal Government to approve. The vastmajority would be children.

While he awaits the decision of the Feds, Florida’sgovernor is also proposing massive cuts in Medicaid reimbursements to a host ofsafety net hospitals. JacksonMemorial Hospital in Miami would be cut by $133.5 million, Memorial Hospital inFt. Lauderdale would be cut by $58 million, Shands Hospital in Gainesvillewould be cut by $52 million, Miami Children’s Hospital would lose $35 million,and Tampa General would be slashed over $32 million.

Shands, Jackson Memorial, and Tampa General all have beenranked among the best hospitals in the country by U.S. News and World Report. This would greatly limit poor people’s accessto them.

Meanwhile, in Connecticut CTNews Junkie reported that a “reduction in health care benefits, asset tests,and a potential cap on enrollment” are all under consideration by theDepartment overseeing its Medicaid program.

The reason is because its caseload is growing tooquickly. In 2010, Connecticut was thefirst state to shift 45,000 state-only medical assistance program clients –many young adults – to Medicaid under a provision of the Affordable Care Act. The Federal Government paid 60% of the costand the state saved millions. But the numberof people signing up for the program has grown to 70,000 in the last eighteenmonths, erasing the savings.

So Connecticut has sent aletter to the Federal Government asking permission to change theeligibility requirements for the program and the benefits package.

Even though Connecticut acknowledges in the letter that thepoor economy is a reason for the unexpected growth in the program, its solution,like Florida’s, is to deny some of its neediest people access to care.

So here’s the question that both Florida and Connecticutmust answer.

If they make thesecuts, where do they think these people will go, and who do they think is going to pay the bill?

Workhouses, a favorite of Scrooge’s? Prisons, which are already the largest mentalhealth providers in the country?

Or perhaps they want them to go to the hospitals from whichConnecticut took $32 million in 2011 and Florida wants to take millions more in2012?

Of course, in bothstates there are good, local alternatives to cutting and slashing, and wishingand hoping that poor people will recover from disease and disability on theirown.

Connecticut could offer the same wellness and diseasemanagement program to these Medicaid recipients as it offers its 50,000 stateemployees. The State projects that itwill save over $100 million this way – close to what it hopes to save in Medicaidcuts.

And Florida could stop slashing public health and prevention– which already took a $56 million hit in 2011 – and instead increasefunding to local public health departments by 10%, giving them the flexibilityto spend the new dollars anyway they want.

A Health Affairsarticle this past summer showed that this approach leads to reductions incancers, heart disease, and infant deaths (here’s a link to a related article and chart I createdfrom the data).

Wouldn’t these cost-saving options be preferable to aScrooge-like denial of care to desperate children and destitute young adults?

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Socialized Medicine in America

2011-12-07T00:01:00.000-05:00

If there were an award given for the worst health policy exaggerationof 2011, it might well go to Newt Gingrich, Mitt Romney, Rick Perry, and achorus of others who call the Affordable Care Act “a government takeover ofhealth care.”

They make this charge to capture votes from a constituencythat fears what life would be like if we had “socialized medicine.”

The problem with therhetoric is this. It isn't true. If you look at who paysthe bill, the United States already has socialized medicine. We just get lessfor our money than practically anyone else in the world.

According new data from the Organisationfor Economic Cooperation and Development (OECD), no other country spendsclose to what our government alone does on health care. Right now, the total government share of ourannual per capita health care bill is around $6,000, or over70% of the total.

Norway is next most expensive, but its total percapita bill is $5,352. The governmentshare is $4,501. In Denmark, the governmentpays only $3,696 annually, and in the United Kingdom, our poster child forsocialized medicine, it pays just $2,933.

There are more relevant comparisons to make, too. According to OECD, the Canadian government’sshare of its annual health care bill is 71% - exactly what ours comes to whenyou add in all our government costs (the OECD does not in its datareporting, which makes our government share – though still second-highest amongthe nations – look artificially small). Healthcare costs much less in Canada than it does here, however. The Canadian government spends only abouthalf ($3,080 per capita) as much as ours on health care.

What are we gettingfor all this government spending? Fewerdoctor visits, shorter hospital stays, and less access to mental health care.

We get an average of 3.9 visits to doctors each year here,compared to 7.7 in Germany, 5.5 in the United Kingdom, and 5.5 in Canada. People in Italy, Switzerland, and Denmark alsoget more doctor visits than we do.

Our average length of stay for an acute care hospital visitis 5.4 days. In Canada, they get 7.7days, in Germany and Switzerland, they get 7.5 days, and in the United Kingdom,they get 6.8.

And we share 2 psychiatric care beds for every 10,000 people. Canada has 4, Germany has 5, Denmark and theUnited Kingdom have 6, and Switzerland has 10.

Perhaps we need lesshealth care because we’re healthier in America.

Only 16% of our population smokes every day, the samepercentage as in Canada. This comparesfavorably to Norway, Germany, and the United Kingdom, where over 20% of thepopulation are daily smokers.

And while we consume almost 9 liters of alcohol per personper year, citizens of Germany, the United Kingdom, Switzerland, and Denmark allconsume far more alcohol than we do.

But if we take better care of ourselves, have shorterhospital stays, and fewer doctor visits, shouldn’t our overall cost of care belower, not higher, than other countries’?

Could we be payingfor quality?

We have access to a lot of medical technology, but not somuch more as to explain why the cost of care is so high here. For example, we have more MRI machines thanany other country in the world, but countries like Greece, Iceland, Korea, andFinland are all beginning to catch up with us.

And we are in a tight competition with this same set ofcountries in the availability of other technology. We have less radiation therapy equipmentavailable to our population than Iceland, fewer mammogram machines than Greece,and not as many CT Scanners as Korea.

Of course, we don’t usually compare our health care to thatin Iceland, Korea, Finland and Greece – and we shouldn’t. Iceland’s annual total per capitahealth care expenditure is $3,538, Finland’s is $3,226, Greece’s is around$3,000, and Korea’s is $1,879.

So why is socializedmedicine such a mess in America?

It isn’t, and won’t ever be, on account of the AffordableCare Act’s phantom “government takeover.”

It’s more likely because politicians pretend that privateinsurers play a bigger role in financing health care than they do, and givethem too much power over transactions between patients and providers.

And – unlike other countries with socialized medicine – it’sbecause we treat health care more as a commodity off which private businesses shouldprofit than a public service we all need.

That’s what exaggerating politicians are really defending.

If you have questions about this column, or wish to receive an email notifying you when future Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

Term Limits Are Bad for Your Health

2011-11-30T00:01:00.000-05:00

It costs an average of $6,000 per person per year in federal,state, and local taxes to cover the government’sshare of our national health care bill.

The three levels of government pay about 71%, or roughly$1.8 trillion, of our nation’s annual health expenditures. It is no wonder that most rational peoplewant policymakers to do more to bring these costs under control.

Policy leaders talk all the time about controlling healthcare expenditures. This would help.

But if we actually want to reduce costs significantly, we haveto invest in prevention and public health. This is a position I’ve pushed in the past. All it takes to understand why is torecognize that prevention and public health have been responsible for half ofour increased life expectancy during the past century while absorbing less than5% of our overall health spending.

This is old health policy news. So why aren’t policymakers doing more inprevention?

The answer may boil down to two words – term limits. Term limits, it seems, are bad for yourhealth.

State legislators have a direct say in how roughly 40-45% of government health dollars are spent, and an indirect say in much more. We now have almosttwenty years of experience with term limit laws. States that limit the terms of their statelegislators do a worse job protecting the health of their people than statesthat do not.

Term limit legislation swept through half the nation in the1990s as citizens sought to rein in the power of lifetime citizenpoliticians. California, Colorado, andOklahoma were the first states to enact them in 1990. Nebraska, the 21^st, was the mostrecent in 2000.

There are currently fifteen states with termlimits for state legislators. Californiaand Florida are the most prominent among them. With just a handful of exceptions, none of them ranks near the top in myStates for YourHealth ranking, the HealthyState rankings (which focus on public health), or the KidsCount rankings (which focus on children and prevention).

Only four of these fifteen term-limiting states – Colorado,Nebraska, California, and Maine – make even the top half of the States for Your Health. Only Colorado, Maine, and Nebraska are in thetop 20 in the Healthy Staterankings. And only California, Maine, andNebraska are in the top 20 in the Kids Countrankings.

Overall, the averageranking for the fifteen states with term limits is 31^st in all threerankings. The average ranking for the 35states without term limits is 23^rd.

Six states – Idaho, Massachusetts, Oregon, Utah, Washington,and Wyoming – enacted term limits and then repealed them. Their average rank is 13^th in myrankings, 11^th in the Healthy State rankings, and 15^th inthe Kids Count rankings.

The reason termlimits have such a significant effect on the health of a state’s population maybe because term-limited politicians don’t have the time to come up to speed oncomplex health issues.

Election to office or appointment to a legislative committeedoes not make one an instant expert on policy. And term-limited politicians are often political lame ducks the day theyget elected, with no incentive to work on issues with a long-term policy payoff.

Public health and prevention initiatives demand patience,with payoffs often measured in decades, not four two-year terms. For example, reducing smokingprevalence from 42% of the U.S. population in 1965 to 21% in 2006 required ageneration of a Surgeon General-led public education campaign, bans on smokingin public places, increased cigarette taxes, and restrictions on sales of tobaccoproducts to minors. Saving billions incancer and heart disease costs required this level of ongoing effort.

It also required having in place long-term legislators withwhom tobacco lobbyists had to deal.

When the top-ranked state for health, Massachusetts, passedits health reform legislation in 2006 that led to near-universal coverage inthe state, two legislators who spearheaded the effort – the Speaker of theHouse and the President of the Senate – had been in office for 27 years and 13years, respectively. And in Connecticut,my second-rated state for health, the current Speaker of the House has been inoffice for 19 years, and the Senate President has served for 18 years. Both have considerable achievements in healthand environmental health during the past decade – long after term-limiting stateswould have put them out of office.

In fifteen states, term limits have led us to trust a largeportion of $6,000 a year in health spending annually to people without thisexperience.

And that has proven to be very bad for our health.

If you have questions about this column or would like to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

The Worst States for Your Health

2011-11-23T00:01:00.000-05:00

Some states do a much worse job than others of keeping theirresidents healthy and providing for high-quality, affordable health care whentheir residents need it. People usuallylive shorter, less healthy lives in these states than they might if they livedelsewhere.

In my last column, I described a new States for YourHealth ranking, and examined the states that finished near the top.

This week, I want tolook first at why Florida, ranked first in one of the seven indicators – percapita Medicare spending on non-institution-based services – only finished 30^thoverall.

Florida’s doesn’t invest enough in public health andprevention. It is 36^th amongthe states in the 2011 Kids Count rankings, and 37^th in the 2011 HealthyState rankings. Children in poorenvironments for their health are more likely to develop both physical andmental illnesses as they age. Obesity,cancers, heart diseases, and mental illnesses are all expensive, and can cutdecades from life expectancy.

Florida’s care quality rankings are much higher than itsprevention rankings. It is 11^thin the number of times its hospital programs made the U.S. News and World Report national rankings. These high quality programs are usually foundin just a few hospitals in major cities, but this is the case in moststates. It is 16^th in nursepractitioners per 100,000 residents, and 19^th best in keepingMedicaid nursing home and hospital spending under control.

Florida is, however, is near the bottom (45^thplace) in the percentage of residents with private insurance. That hurts.

The ten lowest rankedstates either score exceptionally low in the prevention or health carerankings, or consistently low across the board:

50. West Virginia. The lowest-ranked state isn’t at the bottomin any individual ranking. It is just nearthe bottom everywhere – 40^th in the percentage of people withprivate insurance, 43^rd in the HealthyState rankings, and 44^th in KidsCount. It broke into the top half inonly one ranking, the amount its Medicaid program spends on hospitals andnursing homes. Even that may not be sucha good thing. While low Medicaidspending on institutions was considered positive in this ranking, it is also anindicator of low spending on health care in general.

49. Louisiana. Louisiana finished next-to-lastin both the Healthy State and Kids Count rankings. That’s why it’s 49^th here,too. On the other hand, it was 2^ndin per capita community Medicare spending, and has some quality hospitalprograms. It clearly has assets on whichto build.

48. Mississippi. Mississippi is last in the Kids Count and Healthy State rankings, and next to last in percentage of peoplewith private insurance. However, it is inthe top ten in community-based Medicare spending and in the number of nursepractitioners per 100,000. Both could contributeto a healthier state in the future.

47. Oklahoma. Oklahoma is in the bottom tenin nurse practitioners, Kids Count,and Healthy State rankings. It is also one of 18 states with no highlyranked hospital programs.

