Our Health Policy Matters

The President focused on income inequality in his State of the Union speech.  This is an important issue; as the gap widens between those rich and poor. But income inequality is built into our public policy at so many levels – and even at the lowest ends of the economic spectrum sometimes the “wealthier” individuals receive better benefits than those who may need them even more.  A case in point is how the insurance subsidies work in the Affordable Care Act in the aftermath of the Supreme Court ruling of 2012. In these, the poorest individuals and families – those living below poverty level – fare the worst. This is an inequality that could be repaired easily and immediately. Here’s how this particular inequality works.  If you are a single person earning $11,375 per year, you pay the highest percentage of your income for insurance as anyone in any income bracket .  An example:  If you want to buy “silver plan” health insurance on the ...

The President focused on income inequality in his State of the Union speech.  This is an important issue; as the gap widens between those rich and poor. But income inequality is built into our public policy at so many levels – and even at the lowest ends of the economic spectrum sometimes the “wealthier” individuals receive better benefits than those who may need them even more.  A case in point is how the insurance subsidies work in the Affordable Care Act in the aftermath of the Supreme Court ruling of 2012. In these, the poorest individuals and families – those living below poverty level – fare the worst. This is an inequality that could be repaired easily and immediately. Here’s how this particular inequality works.  If you are a single person earning $11,375 per year, you pay the highest percentage of your income for insurance as anyone in any income bracket .  An example:  If you want to buy “silver plan” health insurance on the ...

Within days of the Supreme Court’s ACA ruling that made the Medicaid expansion optional, the governors of Florida, South Carolina, Iowa, and Louisiana all announced that they wanted to opt out of it. The governors of six other states were considering the same thing . However they frame their views for the media, they are in fact an attack on two different constituencies.  The first is lower income uninsured families, elders, and single adults, 17 million of whom expected to become insured as a result of the expansion.  The second is safety net providers - nursing homes, hospitals, community health centers, mental health facilities, and others - who need Medicaid dollars to offset the costs of caring for people who have no insurance. Some hospital providers will even get hit twice - once when they lose direct Medicaid dollars and again when they lose their Medicaid Disproportionate Share (DSH) payments that were cut by ACA in anticipation of the Medicaid expansion...

Within days of the Supreme Court’s ACA ruling that made the Medicaid expansion optional, the governors of Florida, South Carolina, Iowa, and Louisiana all announced that they wanted to opt out of it. The governors of six other states were considering the same thing . However they frame their views for the media, they are in fact an attack on two different constituencies.  The first is lower income uninsured families, elders, and single adults, 17 million of whom expected to become insured as a result of the expansion.  The second is safety net providers - nursing homes, hospitals, community health centers, mental health facilities, and others - who need Medicaid dollars to offset the costs of caring for people who have no insurance. Some hospital providers will even get hit twice - once when they lose direct Medicaid dollars and again when they lose their Medicaid Disproportionate Share (DSH) payments that were cut by ACA in anticipation of the Medicaid expansion...

The Affordable Care Act has finally had its days in court this week. And commentators who were certain on Monday that the Supreme Court would uphold the individual mandate were just as certain on Tuesday that it would not.  Perhaps they have some special insight into the thinking of the Justices. I don’t.  I’ll just wait for the decision.  In the meantime, I’m wondering not how each of us thinks the Court will rule, but how we hope it will rule. The answer isn’t so simple, because we divide into – and often move among – three competing minority camps about health reform in general: The Affordable Care Act represents the best compromise for insuring more people while preserving most of our current public/private payer system. Expanding reform to a single payer system like those favored by other developed nations would be better.  Replacing ACA with a private market-based system is at least worth a try. If we’re as uncertain as polls cited by ...

The Affordable Care Act has finally had its days in court this week. And commentators who were certain on Monday that the Supreme Court would uphold the individual mandate were just as certain on Tuesday that it would not.  Perhaps they have some special insight into the thinking of the Justices. I don’t.  I’ll just wait for the decision.  In the meantime, I’m wondering not how each of us thinks the Court will rule, but how we hope it will rule. The answer isn’t so simple, because we divide into – and often move among – three competing minority camps about health reform in general: The Affordable Care Act represents the best compromise for insuring more people while preserving most of our current public/private payer system. Expanding reform to a single payer system like those favored by other developed nations would be better.  Replacing ACA with a private market-based system is at least worth a try. If we’re as uncertain as polls cited by ...