45t. Arkansas. Arkansas’s profile looks similar to someof the others at the bottom. It has lowprevention ratings that bring down its overall ranking, but it is near the topin number of nurse practitioners and limiting Medicaid hospital and nursinghome spending.

45t. Kentucky. Kentucky isn’t near to the bottom in any singleindicator. It is just consistently weakacross the board.

44. New Mexico. New Mexico is in last place in thepercentage of people privately insured.

43. Nevada. Nevada is in last place in the number ofnurse practitioners.

42. Alabama. Alabama ranks low in prevention and primarycare rankings.

41. Montana. Montana is as high as 25^th in the Healthy State rankings, but it lags in Kids Count and all of the health carerankings.

Two states finished last in individual rankings but did notmake the bottom ten. South Dakota was at the bottom incommunity-based Medicare spending per capita, but ranked 29^thoverall. New Jersey spent the most from its Medicaid program on hospital andnursing home care, but still finished 9^th overall.

To see the complete rankings, click here.

If there is a bottomline, it is this. Despite ourdiscouragement with our public health and health care systems in general, peoplein nearly every state have at least something for which to be thankful. And there will be better days ahead for allof us if policy leaders understand that we want them to do more for our health,not less.

Happy Thanksgiving!

The Best States for Your Health

2011-11-16T00:01:00.000-05:00

When the Supreme Court reviews the constitutionality of theAffordable Care Act next year, it will do so against the backdrop of both anational sentiment for government to do more in the area of health and significantinequalities in access to health and health care based solely on the states inwhich people live.

Anew poll released last week by the Robert Wood Johnson Foundation and theHarvard School of Public Health found that 52% of Americans want government toput more resources into health.

Only 41% gave high grades to our health caresystem, and only 33% gave our public health system high grades.

We would all like a more effective health and health caresystem. But a better national delivery system would make a much bigger difference in some states than in others.

This week, Our Health Policy Matters unveils a newranking of the states that reflects which states invest most effectively in our health and health care.

It was created by combining four existing rankings and threenew ones. It includes mental health aswell as health, the work of other health professionals in addition to doctors,and availability of community care as well as quality institutional care. It ultimately rates the states based on howgood they are at simultaneously:

keeping their children and adults healthy; and
taking care of their residents when they aresick or have chronic conditions; and
providing for both health and health care at aprice their residents can afford.

Taking everythinginto account, here are the ten best States for Your Health, and why:

Massachusetts. Massachusetts is the only state withfive top five finishes among the seven rankings. It takes good care of its children, investsin wellness and prevention, has many top-rated hospital programs including oneof the highest rated mental health facilities in the country, and insures itspopulation well. Where health and healthcare are concerned, every state should want to be more like Massachusetts.
Connecticut. Connecticut is near the top in six of theseven rankings. Its children, workingadults, and elders all thrive on a rich set of high-quality prevention andhealth care services. The only ranking in which it did not excel was one thatmeasured affordability – the high amount its Medicaid program historically spendson hospital and nursing home care.
NewHampshire. New Hampshire rates asthe best state in the nation in three of the individual rankings I combined – the2011 Kids Count child health andwell-being rankings, and two Kaiser Family Foundation State Health Facts rankings – the number of nurse practitioners per100,000, and the percentage of people who are privately insured.
Vermont. Vermont is number one in the Healthy State rankings and in keepingits Medicaid hospital and nursing home costs under control. It has figured out that the best way tocontrol Medicaid spending is to keep its population healthy.
Utah. Utah proves that good health is aconservative value. It takes good careof its children, promotes healthy lifestyles among its residents, and is hometo a high percentage of residents with private employer-based insurance – a keymeasure of affordability.
Minnesota. Strong in the prevention and publichealth rankings, Minnesota is also home to a top hospital. It gives its residents access to qualitypublic health and quality health care at the same time.
Washington. Washington cracked the top ten in only oneindividual ranking, so it may be a surprise that it is ranked so high when theyare all combined. But it does just abouteverything well compared to other states, and isn’t close to the bottom in anycategory.
Hawaii. Hawaii scores high in prevention and keepsMedicaid institutional spending under control. It doesn’t have any of the top rated hospital programs. If it did, it would rank even higher.
NewJersey. New Jersey does especiallywell by its children and its elders, and is in the top ten in three individualcategories. But it is an expensive statefor Medicaid recipients to get sick in, and a lot of that money goes tohospitals and nursing homes.
Wisconsin.Like Washington, Wisconsin is consistently in the top half of the individualrankings. If its residents were able tospend relatively more of their Medicare dollars on community services and lesson institutional ones, it would move up.

There are two states that topped individual rankings that didn’tmake the top ten. California, according to USNews and World Report the best state in the nation to find high qualityhospital programs, tied for 15^th. Florida, first in per capitalMedicare spending on community services, finished 30^th.

To see the full ranking of all the states, click here.

Next week: More aboutwhy Florida finished where it did, and a closer look at the ten states thatfinished near the bottom.

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

Note: Here are the rankingsI used, the reasons I used each of them, and a link to the

original data:

the 2011 Healthy State Rankings and the2011 Annie E. Casey Foundation KidsCount state rankings – to measure the effectiveness of public health andoverall prevention (including mental illness prevention) activities;
the Kaiser Family Foundation (KFF) State Health Facts ranking of thepercentage of peoplewith private employer-based insurance – to measure health care access andaffordability for workers and families;
the KFF StateHealth Facts ranking of the number of nursepractitioners per 100,000 residents – to measure support for non-physicianproviders and high quality primary care;
To measure quality of care and medicalprofessional development, I calculated and ranked the states by the number oftimes a hospital in a state was included in the 2011 U.S. News andWorld Report rankings of best hospitals in the country across specialties,including mental health and overall rankings of children’s hospitals (33 stateshad at least one hospital mention);
To measure the availability of community-basedservices for elders, I used the most recently available data from the Centersfor Medicare and Medicaid Services reporting percapita state spending in each state on Medicare minus hospital and nursing homespending;
To measure the effectiveness of stateintervention to keep people with disabilities in their homes and out ofinstitutions and as a measure of affordability, I used CMS data to calculate percapita state spending on Medicaid hospital and nursing home care as anegative measure.

Because prevention and health care each account forapproximately 50% of the gains in life expectancy over the last century, I gavethe two prevention-oriented rankings – the Healthy State and Kids Countrankings – a combined weight equal to thatof the other five.

Veterans Dazed, Not Dazzled, By Mental Health Care

2011-11-09T00:01:00.000-05:00

Nearly 2.1 million veterans received mental health care fromthe Veterans Administration between 2006 and 2010. According to a GovernmentAccountability Office report released in October, 1.2 million veterans receivedmental health treatment in 2010 alone.

Almost 30% of the 7.2 million veterans who received treatmentfrom the VA received mental health treatment. So did 38% of Iraq and Afghanistan (“OEF/OIF”) veterans. Many more probably needed it.

The GAO report showshow pervasive mental illness is among veterans, and how co-occurring mentalillnesses overwhelm both veterans and their service delivery system.

Younger veterans and reservists are especially affected.

We now have over 22 million living American veterans, but only4 million served during World War II or the Korean War. Seven million served during the Vietnam War,and almost 6 million are OEF/OIF veterans.

OEF/OIF veterans accountedfor 12% of all those receiving VA mental health services in 2010, a three-foldincrease in just five years. The GAO saidthis was expected “because of the nature of OEF/OIF veterans’ military service –veterans of this era typically had intense and frequent deployments.”

Another October 2011report entitled Losingthe Battle: The Challenge of Military Suicide quantifies the tragic effectof this. We lost 33 active andreserve duty Army personnel to suicide in July 2011 alone, and veterans – less than10% of our population – account for 20% of all suicides in America.

There are three reasons why we lose so many veterans tosuicide. They are

Traumatic brain injury, resulting in disability;
Chronic pain from bodily injury; and
Post Traumatic Stress Disorder (PTSD).

PTSD is far and away the most significant of these reasons. I wrote about this in anearlier column. As both the GAOreport and the chart accompanying this column show, nearly half of the veteransreceiving VA mental health care in 2010 had PTSD. Most had at least one other mental health diagnosis,too.

It is a national failure that we don’t do abetter job of identifying suicide risk factors and intervening earlier.

VA screening protocols may be part of the reason. The authors of Losing the Battle report that returning veterans have historicallybeen discouraged from admitting to mental health problems as they fill outtheir post-deployment screening forms. Asa result, the GAO reports the VA now “requires veterans treated in primary caresettings to be screened for mental health conditions such as PTSD, depression,substance abuse disorders, as well as a history of military sexual trauma.”

And it turns out thatveterans are more dazed than dazzled by the mental health care they are offered.

They avoid it, the VA told the GAO, because of stigma, lackof understanding about available services, logistical challenges accessinghealth services, and concerns about the quality of VA care.

Mental illnesses are stigmatizing largelybecause many people still believe that they are “behavioral” weaknesses, not seriousand life-threatening diseases that can shorten life expectancy by 25 years.
Many also believe that services are only for peoplewho are severely mentally ill. Theyavoid seeking care for fear they will be labeled “whiners” and “psychosomatics.”
Veterans, reservists, and non-veterans havelogistical challenges in accessing services. The VA does not have a full complement of mental health providers. At least those they have get paid. Majorinsurance companies are cutting reimbursements to community mental healthproviders, so patients who find providers outside of the VA often can nolonger afford the out-of-pocket cost.
It is impossible to have a quality mental healthcare system unless non-mental health professionals don’t just screen for – but aretrained in managing – mental illnesses.

A 2009 SAMSHA reportfound similar reasons given by the 5.1 million civilians who also reported unmetmental health needs.

We can begin to fix this if we do four things:

Commit a fraction of the resources we committedto the wars to fight the mental illnesses they have caused – in the VA and inthe community, wherever veterans, reservists, and non-veterans receive services.
Increase training of primary and specialty careproviders so they recognize, diagnose, manage, and refer patients with mentalillnesses.
Make periodic mental health screening a part ofwellness exams for everyone, starting with young children.
Insist that insurers honor the mental healthparity mandate.

We remember the sacrifices of our veterans when we fly ourflag. We honor those sacrifices when wetake care of the men and women who made them.

Many organizations now link to Our Health Policy Matters columns. Links are free of charge and can increase readership for both sites. If you know of an organization you think would like to link to OHPM, please email gionfriddopaul@gmail.com.

The Growing Obesity Challenge

2011-11-02T00:01:00.000-04:00

Obesity is a disease, just like cancer, heart disease,mental illness, and addiction. That’s themessage of experts at a recent Future ofMedicine summit on the subject.

And there are missing pieces in the way states with some of the largest concentrations of obese residents, like Florida, Connecticut, Texas,California, New York, and New Jersey, approach the epidemic.

As recently as 25 years ago, obesity was uncommonin America. Most states didn’t evencollect data on it, and not a single state reported obesity in more than 15% ofits population. Connecticut and Floridaboth reported rates under 10%.

The CDC map at that link shows what has happenedsince. Every state in the country quicklygrew bigger.

By 2010, in 12 states, including Connecticut, between 20%and 25% of the population was obese. In24 states, including Florida, between 25% and 30% of the population wasobese. In the remaining 12 states,including Texas, over 30% of the population was obese.

Why has this happenedat a time when people arguably have become more health conscious than everbefore?

The reasons that are emerging from research are changing theway experts think about obesity. Ifpolicy makers listen to the experts, then this will change the way they attackthe problem, too.

According to the research, obesity is not the result of anexercise of free will to overeat, any more than drug dependence is the resultof a desire to overmedicate. Dr. PaulKenny of the Scripps Research Institute, a member of the expert panel convenedby the Palm Beach County, FL Medical Society,argued that low-quality, high calorie food is proving in laboratory studies tobe nearly as addicting as cocaine.

He and others say that we must use a disease model to attackobesity. We must prevent it whenever wecan, and treat it aggressively when it is present.

Unfortunately, identifying a single cause of obesity iselusive. Dr. Kenny suggested that nosingle obesity gene will be found. Dr.RonaldRomear, a practicing pediatrician, said that “in eighteen years, I haven’t seenthe thyroid as a cause” for any of the obesity in the children he treats.

Investing in prevention,therefore, is imperative, and this has become the first line of attack againstobesity in the public policy arena.

The AmericanAcademy of Pediatrics and public health professionals both favor the 5-2-1-0campaign. Children and adults areurged:

* to eat five servings of fruits and vegetables aday,

* to limit television, computer, and video gameplay to no more than two hours a day,

* to exercise at least one hour a day, and

* to drink zerobeverages sweetened with sugar.

Focusing on individual behavior is important. As Iwrote in an earlier column, there are also broader, community prevention strategiesfor states to consider. They couldregulate the amount of sugars added to foods and drinks. They could make an hour of physical educationa mandatory part of the school day, and they could offer safe outdoor playareas in all neighborhoods.

Aggressive treatmentis also part of the arsenal against obesity when it has progressed to criticalstages.

Bariatric surgeries, such as lap band and gastric bypass,are becoming more common. Dr. Andrew Larson,a bariatric surgeon on the panel, noted that 45 state Medicaid programs pay forbariatric surgeries.

But, in the disease treatmentmodel, what are largely being ignored by states are the treatment optionsbetween prevention and end-stage obesity surgery – primary care integration andbehavioral health intervention.

Someargue that primary care providers must play a bigger role in treatingobesity in its early stages. However,primary care providers need tools and resources – including adequatereimbursement for their time – to identify and treat those at risk, and theydon’t currently have them as a matter of policy.

And with addiction at the heart of obesity, states should recognizethe importance of mental health services like counseling. They should make Medicaid coverage for counselingpart of the anti-obesity campaign.

According to a recent George Washington University publication entitled Coverage of Obesity Treatment, neitherFlorida nor Connecticut (nor most of the high-concentration states) does.

Some of us undoubtedly shake our heads, wondering whygovernment should address what we see as personal choice and weakness.

But if the experts are correct, then obesity today is nomore the result of human weakness than cancer or heart disease, and it is inthe public interest that we do more about it.

Cain Not Able

2011-10-26T00:01:00.000-04:00

Herman Cain’s ascendant Presidential campaign brings intofocus the limited health policy thinking that has dominated the campaign sofar.

Here are our current major health policy challenges:

Reversing the trend toward lower investments inthe public health and prevention activities that have accounted for half of ourincreased longevity in the last century;
Assuring fair coverage of the chronicconditions, including mental illness, cardiovascular disease, and cancers, thataffect 60% of our population;
Giving even the uninsured 16% of our populationaccess to high quality, comprehensive, integrated primary, specialty, andhospital care; and
Figuring out how best to pay for all this.

Despite the urgencyof these challenges, the current health policy debate can be condensed into a fourword sound bite – “Repeal Obamacare Individual Mandate.”

Here are the specifics of what the candidates have beentalking about the past couple of weeks.

Mitt Romney and Newt Gingrich are fighting over whetherRomney got the idea for the “individual mandate” from Gingrich or the HeritageFoundation. (Both, it seems, from theirexchange in the last debate.)

Ron Paul wants to abolish our health care system in itsentirety and replace it in part with free care “as a charitablebenefit provided by doctors” for all poor people.

Rick Perry’s first national health policy headline came whenhe advocated eliminating the Medicaid program that pays for long-term nursingand home care for elders and people with disabilities. His last came this past weekend when he questionedHawaii’s vital statistics record-keeping – at least where Barack Obama’s birthcertificate is concerned.

And Herman Cain, the self-proclaimed a “problem solver,” solvedhis business’s financial problems in part by helpingto pay for health insurance for only 17% of his employees.

As Cain’s sketchy healthcare plan shows, his plans for what he would do for the other 83% are fewand far between.

First, he wants to sell insurance across state lines. The Affordable Care Act already will permitthis, but there’s a catch. The onlypolicies that could be sold across state lines must meet minimum coverage standards.

He opposes this. Sowhen he favors selling insurance across state lines, he doesn’t care if it actuallycovers anything for which you might need insurance, such as cancer, heartdisease, mental illness, comprehensive primary care, drugs, or even mosthospital stays.

Second, even though it would violate his 9% flat taxproposal, he wants to allow individuals who buy insurance to be able to deductit from their income tax.

Why? So that businessescould eliminate group health insurance from their employee benefits package –as Cain himself did – and let employees pay for the more expensive individualplans on their own.

Third, he wants to expand the use of health savingsaccounts, into which individuals and families would have to deposit their ownmoney to cover the thousands of dollars of deductibles in the stripped downinsurance policies that would flood the market if his “across state lines” planpassed.

They might get a tax deduction for this – if he violated his9% flat tax policy again – but that’s just another way of shifting even more ofthe cost of health care to individuals and the federal government.

Citizen Cain refersto these proposals as “patient-centered” reforms. But patient-centeredness involves most everythingthat is absent from “Cainsian” health economics.

It is about promoting health and well-being and improvingaccess to affordable, quality care, not making insurance companies moreprofitable.

At least Cain offers a plan on his web site, unlike family-firstcandidate Rick Santorum. And in a nod toMichele Bachmann, Cain did acknowledge in a recent debate – without mentioningher – that he lifted much of his health plan from legislation co-sponsored byBachmann (HR3400) in 2009.

Herman Cain talks a good game about the “sacredpatient-doctor relationship,” but his slapped-together health plan is littlemore than a slap in the face to people with serious health and wellness needs. There’s nothing in it about wellness,prevention, or chronic disease management. There’s nothing about access and quality.

It’s all about stringing together a few of the worst proposalsfor individuals, families, and taxpaying citizens, and dressing them up as analternative to the Affordable Care Act.

Even raising Cain tonew poll heights won’t make him able to sell this.

If you have questions about this column or would like to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Does The PCIP Enrollment Problem Signal the End of Private Insurance?

2011-10-19T00:01:00.000-04:00

There are 4 million or more Americans who can’t get regularinsurance because of a pre-existing condition. You might be one of them. Now there’s a policy that costs less than $300 per month and covers allof your medical needs, including your pre-existing condition.

Will you buy it? Apparently not.

And that may signal thebeginning of the end of private insurance in America.

I first wrote about the diminished role of private insurance in acolumn last month entitled America’sHealth Insurance Myth. Privately-financedprivate health insurance today pays only 17% of America’s health care bill.

Two recent developments suggest that this share will become evensmaller in the future.

The first was last week’s death of theCLASS Act. As a result, long termcare will continue to be an out-of-pocket and government expense only fornearly everyone.

The second was the reportof first-year enrollment numbers for the new Pre-existing Condition Insurance Plan(PCIP). PCIP was created as part ofthe Affordable Care Act. It offers low-costhealth insurance for adults who have – or have had – conditions like mentalillness, cancer, diabetes, and heart disease. (Children are now covered on their parents’policies.)

PCIP is comprehensive. It covershospitals, doctors, and drugs.

There is no means test to qualify. Provided that you have been uninsured for at least six months, all youneed to apply is a note from a physician attesting to your chronic condition.

PCIP is inexpensive. In Florida,the monthly PCIP premium for a forty-year old is only $211 for the standardoption. There are deductibles and co-pays,but annual out-of-pocket costs are capped at $5,950. This may seem like a lot, but it is less than20% of the2009 average charge of $30,655 for a single hospital stay.

The federal government operates Florida’s plan and those of 22 otherstates. Connecticut, on the other hand,is one of 27 states that choose to run their own programs. In Connecticut, PCIP insurance costs $381 permonth, but out-of-pocket costs are capped at $4,250 per year. So its overall costs are similar to Florida’s.

Of an estimated 4 million peopleeligible for PCIP and 375,000 expected to sign up in the first year, only30,395 bought policies. Just 1,454people enrolled in Florida, and only 62 enrolled in Connecticut.

Why so few?

The answer is obvious in states like Massachusetts, which has only onePCIP enrollee, and Vermont, which has none. They have near universal coverage, so they don’t need PCIP.

What about states without universal coverage? Pennsylvania had the highest first-year enrollment. It had 3,762 people insured through PCIP. Ifevery state were like Pennsylvania, then PCIP would have around 100,000enrollees today, still far below the expected number.

There are three explanations forwhy people aren’t enrolling in PCIP that speak to how little faith we have ininsurance.

The first is that they believe that when there’s a crisis, hospitalsand doctors will treat them whether or not they are insured. Health care providers rarely turn their backson people in need.

But someone still has to pay the bill. And it usually gets paid through hidden charges in everyone else’sinsurance premiums.

The second is that people don’t think they can afford even $211 permonth for health insurance, or up to $5,950 in medical bills in a year.

But when the costs of common chronic diseases routinely run into sixfigures, the alternative can be bankrupting.

The third is that we don’t trust insurance. Insurance companies take our money, fightwith us about covering our bills, and make huge profits.

But PCIP isn’t like that. Unlikeother insurance, it is designed topay out far more money than it takes in. PCIPs paid out four times in benefits what they charged in premiums during the first few months of the program, and Congress set aside $5 billion – of which only afraction was spent – for this.

Here’s the bottom line. If $211 a month is too much to pay for insurance weare sure we will use, then health insurance is dying in America. Many of us say we will rely on our own resources, but also expect a government safety net to be there when our resources fall short.

If we roll the dice and don’t buy PCIP when we can, thenwe may lose more than we think. Thereare political leaders who are already celebrating the demise of the CLASS Act. Many also would happily repeal both PCIP andthe Affordable Care Act, and replace them with… well, nothing.

For moreinformation about federal and state PCIP, visit https://www.pcip.gov/. If you have questions about this column orwish to receive an email notifying you when new Our Health Policy Matterscolumns are published, contact gionfriddopaul@gmail.com.

Supreme Court Ruling Against Individual Mandate Could Result in Care Denial to Poor

2011-10-12T00:01:00.000-04:00

Opponents of the Affordable Care Act (ACA) are now lookingto the Supreme Court to overturn the 2010 law before time runs out on them.

After ACA became law eighteen months ago, they wereoptimistic that they could beat back several of its key provisions. These included the minimum medical lossratios, the expansion of Medicaid, the health insurance exchanges, and the individualmandate.

A brief review of thecurrent status of each shows why the individual mandate is the last onestanding. But as the arguments for andagainst it have crystallized in the Courts, they show how the Supreme Court couldopen a Pandora’s Box best left closed.

Minimum loss ratios

ACA mandates that all private insurance plans will have topay at least 80 to 85 cents in benefits for every premium dollar collected, orrebate the difference to policy holders beginning in 2012. Opponents argued that many existing planswould be forced out of the market because of high administrative costs.

However, the federal government has approved severalshort-term waivers from the requirement, deflating opposition. Also the Center for Medicare and MedicaidServices has told Florida that it must meet the 85% minimum loss ratio in its publicMedicaid program, too. Once privateinsurance rebates start to flow to consumers in 2012, the remaining oppositionwill likely melt away.

Medicaid Expansion

Beginning in 2014, everyone below 133% of poverty will beeligible for Medicaid. The 26-statelawsuit against the ACA – the one most likely to be taken up by the SupremeCourt this term – argued that the Medicaid expansion imposed anunconstitutional financial burden on the states.

But the Courts have already ruled against the states on thisone, and so the Medicaid expansions will go forward in two years unlessCongress changes the law.

Health InsuranceExchanges

Beginning in 2014 states will have to have exchanges throughwhich consumers will purchase health insurance. Only plans offering the minimum benefits mandated by ACA can be offeredon the exchanges. Some state regulatorsargued that they did not have the authority to enforce the “minimum benefitprovisions” mandated by ACA. Florida decidedto establish its own exchange that will not meet the ACA requirements.

However, a dozen other states are already moving forwardwith their approved exchanges, undercutting “lack of state authority” argumentand putting Florida out on a limb.

The IndividualMandate

Beginning in 2014, a system of subsidies and penalties willgo into effect to encourage people to purchase health insurance. Those making up to 400% of poverty willreceive subsidies for health insurance, but all those above 133% of poverty whorefuse to purchase insurance will have to pay a federal income tax penalty.

The crux of the legalargument against the individual mandate is that it is unconstitutional for the Federalgovernment to impose a tax penalty on an individual for refusing to purchase aconsumer product. However, opponentshave conceded that it would be Constitutional to impose such a mandate at thetime of service.

Judge Stanley Marcus, one of the judges who heard theappeal that may now go before the Supreme Court, made this clear in his dissent.

He wrote that “the plaintiffs and, indeed, themajority have conceded, as they must, that Congress has the commerce power toimpose precisely the same mandate compelling the same class of uninsuredindividuals to obtain the same kind of insurance, or otherwise pay a penalty,as a necessary condition to receiving health care services, at the time theuninsured seek these services.”

So what the SupremeCourt is being asked to decide is not “if” the individual mandate is constitutional,but “when.”

Some legal experts don’t think that there is much of adistinction in this.

But if the Supreme Court feels differently, and ultimatelydecides that it is Constitutional to impose the tax at the time of service, butnot in advance, then this may well open up a Pandora’s Box that we would allrather stay tightly closed and locked.