How will the Supreme Court respond to an argument next week that might lead to the disintegration of health care in America? In recent years, we have been making slow policy progress in better coordinating and integrating primary and specialty care, and health and mental health care.  Two milestones were the passage of the federal Mental Health Parity Act in 2008 and the Affordable Care Act provisions in 2010 that prohibit insurance discrimination against people with pre-existing conditions, both in coverage and in cost. These are opening more primary care doors to people with mental illnesses.  80% of all mental health problems are first seen in a primary care office.  And it now pays for a primary care clinician to screen for mental health problems.  According to one recent projection completed by the Mental Health Association of Palm Beach County (available on request from that organization), a primary care practitioner can generate in excess of $...

How will the Supreme Court respond to an argument next week that might lead to the disintegration of health care in America? In recent years, we have been making slow policy progress in better coordinating and integrating primary and specialty care, and health and mental health care.  Two milestones were the passage of the federal Mental Health Parity Act in 2008 and the Affordable Care Act provisions in 2010 that prohibit insurance discrimination against people with pre-existing conditions, both in coverage and in cost. These are opening more primary care doors to people with mental illnesses.  80% of all mental health problems are first seen in a primary care office.  And it now pays for a primary care clinician to screen for mental health problems.  According to one recent projection completed by the Mental Health Association of Palm Beach County (available on request from that organization), a primary care practitioner can generate in excess of $...

We’re now just a little more than a month away from the day the Supreme Court will hear the arguments that determine the fate of the Affordable Care Act.   The fight will be narrow – about the constitutionality of the individual mandate and Medicaid expansions.   The consequences for health care financing, however, will be widespread. And, ironically, both states rights conservatives and pro-national health insurance progressives may end up rooting against their own positions. To understand why, consider the four ACA Supreme Court issues that will be argued.  The first is the constitutionality of the individual mandate under the Commerce Clause of the Constitution.   To be constitutional under the Commerce Clause, a law has to regulate economic activity that “has a substantial effect” on interstate commerce.  While it may seem that all the activity under ACA will have a substantial effect on interstate commerce, Judge Vinso...

We’re now just a little more than a month away from the day the Supreme Court will hear the arguments that determine the fate of the Affordable Care Act.   The fight will be narrow – about the constitutionality of the individual mandate and Medicaid expansions.   The consequences for health care financing, however, will be widespread. And, ironically, both states rights conservatives and pro-national health insurance progressives may end up rooting against their own positions. To understand why, consider the four ACA Supreme Court issues that will be argued.  The first is the constitutionality of the individual mandate under the Commerce Clause of the Constitution.   To be constitutional under the Commerce Clause, a law has to regulate economic activity that “has a substantial effect” on interstate commerce.  While it may seem that all the activity under ACA will have a substantial effect on interstate commerce, Judge Vinso...

States’ Medicaid elephants are being dragged into the courts this year.  States had better be careful, or they just might get trampled under the weight of people they’ve failed to enroll. Last week, CT News Junkie reported the story of a class action lawsuit filed on behalf of almost 7,000 potential Medicaid recipients in Connecticut as of November 2011 whose applications were not processed within the 45 days mandated by federal law.   And Health News Florida, among others, reported that Florida’s Attorney General Pam Bondi filed a brief with the Supreme Court on behalf of twenty-six states (Connecticut is not one of them) alleging that Congress exceeds its authority when it “coerces states into accepting onerous conditions” of participation in the Medicaid program –even when it pays 90-100% of the costs of those provisions.  The two battles raise similar questions about how states avoid Medicaid costs today. The Supreme Court brief is supposed ...

States’ Medicaid elephants are being dragged into the courts this year.  States had better be careful, or they just might get trampled under the weight of people they’ve failed to enroll. Last week, CT News Junkie reported the story of a class action lawsuit filed on behalf of almost 7,000 potential Medicaid recipients in Connecticut as of November 2011 whose applications were not processed within the 45 days mandated by federal law.   And Health News Florida, among others, reported that Florida’s Attorney General Pam Bondi filed a brief with the Supreme Court on behalf of twenty-six states (Connecticut is not one of them) alleging that Congress exceeds its authority when it “coerces states into accepting onerous conditions” of participation in the Medicaid program –even when it pays 90-100% of the costs of those provisions.  The two battles raise similar questions about how states avoid Medicaid costs today. The Supreme Court brief is supposed ...

When the Supreme Court reviews the constitutionality of the Affordable Care Act next year, it will do so against the backdrop of both a national sentiment for government to do more in the area of health and significant inequalities in access to health and health care based solely on the states in which people live.   A new poll released last week by the Robert Wood Johnson Foundation and the Harvard School of Public Health found that 52% of Americans want government to put more resources into health.   Only 41% gave high grades to our health care system, and only 33% gave our public health system high grades. We would all like a more effective health and health care system.  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 new ranking of the states that reflects which states invest most effectively in our health and health care.  It was cr...