Even a narrow ruling against the “pre-tax” could have afar-reaching unintended consequence for indigent, uninsured people. These people include many of the over 50million uninsured people today and the 22 million who will still be uninsuredafter ACA implementation. A Supreme Court ruling that holds that peoplecould be forced to pay at the time of service could also be construed aspermitting providers to deny care to those who cannot afford it.

Opponents hope that a Supreme Court ruling against “pre-taxing”will result in a political unraveling of the law. It could well happen, but notin the way they intended.

If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Florida's Shame is Connecticut's Gain

2011-10-05T00:01:00.000-04:00

The next time Florida’s Governor tellsyou that the only way to create private sector jobs is to cut public sector healthspending, don’t believe him.

Accordingto news reports, the Governor’s Office is already warning state health agenciesto expect more budget cuts in 2012. He wantsthe dollars to implement his 7-7-7 plan to create 700,000 jobs in 7 years.

source: US DOL data, 2011

How’sthe plan working out for Florida so far? Dismally, by two different measures. The first is the 2011 state unemploymentclaims data. The second is the story of whyFlorida just lost another 7,500 jobs in health research.

The 2011 unemploymentdata show that Florida’s Governor has been more effective at killingjobs than creating them. The week beforeGovernor Scott took office, 14,139 Floridians lost their jobs and filed newunemployment claims. In 36 of the 37weeks since then, the number has been higher than that. Another 15,713 Floridians filed newunemployment claims during the most recent September week for which data areavailable.

To add insult to injury, there was apress conference a thousand miles away in Connecticut last week that explained why Florida’s job creation performance has been so dismal thisyear.

Jackson Laboratory, a Maine-based company, announcedthat it will build a new, $1.1 billion research lab on University ofConnecticut Health Center property in Farmington, Connecticut. The lab will produce over 661 new researchjobs, support 842 construction jobs, andcreate an estimated 6,200 spinoff and indirect jobs.

Jackson carries out cutting edgeresearch in the genetics of Alzheimer’s disease, cancer, and diabetesprevention. Landing the company was ahuge victory for Connecticut. A sourceclose to Connecticut’s Governor reportedly proclaimed that it “will makeConnecticut a world leader in the science of genomics.”

Thiswas all supposed to happen in Florida, as a part of that highly-touted 7-7-7plan. But in June, Jacksonannounced that it had “withdrawn” its request for $100 million from Florida to locatein Sarasota. In its June release, itsExecutive Vice President was gracious, but clear, about why it wentelsewhere. “We respect that thestate had to make difficult priority decisions in order to balance the budgetthis year,” he said. But the lack ofdollars “and the uncertainty of future funding made such a venture toospeculative to undertake responsibly.”

In a story last week, the Hartford Courant, Connecticut’s newspaperof record, offered up a slightly different, and blunter, quotation from a company official. It reported that a “Jackson source said ‘politiciansin Florida took a dramatic, hard turn to the right, and funding dried up.’"

One local Florida health leaderrecently said that “we used to just show ‘em a palm tree” to get people torelocate to Florida from the north. Apparently,Florida can no longer sell itself to actual job creators on good looks alone.

Asa result, the University of Connecticut – instead of the University of SouthFlorida – will reap the benefits of a billion dollars of private investment inone of the most rapidly growing areas of health care. In return for a $192 million loan and $99million in support of research, Connecticut, instead of Florida, will get over 7,500new jobs.

CT News Junkie, anonline publication, rubbed it in with a headline article on September 30^thentitled “Florida’sLoss is Connecticut’s Gain.” Inthe accompanying photo, Jackson Laboratory CEO Edison Liu is shown holding up aUCONN tee shirt as UConn’s President speaks, flanked by the Speaker of the ConnecticutHouse and the Chairman of her Board of Trustees.

This wassupposed to be Florida’s photo op. Butopportunity knocked, and no one answered.

Floridahas only its “hard turn to the right” to blame for the clouds over its horizon. That’s why over 7,500 jobs will begin to flynorth this winter.

Florida should be a leader in health researchand treatment, especially research and treatment in diseases affecting an agingpopulation. But Florida can’t leadwhen its elected officials are running backwards.

Florida’sGovernor and Legislature have been slashing from health and mental healthprograms – including public health, Medicaid, and – as it turns out – even economicdevelopment spending. And now theGovernor, who should be ashamed by what happened with Jackson, wants to slashsome more.

The nexttime you visit Farmington, Connecticut, take a good look at where over 7,500would-be Floridians will be buying their homes, paying their taxes, andspending their money for years to come. You won’t see a single palm tree.

If you have questions about this column or would like to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

CLASS Warfare

2011-09-28T00:01:00.000-04:00

Is the CLASS Act already dead and buried, a full year beforeit comes to life?

A couple of months ago, I wrote a column about the ill-advised,bi-partisan Congressional effort by the Senate “Gang of Six” to deep-six theCLASS Act.

The CLASS Act is the new national privately-financed longterm care insurance program authorized by Congress in 2010. Without going into all the details again, itis intended to make long term care insurance care available to the workingmiddle class. This would take pressureoff of the Medicaid program, resulting in billions of dollars of savings totaxpayers.

The CLASS Act won’t even take effect until October, 2012, andthe Administration hasn’t even announced exactly how it would bestructured. But the Department of Healthand Human Services may be closing down the CLASS office. This past weekend’s newsreport from the Hill and other media outlets noted that it has let itsactuary go and asked the Senate not to appropriate $120 million needed for the CLASSAct’s implementation.

That’s not “lifesupport,” as one writer who is sympathetic to the Act suggested. It’s a death rattle.

A program designed to cost the government next to nothing,provide benefits that people need, and save taxpayers significant dollars shouldbe popular with elected officials. However, that’s not the case here.

According to the Hill,Senator Kent Conrad, a Democrat, has called the CLASS Act “a Ponzi scheme ofthe first order.” Representative PhilGingrey, a Republican, agrees with him. Last March, according to Howard Gleckman in his Caring for Our Parents blog,Rep. Gingrey called the CLASS Act “a Bernie Madoff Ponzi scheme run by theSecretary of Health and Human Services.”

On CNN almost two years ago – before the CLASS Act was evenenacted – Senator Lindsey Graham called anyone who would vote for it a“co-conspirator to one of the biggest Ponzi schemes in the history ofWashington.” And Senator John Thune alsocharacterized it in a 2009 Timearticle as “a classic definition of a Ponzi scheme.”

Aside from thehyperbolic tic that appears to compel all these members of Congress to refer tothe CLASS Act in precisely the same way, and in the most demeaning mannerpossible, you get the bi-partisan picture. They oppose it.

Their problem seems to be that it would collect premiumsfrom a lot of people to pay for the care needs of a few. What they call a “Ponzi scheme” is oftenreferred to as “insurance.”

Other opponents have literally thrown the kitchen sink atthe CLASS Act. Heritage Foundationwriters have made the simultaneous and contradictory arguments that too few andtoo many people will enroll, premiums will be too low and too high, benefitswill be too small and too great, and the Trust Fund it establishes will be sobig the Congress will raid it and so small that it will have to be subsidized.

The real problemseems to be that as it is currently designed, the program’s primarybeneficiaries will be working members of our disappearing middle class.

This is because most well-to-do aging Americans, likemembers of Congress, have personal wealth sufficient to help finance their longterm care. Long-term care insuranceisn’t a necessity for people who have over $1 million in assets, because theycan usually generate enough income from these assets to pay for their own longterm care needs.

Or they can protect these assets by transferring them totheir children, and qualify for Medicaid just like any other indigentperson.

Transferring assets to qualify for Medicaid is a commonoccurrence, but no one seems to know exactly how common. In one analysis in New York, 7%of Medicaid applicants were denied because of a recent transfer of assets. The percentage transferring assets successfullywas likely much, much higher.

Maybe limiting the CLASS program to working people, orsetting a $50 per day benefit level, or locking in an age-related premium aren’tthe best approaches to setting up the program. Perhaps its Trust Fund will prove too tempting for politicians who toraid for other purposes.

But we need long term care insurance or our long term caresystem will collapse one day. And the currentprivate plans are far too scarce, and too few people are enrolled in them.

So, instead of doing something about this, Congress willkill the one program it has passed that promised to make a difference – and, atthe same time, help the middle class afford long term care.

That’s what CLASS warfare is all about.

If you have questions about this column or would like to receive an email notifying you when new Our Health Policy Matters columns are published, please send an email to gionfriddopaul@gmail.com.

Uninsured Numbers a Compelling Case Against States' Rights

2011-09-21T00:01:00.000-04:00

“States’ rights” is as popular a rallying cry as ever as we enter theearly stages of the 2012 election campaign.

To advocates of states’ rights, they are code words for state innovationand initiative, unhampered by the demands of a federal government. Intheir minds, we are a United States of America.

To skeptics, we are a United States of America, and states’rights are the code words of political leaders who want to run their states as fiefdomsand answer to no higher authority.

The new2010 uninsured numbers released by the U.S. Census Bureau last week make acompelling case against the states’ rights position.

In the South, where the drum roll for states’ rights beats most loudly,19% of all people were uninsured 2010 forthe entire year. This was more than inthe West, where 18% were uninsured, the Midwest, where 13% were uninsured, and theNortheast, where only 12% were uninsured.

Place clearly matters where healthinsurance is concerned, and innovation and initiative in providing coverage forhealth care take a back seat in the Mecca of states’ rights.

Geography is an important factor in determining insurance status, butit isn’t the only one. Others include:

· Race and ethnicity – 31% of Hispanics wereuninsured for the entire year, as were 21% of blacks;

· Immigrant status – 34% of all foreign-born U.S. residentswere uninsured, including 45% of those who are not citizens and 20% of thosewho are;

· Income – 27% of people in households with lessthan $25,000 per year were uninsured.

But as bad as these numbers look, what’s behind them in themore detailed tables that accompanied the Census Bureau release is worth examining.

It isn’t race, immigrant status, or income driving the health insurancenumbers. It’s geography.

Consider this fact. The newsheadlines reported that 16.3% of the population of the United States as a wholewas uninsured. But when you removepeople over the age of 65 – who are almost universally insured through thefederal Medicare program – the percentage rises to 18.4%.

But in the two biggest southern states of Florida and Texas – where thenew leaders of the states’ rights movement sit in Governor’s chairs – the numbersare far worse.

In Florida, 24.6% of all peopleunder the age of 65 were uninsured in 2010 forthe entire year.

In Texas, 26.9% of all peopleunder the age of 65 were uninsured in 2010 forthe entire year.

Florida has earned its states’ rights badge through Governor Rick Scott’sattack on the Affordable Care Act. Hisadministration has refused to implement its consumer protections. He has famously refused to accept public fundingfor many needed services because the funds were associated with the Act. And he has turned down dollars to set up ahealth insurance exchange that would make more privately-funded insuranceavailable in the state, too.

Texas has earned its badge through Governor Rick Perry’s attack onMedicaid. He has advocated repealing theMedicaid program in its entirety, making Medicaid a block grant so that Texascan do whatever it wants with it. He oncesuggested seceding from the union if he didn’t get his way.

The one thing that neither RickPerry nor Rick Scott can do is blame the federal government for the failures oftheir states to insure their populations properly. Nor can they blame racial, ethnic,immigration, and income factors.

Mississippi, South Carolina, Maryland, and Georgia all have higherpercentages of African Americans than Texas and Florida, but lower percentagesof uninsured people. New Mexico has ahigher percentage of Hispanics than Texas, but a lower uninsured percentage. And California has more undocumentedimmigrants than Texas and Florida combined, but a lower uninsured percentage,too.

Florida and Texas are also by no means the poorest states in theunion.

Florida and Texas have reached the bottom of the uninsured barrel throughtheir own policy actions and despite their considerable assets.

When their governors talk about states’ rights in the area ofhealthcare, they seem to be arguing that every state should aspire to theirlevel of failure.

Meanwhile, the one thingeveryone seems to agree on is that more people in Texas and Florida will becomeinsured when the Affordable Care Act is implemented by the federal government ina little over two years.

This has been characterized in recent Presidential debates as a federaltakeover of health insurance. But doesanyone seriously believe that we would ever have needed an Affordable Care Act –or that it would have passed – if every state, including Texas and Florida, hadtaken care of its own problem like Massachusetts did?

In Massachusetts, only 6% of the population was uninsured in 2010.

If you have questions about this column, or would like to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

America's Health Insurance Myth

2011-09-14T00:01:00.000-04:00

The recent heavy-handed action by Blue Cross and Blue Shieldof Florida (BCBSFL) to terminate and amend all of its contracts with mentalhealth providers brings to light a well-kept national health care financingsecret.

It is an American myth that we rely on private insurance companiesto finance our healthcare delivery system.

America’s privately-financedprivate health insurance companies pay so small a share of the nation’shealthcare bill today that they could vanish tomorrow and we would barelynotice anything but the cheering.

Insurance companies have been marginalizing themselves by years of short-sighted actions against both providers and patients. They are well on the way to becoming little more than bundles of administrative costs and profits. And it may already be too late for them to do anything about it.

According to the Centers for Medicare and Medicaid Services(CMS), ourtotal U.S. health care expenditures in 2009 were just under $2.5 trillion. Privately-financedprivate insurance pays a stunningly small percentage of that – far, far lessthan most people believe and far less than the sky-high health insurancepremiums they often charge would suggest.

Like it or not, it is the government that pays most of thebill.

Medicare and Medicaid pay over one-third. According to the Office of Management andBudget, Medicarepaid $517 billion in 2009-2010 – 21% of the total. CMS calculated that the combined federal andstate Medicaid share was $374 billion in 2009, which accounts for 15%.

Other direct governmental health care expenditures accountfor another 20%, or $510 billion.   Theseinclude mental health and substance abuse spending, workers compensation,Indian Health Services, vocational rehabilitation, maternal and child health, CHIP,Department of Defense, Veterans Affairs, and other federal, state, and localexpenditures.

As a result, thegovernment’s direct share of health care expenditures comes to approximately56% of the nation’s total healthcare bill.

But there’s more. Government workers account for around one-sixth of our national laborforce. Their private health insurance ispaid for by governments.   The FederalEmployee Health Benefits Program costs $40 billion. And according to a source at theManhattan Institute, state and local benefit programs cost an additional$132 billion in 2008. Government-fundedprivate insurance therefore accounts for another7% of total health care spending.

But we’re not finished yet.

The government also subsidizes private insurance through taxdeductions for premiums. The Kaiser Family Foundation estimatedthat the value of this tax expenditure was around $200 billion in 2007.

When you add that in,too, it brings the government’s share to around 71% of the total.

According to CMS, private insurance paid $801 billion, or32%, of our total health care bill in 2009. But when you remove the $372 billion of government contributions to thisshare, the privately-funded private insurance share of health care costs goesdown to $429 billion, or to around 17% of the nation’s health care bill.

CMS reported that in 2009 the remaining 12%, or almost $300billion, was paid out-of-pocket for health care, through co-pays, deductibles,and other direct payments by or on behalf of individuals.

But here’s the thingabout the 17% paid by private insurance companies using private dollars. It costs us all at least one-third of that topay for their profits and administrative expenses.

Private insurers regularly keep at least 15-20% of everypublic or private premium dollar they collect for profit and expenses. This means that we have to pay insurancecompanies something like 6% on top of the 32% they pay toward health costs fortheir profits and administration. If wedidn’t have to cough up that 6% in fees, we could spend it all on healthcare.

This means that the net value of the privately-funded private insurance shareof the nation’s health bill is something like 11% of the total, just about whatwe already pay out-of-pocket.

It is maddening that private insurers pay out so little for theprivilege of treating providers and patients so shabbily. According to one Florida mentalhealth provider, BCBSFL is also adding new paperwork requirements, randomand aggressive auditing, other intrusive requirements, and even “legibilityreviews” to the mental health treatment manual it will release to its newprovider network in December.

We need our government to be more aggressive by enforcing mentalhealth parity laws and the consumer protections in the Affordable Care Act. It must improve its regulation of an industry where the administrative bloat is alreadyat least half as big as the benefit, and the benefit is no bigger than what wealready pay in co-pays and deductibles.

But the most telling anti-consumer position was staked out in an August 17, 2011 letter from the Deputy Insurance Commissioner of Florida to a representative of a coalition of mental health parity advocates: "I would note that the Office of Insurance Regulation has no jurisdiction with respect to enforcement of federal law." Since Florida also denies the authority of the federal government to enforce insurance mandates, who's left to advocate for consumers?

Where private insurance is concerned, it seems that we have laws with teeth, but regulators with no bite. I wonder why.

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Why Research Matters

2011-09-07T00:01:00.002-04:00

A few weeks ago, we were tantalized by the news that a new treatment for leukemia might be on the horizon.

Three very sick patients were injected with a new drug. It was made from – of all things – a modified version of the virus that causes AIDS. After a year, two were disease-free and the third had a 70% reduction in disease tissue. One researcher was quoted as saying that the results “exceeded our wildest expectations.”

But the rest of the story pointed out that the discovery almost didn’t happen. There wasn’t enough research money for a full trial. Neither the National Cancer Institute nor pharmaceutical companies had funding for the research. A family foundation stepped up, but that’s why there were only enough funds for three patients to participate initially.

The National Institutes of Health (NIH) is the largest funder of biomedical research in the United States. In requesting a budget of $32 billion for FY2012, it noted that research that it funded has reduced death rates from stroke by 70% and deaths from coronary heart disease by 60% since 1970. It has also contributed to the amazing results that have been achieved over the last twenty years in HIV/AIDS management, and to a significant reduction in cancer deaths as well.

We spend $2.4 trillion on health care in America. Shortly after NIH made this request for just over 1% of that, Congress cut its funding to $250 million below 2010 levels.

On its cover, the AARP Magazine for September/October 2011 trumpets “Amazing Medical Discoveries That Will Change Your Life.” These discoveries were the result of funded research. They include artificial retinas, prostate cancer vaccines, and magnets for depression relief – all currently available. AARP sees new breast cancer drugs and adult stem cells for coronary artery disease treatment in just a few years, and even more exotic treatments down the road.

These discoveries will all make a huge difference in how we live.

Research isn’t just the work of scientists in labs, and doesn’t just result in new drugs and treatments. Sometimes, it results in safer medical procedures that not only preserve life, but also lower costs at the same time.

NIH says that research advances have saved trillions of dollars.

Here’s one story of money-saving research advances. Jeffrey B. Cooper, a biomedical engineer at Massachusetts General Hospital, has made patient safety his life’s work. Though he has labored in relative obscurity – I doubt that more than a thimble full of policy leaders outside of the Greater Boston area have ever heard of him – he played a key role in the development of modern anesthesia “standard of practice” guidelines, developed technology to manage the use of anesthesia in operating rooms, and facilitated the development of simulation training to ensure patient safety.

The bottom line results of his work suggest that there is more than one way to achieve tort reform. As training and practice standards evolved and improved, there were fewer adverse patient reactions to anesthesia and fewer deaths. This resulted in lower costs to insurers, which led to lower malpractice rates for physicians.

Research brings about medical advances, improved training, and better patient treatment. But that’s not all.

The Framingham Heart Study was recently in the news because it released some new research linking poor health habits in middle age to brain shrinkage. What makes this Study remarkable is that it has been ongoing since 1948. NIH is a partner, along with a number of other public and private institutions. It is following its third generation of individuals now, and has participated in some of the most important advances in our understanding of cardiac disease risk factors.

We have another federal agency devoted to disease prevention, the CDC. Its total budget of $11 billion is less than one half of one percent of our annual health care expenditures.

Most of us take for granted or devalue these agencies, and the many hundreds of researchers who have developed cures or treatments for disease, procedures and training that save patient lives, and strategies for preventing chronic conditions.

The people who settled Jamestown did not yet know that blood circulated in the body, and those who prepared to declare our freedom from England still did not even know what oxygen was.

But our nation’s founders were scientists as well as public officials. Modern health care is the result of their embrace of the miracle of modern science.

But in today’s United States, not everyone has equal access to advanced prevention and treatments. Our health care safety net no longer catches everyone.

And we’re forgetting the value of research – that because of it we now live longer, healthier lives.

Research requires funding, and a willingness to embrace the legacy of our parents and grandparents.

If you have questions about this column, or wish to receive an email notice when Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

A Different Kind of Individual Health Mandate

2011-08-31T00:01:00.017-04:00

According to a recent report in Health Affairs, health spending in the United States is projected to rise by 5.8% per year over the next decade.

source: CT OPM

Rising health care costs are a problem that must be brought under control. One approach is to do what Florida's doing. It is forcing state employees into a single HMO, removing all competition from the market while praying that the HMO won't be motivated by making a profit.

Another is to look at what the State of Connecticut is doing.

It is betting over $100 million that its employees and retirees will respond to a different kind of “individual mandate” from the one under fire in the Affordable Care Act. Connecticut has decided to give financial incentives to employees and retirees to manage their health. It will also penalize financially those who do not.

State workers overwhelmingly voted to accept the new deal earlier this month. If the plan works, then it may signal a new path for every state hoping to cut its future health care spending.

Connecticut was motivated to undertake this challenge by its mind-boggling budget deficit. The deficit in the coming two years was projected to be 50% higher than the entire annual state budget was just a little more than 30 years ago.

To avoid thousands of layoffs, it entered into negotiations with its unions to change salary and benefit packages.

At the bargaining table, negotiators decided not just to employ the old, failed cost-containment strategies of reducing benefits to workers and squeezing payments to providers. They took a different approach by promoting the participation of employees and retirees in disease management and health maintenance programs.

They created a new “Health Enhancement Program” for all Connecticut state employees and all future retirees. Those who choose to participate in the “voluntary” program will benefit financially. Those who do not will pay higher insurance rates as a penalty.

Participants in the Health Enhancement Program will receive some excellent chronic disease management services, including free health care and drugs. They will not have to pay any co-pays for office visits related to diabetes, asthma, heart disease, hyperlipidemia, or hypertension, as long as they adhere to the schedule of visits recommended by their health care provider.

Participants in the program will also pay reduced co-pays for drugs needed to treat these conditions. The co-pays will be as low as zero for all diabetes prescriptions and for generic drugs used to treat the other conditions.

In return, participants will have to agree to focus on staying healthy. They must get regular physicals, eye exams, and dental cleanings. If they and their dependents do all these things, they will receive a cash award of $100 per year for their efforts.

On the other side, those who choose not to participate will pay more for health insurance and health care. They will pay an additional $100 per month for their insurance. They will pay higher drug co-pays. They will also pay a new $350 deductible per individual, with a $1,400 family cap, for health care services not covered by co-payments.

Connecticut is betting heavily that its employees, retirees, and their dependents will want to manage their health – and, most importantly, that it will pay off in reduced costs to the state.

In June, the Office of Policy and Management estimated that the Health Enhancement Program will save the state over $100 million annually in health care costs. OPM believes that 50% of those eligible will choose to participate, and that this will result in a 10% reduction in health insurance claims – even though some participants will be required to visit health and dental health professionals far more often than they do now.

The penalty provisions save the state another $18 million, which the non-participants will pay out-of-pocket in higher premiums and deductibles.

There may be two big holes in the Connecticut plan that will reduce the savings to the state. While mental health and chronic pain services are still included in health plans just as before, the Health Enhancement Program does not include them among the conditions managed in the program.

Both affect a large number of people, lead to many expensive and preventable health care encounters, and often co-occur in a patient with the covered chronic conditions. If a patient’s unmanaged mental illness leads to a failure to comply with a diabetes disease management program, both the patient and the state will lose.

Still, the Connecticut plan goes beyond what most other states have attempted, and is well worth a try. Changing the trajectory of increasing health care costs isn’t easy. It will be interesting to see if Connecticut’s health “mandate” proves more popular and effective than the alternatives.

If you have questions about this column, or wish to receive an email notice when Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

BCBSFL Wrong To Cut Mental Health Providers

2011-08-24T00:01:00.015-04:00

A recent story in Health News Florida broke the news that Blue Cross and Blue Shield of Florida (BCBSFL) has notified all of its participating mental health providers that their contracts are being terminated as of November.

Those who wish to continue to see BCBSFL patients will have to sign a contract with a new provider partially owned by Blue Cross and Blue Shield. Their payments will be cut between 25% and 55%.

BCBSFL’s notice caused a justifiable uproar – one that may extend beyond the boundaries of the state.

Mental health advocates see the action as a violation of the federal Mental Health Parity Act, because only mental health providers have been singled out.

Florida residents are also concerned. BCBSFL has four million members, and insures over 7 million people in the state. They all may lose access to providers as a result of this action.

But up to 80 million on Blue Cross Blue Shield plans outside of Florida will also be affected. Blue Cross Blue Shield plans around the country use one another’s provider networks. Florida’s providers who are dropped by BCBSFL are also automatically dropped from every out-of-state Blue Cross Blue Shield plan, too.

There is a nagging sense that what is behind the BCBSFL decision is a desire to deny coverage for mental illness by denying the people it insures access to mental health providers.

Providers are already forced to accept low BCBSFL rates when they treat patients. I have a recent statement indicating that a Florida provider gets $51.97 from Blue Cross and Blue Shield for an hour of counseling.

This may seem like a lot of money, but it is not. At that rate, a provider would have to treat seven patients per day, five days per week, fifty weeks per year, to gross $91,000 per year. But office expenses, the cost of help, taxes, and insurance would all have to come from this, leaving the provider with a salary of perhaps $50,000.

And BCBSFL thinks this is too generous?

In the interest of accuracy, I should point out that the provider in question is an out-of-network provider who nevertheless handles the BCBSFL paperwork and accepts the payment on behalf of the patient – relieving the patient of this headache. Also, the $51.97 payment wasn’t even made by BCBSFL, but by an out-of-state plan. I contacted the out-of-state plan, and its representative confirmed that it paid the rate set by BCBSFL.

If this is the BCBSFL standard, then we pay plumbers, electricians, carpenters, and auto mechanics more than BCBSFL pays mental health professionals.

Is our mental health care really worth less than our clogged kitchen sinks, our burned-out fluorescent lights, our broken porch railings, and our regular oil changes? BCBSFL seems to think so.

BCBSFL could make the argument that it pays only a portion of the mental health provider’s bill, and the patient co-pay makes up the difference. Fair enough. So I added in the co-pay and the provider’s reimbursement went up to $64.

This is still less than we pay carpenters, plumbers, electricians, and auto mechanics.

The cost of mental illness in America is staggering, but it is not because of high counseling rates paid to psychologists. Using current research, Mental Health America has argued that the economic costs of mental illness are now in the vicinity of $200 billion per year. In addition, mental illnesses cost over $57 billion a year to treat, making mental illness the third most costly chronic condition.

But, according to a recent article in the New England Journal of Medicine, private insurance pays for only 27% of our nation’s mental health costs (versus 37% of all health costs), leaving almost three-quarters of the mental health bill for federal, state, and local governments.

Not bad for a country which continues to believe that it’s not paying for mostly single-payer, government-sponsored, national health insurance.

Poor coverage for mental illness is one of the reasons that states have had to mandate mental health benefits. It is also a reason why Congress passed the Mental Health Parity Act and put consumer protections into the Affordable Care Act.

But in a state like Florida, where both the Governor and the Insurance Commissioner have repeatedly opposed the interests of consumers, BCBSFL may not be held accountable. This is unfair and wrong.

It is also the best argument I can think of for why we need a government that is willing to stand up to private insurers on behalf of its citizens.

If you have questions about this column, or wish to receive an email notice when Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

For a Less Healthy State, Cut Business Taxes

2011-08-17T00:01:00.010-04:00

In a recent column, I wrote about the importance of public health spending in reducing the death rate.

What other public policy strategies also lead to a healthier state?

Chart shows positve healthy state rank relationship to health spending, negative to business tax climate.

There are quite a few. I compared several other state rankings with the most recent state health rankings published earlier this year. These included health care spending per capita, per enrollee Medicaid spending, Medicaid spending for people with disabilities, Medicaid spending on children, and state mental health agency spending. I also looked at rankings in per capita income, household income, the percentage of people with private health insurance, and business tax climate.

It turns out that a higher state ranking in eight of the nine areas is related to a higher state health ranking. In only one area – business tax climate – did a higher ranking predict a lower state health ranking.

Like spending on public health, more generous health care spending – including safety net spending – is a strong indicator of a healthier state. The healthiest state, Vermont, was 8^th overall in per capita health care spending. Massachusetts, the second healthiest state, ranked second in Medicaid spending for people with disabilities. Maine, which topped the state list in mental health spending, was the eighth healthiest state overall.

The strongest indicators of a healthier state among the five areas of health spending were Medicaid expenditures on behalf of people with disabilities and the state’s ranking in per capita mental health spending.

The next strongest was overall Medicaid spending. Behind this were overall health care spending per capita and Medicaid per capita spending on children. Spending more on children generally means better prevention, and spending more on health care usually means better health care. Both contribute to a healthier population.

Some people might argue that there are economic factors at play here. After all, wealthier people are healthier than poor people, so it stands to reason that higher per capita income would be a much better predictor of a state’s health ranking than entitlement spending would be.

Higher per capita income is, in fact, related to a higher healthy state ranking. Eighteen of the states in the top 25 in the healthy state rankings are also in the top 25 in per capita income. However, a state’s per capita income ranking is no better a predictor of the state’s health ranking than is its overall spending on Medicaid.

Put another way, a state’s spending on mental health and disabilities services is a better indicator of a state’s health ranking than is its per capita income.

Another economic factor – the state’s ranking in the number of people who are privately insured in the state – is strongly related to the state’s health ranking. The more people on private insurance, the healthier it is for a state.

So it turns out that there are many policy decisions state legislators can make to improve the health of the people of their states. They can spend more on Medicaid, put more state resources into mental health services, get more people on private insurance, increase minimum and living wage standards, and make sure that health care providers are plentiful and paid decently for their services.

Most states are doing exactly the opposite today.

Some are even taking it one step farther. They are cutting business taxes in an effort to improve their business tax climate.

However, the better the business tax climate ranking, the lower that state’s health ranking seems to become.

Nevada, for example, has the 4^th best business tax climate, but it was the 47^th healthiest state. Florida has the 5^th best business tax climate, but it was the 37^th healthiest state. The least healthy state, Mississippi, had the 21^st best business tax climate.

Chart shows poor relationship of business tax climate to per capita income and private insurance rankings.

There is a reason why so-called “business tax expenditures” don’t translate into a healthier state. It is that these don’t appear to improve a state’s economy.

A better business tax climate ranking is related to lower, not higher, per capita income, and has no effect at all on the state’s ranking in the number of people who are privately insured.

A good business tax climate does not have to lead to a poor state health ranking. New Hampshire, for example, is the third healthiest state and has the seventh healthiest business tax climate. But it also prioritizes health and worker benefits. It is in the top tier of state per capita mental health and Medicaid spending, its per capita income is high, and its employers are tops in providing private health insurance to workers.

We can have a healthier population working within the constraints of bad economic times. We just have to stop knee-jerking about entitlements and taxes, focus our attention on what works, and invest in our people again.

Column note: The two charts accompanying this blog may be difficult to interpret because of the number of state data points on them. I added the liner trend lines to simplify them. Trend lines that move in the same direction as the line to which they are being compared (the healthy state ranking in the first chart and the business tax climate in the second) have a positive relationship to it; flat lines have no relationship and those moving in the opposite direction have a negative one. For further reference, I have created a new page with a table (see the “State Rankings” tab) of all the state rankings I used. The sources for the rankings and the charts are on that page.

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Entitlement Reform Could Lead to Mental Health and Health Care Armageddon

2011-08-10T00:01:00.002-04:00

It was hard to witness the embarrassing spectacle of politicians responding to the credit downgrade by circling their firing squad yet again.

I’d like to see some grown-ups emerge from the mess. But I’m not holding my breath.

Sources: CBO, GIH, KFF, CDC, NAPH

Our debt problem was caused by tax cuts that didn’t create jobs, wars for which we didn’t pay, and an unsustainable and under-regulated financial bubble that burst. It wasn’t caused by entitlements.

Despite this, politicians are pushing entitlement myths and reforms. But in the unsteady hands of this unstable Congress, entitlement reform could result in a health and mental health care Armageddon that could blow us all back into the 19^th century – the stone age of modern medicine.

The Social Security and Medicare Trust Funds still have surpluses. They aren’t responsible for the debt. In fact, Social Security Trust Funds hold U.S. debt, just like China.

We can do two things about future Social Security and Medicare costs. We can cut benefits, which our citizens don’t want, or raise Social Security and Medicare taxes to pay for the benefits people do want. It would take a 1%-2% Medicare tax increase to preserve Medicare as it is today for the next three generations.

Medicaid is a different story. Medicaid doesn’t have a trust fund. It contributes to the federal deficit and debt, and we need to lower its cost.

However, the federal deficit this year will be at least $1.3 trillion. The entire federal share of the Medicaid program is approximately $300 billion.

Suppose Congress passed the most radical entitlement reform possible – eliminating the entire Medicaid program – as Texas Governor Rick Perry once proposed. The federal deficit would still be over $1 trillion.

The debt wouldn’t go down much, either. Our national debt is over $14 trillion today. Before the passage of the recent deficit reduction act, the CBO projected that the debt would grow to $23 trillion by 2020. The Act reduced this by almost $1 trillion in Round 1, with at least another trillion to come in Round 2.

If Medicaid’s $300 billion per year, plus inflation, were made part of Round 2 cuts by the “SuperCongressional Committee,” the U.S. debt would still be almost $20 trillion in 2020.

This assumes that there would be no bad outcomes from such a radical action. However, eliminating Medicaid would kill health and mental health care in America.

If Medicaid were eliminated, then the number of uninsured people would mushroom to one-third of our population. Many would have chronic diseases.

We would witness the first major fallout within a few weeks. Sixty percent of nursing home beds are funded by Medicaid. So nearly every nursing home in America would collapse, unable to finance their operations. Frail elders and people with chronic conditions would be released. Social services providers would be overwhelmed.

Within a few months, the fallout would spread to every community health center in America. Without Medicaid, which accounts for 37% of CHC revenue, they, too, would crumble. Millions of their patients would flood into hospitals for care.

Most hospitals could probably survive this onslaught for a year or two, but the pressure on them would be terminal. Public hospitals, which get 35% of their revenue from Medicaid, would fail first. Then private hospitals, which get 17% or more of their revenue from Medicaid, would fail, leaving vast areas of our national landscape without emergency, trauma, or surgical care.

Behavioral health services, which get 26% of their revenue from Medicaid, would implode next. People with mental illness would be out on the streets or hidden away without services.

Private physicians could hold out a little longer. But within a few years, patient-hoarding would be their only survival strategy, and most of their practices would die. A few urgent care centers, surgical centers, and concierge practices would remain, but their prices would skyrocket. Few could afford them.

By 2020, without Medicaid pretty much all that would be left of our health system would be our public health services and our $20 trillion debt. A significant percentage of 14 million healthcare jobs would be lost. Life expectancy would plummet to pre-1900 levels, and most diseases would be death sentences again.

“Entitlement reform” is a new catch phrase for politicians who do not want to face reality. To balance our federal budget and pay off our accumulated debt, we will have to raise taxes, pay for the wars we’ve already fought, and create more jobs – including jobs in the public sector, in which one in every six U.S. workers is employed.

The discourse in our Congress must be more grown-up. We must pay for what we have already consumed and what we want in the future.

But paying bills is a bigger nightmare to some politicians than destroying our health and mental health care systems. So the demonizing myth of entitlements will continue.

If you have questions about this column or wish to receive an email notifying you when future Our Health Policy Matters columns are published, please contact gionfriddopaul@gmail.com.

Column note: There are more hyperlinks than usual in today's column, and I want to thank especially the Congressional Budget Office, SAMHSA, the Center for Medicare and Medicaid Services, the Center for Budget and Policy Priorities, Grantmakers in Health, the National Association of Public Hospitals, Gallup, the Federal Bureau of Labor Statistics, the Kaiser Family Foundation, and the Centers for Disease Control and Prevention for the valuable information they make available through their web sites for use by people like me!

Public Health Spending Prevents Deaths

2011-08-03T00:01:00.015-04:00

If you are as grateful as I am that the nonstop coverage of debt ceilings and deficits is behind us for a while, and want to talk about something even Congress should be able to agree is worthwhile, then just repeat after me these two magic words. (No, not those two!)

The words are "public" and "health." There is a new article out entitled Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths.

Source: Mays and Smith, Health Affairs, 7/11

The article has been published online by Health Affairs, and is in the August 2011 edition of the print journal. It was written by Glen Mays and Sharla Smith.

Spending on public health has long been one of our government’s great success stories. It keeps our water clean, our air free of pollution, our food pure, our children immunized, and our homes and neighborhoods free of lead, rats, and violence. It also promotes our health.

I wrote in a previous column about what this means for individuals like you and me. Our life expectancy in America grew by 30 years during the last century.

The Health Affairs article makes it clear that public health is still getting the job done today.

Here’s the bottom line. When more money is spent on public health, death rates go down. When less money is spent on public health, death rates go up.

It can’t be much clearer than that. The authors studied public health expenditures and death rates in a number of communities between the years of 1993 and 2005.

Local health departments whose spending increased by an average of 10% per year during those years experienced significant declines in infant deaths, deaths from heart disease, deaths from diabetes, and deaths from cancer.

These declines were not inconsequential. For each 10% increase in public health funding, there was a decrease of 3.2% in deaths from heart disease, a decrease of 1.4% in deaths from diabetes, and a decrease of 1.1% in deaths from cancer.

There was also a 6.9% decrease in infant deaths.

These percentages may seem small, but consider this. In a county of one million people, a 10% increase in public health funding per year for twelve years means a decrease of over 1,000 deaths from heart disease alone.

These are not avoided deaths among people who had heart attacks and were saved by advanced medicine. These deaths usually occur among people who seem healthy. If it weren’t for public health, these thousand people wouldn’t be playing with their children and grandchildren, walking and jogging along our streets, working at jobs, dining in our restaurants, shopping in our stores, and even serving as elected or appointed officials.

It seems a no-brainer to invest in public health. However, one-third of local health departments actually had their funding reduced during the twelve year time period of the study. The communities they serve had an increase in deaths equivalent to 430 for every one million people.

We’ve all heard how tight our public budgets are as public officials work to reduce spending. Can we afford to save this many people through public health?

The short answer is yes, and the longer one involves some embarrassment that we don’t try harder. The average community spends about $40 per person per year on public health. Increasing this expenditure by 10% would average out to $4 per person per year, about the cost of one movie rental or one beer per year.

Local people have also already delivered a message about this to state and federal officials. They don’t mind giving up a movie rental or a beer every year to save 1,000 lives.

In states where counties or cities control their own local health departments, the authors note that public health spending is 24% higher than it is in states where the states themselves control the local health departments. It turns out that local people are willing to give up a movie rental and a beer for public health.

The authors calculated that the ten percent increase in public health spending per community would increase local public health budgets by an average of only $312,000 per community each year. Compared to the billions and trillions of dollars our elected officials have been talking about – or even the $9.2 million one hospital recently charged the estate of a dead patient – $312,000 doesn’t seem like a very big number to me.

Public health is responsible for 50% of the gains in life expectancy in the United States during my lifetime. We can certainly do better than to give it less than 5% of all health funding, as we do today.

Public health doesn’t need a lot to do its job. Just 5.05% would make a measureable difference. And 5.5% across the nation could save the lives of millions.

If you have questions about this column or wish to be added to an email list to receive notices when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Deep Sixing the CLASS Act

2011-07-27T00:01:00.002-04:00

The debt ceiling and deficit reduction command the attention of Congress this week. Its members are trying to find trillions of dollars of cuts to balance the budget.

So why are some members of Congress trying to do something that is guaranteed to increase the already sky-high cost of the Medicaid program? Do they want to drive us further into debt?

The Senate Gang of Six wants to deep six the CLASS Act before it takes effect. The CLASS Act is the new national long term care insurance program that will take effect next year. It will cost the federal government nothing and is projected to save the Medicaid program billions of dollars.

The Medicaid program, as most U.S. citizens now know, is a federal/state partnership resulting in different plans in every state. In 2010, roughly 55 million people were insured through state Medicaid programs. If they were all combined into one plan, Medicaid today would be the single largest health insurer in the nation.

Of the 55 million people on Medicaid, half are children, and many more were working adults. But they are not the most expensive people on the program.

The biggest costs in the Medicaid program are incurred on behalf of the five million elderly and nine million people with disabilities on Medicaid – the long term care populations.

Many members of Congress have put the Medicaid entitlement program at the top of their deficit reduction hit list. The federal government paid about $275 billion for Medicaid in 2010, and total state outlays approached $200 billion more. That constitutes almost a half trillion dollars of health care spending.

Almost half goes to long term care. Medicaid typically becomes a long term care payer when an elderly person develops an age-related condition, like Alzheimer’s, which forces them to enter an institution for twenty-four hour care and exhaust their personal savings. It also pays for younger people with mental retardation, or people with serious mental illness or other chronic diseases.

The challenge for policymakers wanting to control Medicaid costs is, therefore, to control long term care spending for people with chronic conditions. Cutting nursing home provider rates has long been a favored strategy, but this has never succeeded in reducing costs for any length of time.

Policy makers have also explored managed care options. These don’t work as well with people with chronic conditions as they do with a healthier population, because people with chronic conditions already have significant care needs.

So policy leaders are faced with only two choices.

The first is for government to deny people care. This is taking health care rationing to an extreme, choosing to leave older, sicker, and poorer Americans to fend for themselves while the government protects the interests of those who are better off. This choice is inhumane and morally reprehensible to most people.

The second is to devise a plan through which all people can pre-pay some of the cost of their long term care through private insurance before they get sick, reducing the government’s financial burden.

When Congress passed the CLASS Act in 2010, it chose the second way, the humane and rational way.

It didn’t want to burden taxpayers, so it required the CLASS Act to be self-sufficient. Premiums had to pay the full cost of benefits. The premiums will only be affordable if younger, healthier people participate. But if having to rely on Medicaid when they get sick is the alternative, then that may be the only reason people need to purchase a policy.

Earlier this year, the Congressional Budget Office projected that the CLASS Act will save the federal government $83 billion in its first ten years of implementation. That’s a lot of money.

This month, however, the Gang of Six joined an increasingly dissonant chorus wailing against common sense and humane, rational decision-making. They don’t like the CLASS Act, so they want to get rid of it. This won’t save anyone – ever – even a dime.

The law may be flawed in its present form and need some revisions, but it’s the right idea. Private long term care financing has to be part of our Medicaid long term care financing solution.

It is too soon to tell whether the CLASS Act will be deep-sixed as part of “deficit reduction,” gutted before it takes effect, left to languish unimplemented in 2012, or implemented as promised.

But there’s no way for our elected officials to argue that they care about deficit reduction if they jettison an $83 billion savings in Medicaid.

Unless, that is, they’re planning to choose the morally reprehensible option.

If you have questions about this column, or wish to be put on an email list notifying you when new Our Health Policy Matters columns are published, please contact gionfriddopaul@gmail.com.

Get Medicare Out of the Debt Debate

2011-07-20T00:01:00.011-04:00

The U.S. debt debate is heating up as Congress and the President argue about the “cut, cap, and balance” plan and move closer to the August 2^nd deadline to raise the debt ceiling.

The debt debate is important. Our U.S. debt is now over $14 trillion, and we need to do something about it. But Medicare cuts are on the table, and war spending is not.

So I would like to propose a switch. Take Medicare cuts off the table, and put war cuts on it.

The wars in Afghanistan and Iraq have cost this country over $1.2 trillion since 2001. The debt ceiling wouldn’t even be an issue if it weren’t for these, because we never paid for them. We got the two men we wanted. It’s time to pay the bill and get out.

On the other hand, the 2011 summary of the annual report of the Medicare Trust Fund trustees shows that we still have surpluses in the Medicare Trust Funds. The Medicare Part A Trust Fund had $271.9 billion in it in 2010. The Part B and D Trust Fund had $72.1 billion in it.

Contrary to what some members of Congress would like us to believe, Medicare isn’t responsible for today’s national debt.

We should be talking about Medicare not because it has contributed to our debt, but because Medicare taxes are not covering the full cost of Medicare today and we’re dipping into the Trust Fund balance.

It won’t take very much to wipe out the Medicare deficit - certainly not as much as the Medicare “sky is falling down” politicians want us to believe.

The net government outlay for Medicare in 2010 was in the vicinity of $450 billion for a program that covers over 48 million Americans. Gross spending was about $100 billion higher than that, and included premium payments, co-pays, and costs covered by other non-governmental revenues.

To pay for this, the Medicare Part A Trust Fund had $215 billion of income in 2010, including interest. $182 billion came from dedicated Medicare taxes. The Medicare Part B and D Trust Fund had $212 billion of total income, about $205 million of which was general tax revenues.

Those reflect a shortfall in Medicare tax revenues, which are supposed to cover the cost of the program. The shortfall for this year isn’t insignificant. It is projected to be $34 billion in the Medicare Part A Trust Fund, and that will have to come from the Trust Fund balance.

However, this short-term problem was almost completely solved by the passage of the Affordable Care Act, which includes a .9% Medicare tax increase for high wage earners beginning in three years. Because of the ACA, even if Congress does nothing more to address the Medicare shortfall, it will go down to only $6 billion, or 1.8%, by 2016.

But that’s not good enough for the trustees, who also look at the problem from a long term perspective. Today’s negative numbers will add up before then, wiping out almost half of today’s $270 billion balance in the next five years.

Looking 75 years down the road, the trustees identified another problem. They calculated the current Medicare cost to be 3.76% of taxable payroll, and project that it will grow to 4.9% of taxable payroll in 2085. The current Medicare tax rate, however, is only 2.9% of taxable payroll.

So, now we know what it would take to close the long-term Medicare shortfall using tax revenues alone – a 2% increase in the Medicare tax rate. Half of this would be paid by individual taxpayers and half by their employers.

This would cost the average American making $45,000 per year less than $38 per month. It would preserve Medicare as we know it today for him, his children, his grandchildren, and probably even his great-grandchildren.

That’s it. If we did this, we wouldn’t need to embrace any of the bad ideas floating around Congress today, such as privatizing Medicare, creating Medicare vouchers, further limiting or eliminating the prescription drug benefit, forcing beneficiaries into HMOs, or raising the age of eligibility.

But if we were to do anything positive to contain costs in the next seventy-five years, such as keeping our population healthier or finding cures for any of our major chronic diseases, it would take even less to guarantee every American low-cost health insurance in retirement.

Think we can’t afford this? The average monthly cost per Medicare taxpayer for the two wars for the last ten years has been around $63 per month. Before continuing the cold war on Medicare, we should stop throwing away money on the hot ones.

If you have questions about this column or wish to be added to an email list letting you know when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

How Increasing Our Obesity Rate is Becoming Federal Policy

2011-07-13T00:01:00.011-04:00

Obesity rates in America are higher than ever.

This is the conclusion in a new Robert Wood Johnson Foundation report entitled F as in Fat: How Obesity Threatens America’s Future. Released last week, the document notes that one-third of children and two-thirds of adults are now obese or overweight.

Obesity is no minor health matter. It is linked to disease, disability, and premature death.

The report received some media attention for a couple of days, but then we had our fill of it. It faded into the news background largely because we’ve heard the story before.

No one disputes the two major causes of obesity in America. Americans take in too many calories, and work off too few.

If we accept these causes at face value, the story ends as we decide that weight is a matter of individual – not governmental – responsibility.

The individual choice argument is a powerful one for those who do not think that the government needs to “interfere” with people’s food and exercise choices. But it’s wrong.

The forces of governmental inaction regarding the food we eat are powerful.

First, the “freedom to choose” argument is the same argument the Tobacco Institute used successfully against governmental regulation of smoking for many years. Smoking was “an adult custom,” the argument went. Two-thirds of people chose not to smoke, and those who did should be left alone.

Despite overwhelming evidence about the harmful effects of smoking, it took almost thirty years to overcome most of the prejudice against governmental regulation of smoking in public places.

Second, there is an even stronger prejudice against governmental action regarding weight, because weight doesn’t have second hand effects like smoking. On the contrary, the weight debate often devolves into an argument about the extremes. Isn’t it worse to be morbidly underweight than it is to be morbidly overweight? Many people think so. Morbid underweight even carries a diagnostic label, anorexia, with no real counterpart on the opposite end of the scale.

When former Surgeon General David Satcher issued a call to action against obesity in 2001, the nation responded by grabbing a snack, taking a seat, and tuning him out. In a Forward to the RWJF report, he writes that 12% of children were overweight in 2001. The percentage tripled over the next decade. Three out of every five adults were overweight in 2001. Two out of three are today.

So why are we so bad at exercising our individual responsibility to eat well?

Governmental action, or in this case, inaction, may have something to do with it. As individuals, we are doing some things right, like eating more fruits, vegetables, and milk products today than we did a generation ago.

But the biggest weight culprit may have nothing to do with individual choice. It appears to be the sugars added during processing to the foods we eat, and the government’s failure to use its own data to regulate this added sugar effectively.

A recent USDA report notes that Americans now consume 30 teaspoons of added sugars every day. These are often added to our foods during manufacturing, long before we reach for our own sugar bowls. They add the equivalent of 477 total calories to our daily diet. We’re hooked on added sugars, which may well be the nicotine of the 21^st century.

Food manufacturers start spooning added sugars into our mouths early in our lives. Baby foods need no added sugars. According to another USDA report published in 2006, however, more than half of the sugars in babies’ teething biscuits were added sugars, as were two-thirds in a “fruit supreme” baby dessert.

We expect sweet desserts, but some non-dessert products have even more added sugars. Frozen lemonade from concentrate had more added sugar per 100 grams of carbohydrates than cinnamon raisin sweet rolls or chocolate glazed donuts. A “low calorie” Caesar dressing had almost as much added sugar as a jelly donut.

Telling us to eat less is just background noise when we’re pumping empty calories into our manufactured foods.

Our government should report on, and regulate, the sugars and other substances that are added to our foods. But the USDA agency program that produced the two reports lost 10% of its funding in 2010. It will suffer much deeper cuts if the USDA budget passed by the House in June is approved as part of the deficit reduction deal.

This program area accounts for 2% of USDA spending, and 8/100ths of one percent of the US Federal budget. Eliminating the program area entirely would close the deficit by two-tenths of 1%.

Without information or regulation, the sugars will keep coming whether we want them or not. And we’ll continue to get fat.

If you have questions about this column or wish to be added to an email list notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Florida's Medicaid Millionaires

2011-07-06T00:01:00.043-04:00

Florida recently elected to turn down – again – over $2 million in Federal money to pay the administrative costs of expanding its Medicaid long term care program’s home and community based services.

In March 2011, Florida qualified for over $35 million to join most of the rest of the nation in participating in the Money Follows the Person program. The program was created during the Bush Administration as a way of helping people move back out of nursing homes into the community.

It became so popular in the 29 states (and District of Columbia) participating in it that it was expanded as part of health reform. Thirteen additional states, including Florida, were invited to participate. Former Governor Charlie Crist authorized Florida’s Agency for Health Care Administration (AHCA) to file Florida’s application.

Rejecting the program means that people who want to leave Florida nursing homes won’t be given control of the resources they need to do so.

On the other hand, as a result of Florida’s 2011 Medicaid reform legislation, people who don’t want to leave Florida nursing homes may be forced out, and the money will go to managed care companies.

When Florida’s current Governor Rick Scott took office there was some question as to whether he would pursue the Money Follows the Person program. After saying he would not implement anything in the Affordable Care Act, he changed his mind and said that he would accept the federal money for this program. He sought approval from the Legislature to draw down the dollars.

Then, he apparently changed his mind in May, and allowed the legislative session to pass without pushing for the action needed to allow AHCA to accept the money.

After a strong reaction from the public against this decision, the Governor asked legislative leaders to revisit the issue in late June. Key Senators cast a bipartisan vote to accept the money, but House members refused on a party line vote.

Though DHHS earlier said that it would leave the door open to Florida for the remainder of the year, this action may finally kill Florida’s participation in the program.

According to an Associated Press article, at least one of those who voted against it argued that Florida did not need to duplicate its existing programs.

But Florida spends only about half as many of its Medicaid dollars on home and community-based services as the national average. In 2009, AARP put Florida’s percentage at 14%, while the national percentage was 27%.

This would suggest that at the very least, Florida does need to “duplicate” its existing programs.

Another House member correctly pointed out that although these dollars could have lessened the burden on state taxpayers, they were still federal taxpayer dollars.

This begs a bigger question. Why would Florida’s elected officials not want tax dollars Floridians pay to Washington to come back to Florida to help meet our needs? Because of this decision, Florida’s share of these federal home care tax dollars is going to be sent to, and used by, residents of 41 other states and the District of Columbia instead of Florida.

It was a nice gesture for Florida’s state legislators to send $35.7 million to the people of Texas, Arkansas, North Carolina, Georgia, Louisiana, Mississippi, Kansas, Iowa, and Ohio, among others. But they don’t represent these states.

What they did to the Floridians they do represent was the equivalent of either imposing $35.7 million in additional taxes without adding new services, or cutting $35.7 million in services without reducing taxes. Either way, Floridians lose.

These home and community-based dollars typically provide for the care of adults with disabilities. About a third of program participants nationwide have physical disabilities, and about a third more have developmental disabilities. Most of the people in Florida who would have benefited from the program are among the almost 900,000 Medicaid recipients between the ages of twenty and sixty-five.

In nursing homes, many will become Medicaid Millionaires. The lifetime cost of their nursing home care will probably exceed $1 million. So long as they remain institutionalized, there is zero chance that they will ever be able to contribute independently to the cost of that care.

If they were to return home, that picture changes. People with significant disabilities on the Money Follows the Person program are living and even working in the community again, spending – and sometimes even saving – a little money. Early evaluation data from the Kaiser Family Foundation also suggest that the program is less costly per person than either nursing home care or other home and community-based programs, like Florida’s.

Nationwide, twelve thousand people had returned to homes and apartments because of the Money Follows the Person program as of the end of 2010. It’s too bad at least some don’t get to call Florida their home today. Perhaps they’ll retire here.

If you have questions about this column or wish to receive an email notice when future Our Health Policy Matters columns are published, please contact gionfriddopaul@gmail.com.

Fifty Years Later: Class, Children, Mental Illness, and Cancer

2011-06-29T00:01:00.027-04:00

Fifty years ago, we already knew that there were environmental causes of chronic conditions like mental illness. Had we taken them on as an American nation-building project with the zeal with which we have approached nation-building overseas, we would be a healthier country today.

Will we do any better in the next half-century?

I’ve recently been reading a book written in 1969 about the 1968 Presidential campaign, called An American Melodrama. It is a very long book about a very short political campaign by today’s standards.

Bobby Kennedy, for example, didn’t announce for the Presidency until March, and George Wallace – who won several southern states as a third-party candidate – didn’t pick his running mate until October. Political scientists will find many parallels from that time to today. One example: former Governor Romney was the early favorite for the Republican nomination. (He never made it to the starting gate.)

It was a campaign and a time repeatedly rocked by violence, and worries about domestic terrorism consumed policymakers and the public. About halfway into the book, the authors – without today’s benefit of hindsight – searched for an explanation for the tensions of those days. They found it partially in a mental health study published in 1961.

It was entitled Mental Health in the Metropolis: The Midtown Manhattan Study (Volume 1).

The authors surveyed a sample of 1,660 adult residents of Midtown Manhattan. They found that 23.4% of Midtown adults were impaired by mental illness, and 45.2% had at least moderate symptoms of mental illness.

These percentages are almost identical to the percentages of US residents today who have diagnosable mental illness in a given year (around one quarter of the population) and who will have a diagnosable mental illness in their lifetime (around one half of the population).

They believed that the high percentages of mental illnesses must be related in some way to the conditions in which people lived.

So they tested this belief, by identifying and measuring attributes of good mental health:

·         Freedom from disabling inner tension
·         Ease of social interaction
·         Feeling of adequacy in social roles
·         Capacity to accept deprivations and individual differences
·         Identification with ethical and moral values
·         Adaptability to stress
·         Healthy acceptance of self
·         Conservative handling of hostilities and aggressions

They divided the Midtown population into six socioeconomic groups, and found a direct relationship between class and mental health. Only 17.5% of those in the highest socioeconomic group had symptoms of serious mental illness, versus 32.7% of those in the lowest group.

Arguably, their most important finding wasn’t just about class, however. It was about child health. They divided the adult population into the socioeconomic groups based on the socioeconomic status of their parents, not themselves. In other words, the “class” measure was a measure of the impact of childhood socioeconomic status on adult mental health.

We know today that many of the preventable causes of adult mental illness are rooted in childhood, and socioeconomic status is the culprit in a variety of chronic diseases besides mental illness.

In its recent publication Cancer Facts and Figures 2011, the American Cancer Society devotes a special section to a description of socioeconomic status as a carcinogen. Low socioeconomic status leads to a doubling of cancers among men and similar large increases in many types of cancer among women.

As public health professionals have been explaining for years, environmental factors linked to socioeconomic status – such as exposure to violence, abuse and neglect, poor diet, unsafe living conditions, lack of health insurance, limited educational opportunities, and increased risk of smoking – are among the causes of some of the most common chronic diseases in America – mental illnesses, cancers, cardiovascular disease, hypertension, and diabetes.

We haven’t addressed these environmental factors adequately in the last fifty years, and we have no unified governmental vision for doing so now, either.

We’ve been too busy fighting endlessly about the role of our government at home and insufficiently about the role of our government overseas.

We celebrate Independence Day this weekend. As we do, we should remember that we didn’t fight for our independence on foreign soil and we weren’t magically transported from 1776 to 2011 without anything happening in between. We can explain why Americans today are less healthy than their counterparts in many other developed nations by taking notice of the conditions in which we live and how we got to this point.

We may know where we want to be in the future. But if we stumble around in the present with no clear sense of our relatively recent past, we won't get there.

If you have questions about this column, or to receive emails notifying you when future Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Why Medicaid Cost Containment Fails To Contain Medicaid Costs

2011-06-22T00:01:00.011-04:00

For over thirty years, states have tried and failed to contain Medicaid costs.

And if they continue to do what they’ve always done, then “more flexibility” through block grants – code words for cutting people and benefits from the programs – isn’t going to help.

This is because the strategies they have used don’t work. I wrote a few weeks ago about problems with some of the specifics of Florida’s Medicaid reform bill this year. In this column, I want to add a more global perspective.

source: US DHHS, 2007

Between 1980 and 2004, total personal health care expenditures in the United States increased by 726%. Total Medicaid expenditures increased by 1,028%.

That’s a pretty compelling opening argument against the four common “cost containment” strategies -- cutting provider rates; reducing the number of people eligible; eliminating chronic disease detection, prevention, and management services; and making recipients pay for services.

These strategies have two things in common that lead to higher Medicaid costs – they cause patients to become sicker before getting care, and they force Medicaid to pay higher-cost providers.

Consider the well-documented problem with cutting provider rates, a most favored state strategy.

Providers often opt out of the Medicaid program when rates are cut. A Merritt Hawkins and Associates 15-city survey in 2009 found that only 65% of family practice physicians, 44% of orthopedic surgeons, 44% of dermatologists, and 41% of obstetrician/gynecologists accepted Medicaid.

The American Psychiatric Association reported in 2010 that 46% of psychiatrists were accepting no new Medicaid patients as of 2008, and only a third were participating fully in the program. Also, many who do accept Medicaid patients work in community mental health clinics, not as independent practitioners.

Paying community providers too little doesn’t keep costs down. It just pushes patients to hospitals. Medicaid paid for only 10% of all hospital care in 1980, but the percentage increased to 17% in 2004.

Ignoring the needs of the near-poor population is another strategy with the perverse consequence of raising Medicaid costs.

Poverty and illness go hand in hand. People living in poverty are approximately 50% more likely to suffer from migraines, chronic back pain, chronic neck pain, and heart disease as are people who are well off.

Yet those are the only people who often qualify for Medicaid.

This is bad for the program, because people just above the poverty level are often uninsured. They are around 10% less likely than those below poverty to have a variety of chronic conditions, including migraines, low back pain, heart disease, and cancer.

But they are also one diagnosis away from poverty and Medicaid.

According to a study published earlier this year by the U.S. Library of Medicine, treatment for localized breast cancer costs the Medicaid program an average of $22,343 after twenty-four months, but the cost of advanced breast cancer averages $117,033 over the same time period.

When the Affordable Care Act required Medicaid to cover people up to 133% of poverty in 2014, it didn’t go far enough. 200% of poverty would have been far better to reduce Medicaid costs, provided the program offered a full range of early disease detection and health maintenance services.

Though it may seem counterintuitive, covering more people with a greater range of services is the way to save Medicaid money.

Here’s an example. A major expansion in the Medicaid long term care program in the 1980s and 1990s was saving $8 billion every year by 2004.

The expansion was to new home and community-based services, beginning in 1981.

Medicaid paid 50% of the nursing home bill in 1980, but only 44% in 2004. It accomplished this by increasing Medicaid’s share of payments for home health care from 12% in 1980 to 32% in 2004. Because many home health care services cost less, the overall Medicaid share of long term care payments went from 46% for of total long term care costs in 1980 to less than 41% in 2004.

If Medicaid had continued to spend the same percentages on nursing and home care in 2004 as it spent in 1980, it would have spent $73 billion on these 2004. Its actual bill was $65 billion – not a small amount, but $8 billion per year less.

That’s a pretty big difference. Long term care costs increased by 833% in that time frame, to $158 billion. But Medicaid long term care costs increased by “only” 738%.

While program expansions are often seen as the culprit in Medicaid growth (the number of people on the program grew from approximately 20 million in 1980 to over 50 million in 2004), the long term care experience – where most of the money still goes – suggests something different.

To save Medicaid money, we should do more, not less, with it, and stop pushing “cost containment” strategies that don’t contain costs.

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