Be Careful What You Wish For

March 5, 2015

So here I was elaborating on reasons Congress should renew funding for the Children’s Health Insurance Program. No sooner had I finished the post than the Center on Budget and Policy Priorities published a damning brief on a draft bill that would — sort of.

The draft is especially worrisome because it’s the product of the chairmen of the committees that have primary responsibility for CHIP — Senator Orrin Hatch, who heads the Senate Finance Committee, and Congressman Fred Upton, head of the House Energy and Commerce Committee.

The Hatch-Upton bill would significantly reduce federal funding for CHIP in several different ways. It would, among other things:

  • Altogether deny a federal match for the healthcare costs of children in families with incomes above 300% of the federal poverty line — currently $60,270 for a single parent with two children. Eighteen states and the District of Columbia currently cover children at this income level.
  • Use the regular Medicaid matching rate, rather than the higher CHIP rate for children whose family incomes are between 250% of the FPL and the 300% cut-off. If the law were in effect now, 27 states and the District would lose, on average, 13% of their match.
  • Repeal the higher CHIP matching rate that the Affordable Care Act established for 2016 through 2019, when CHIP would officially expire, unless renewed. So all CHIP programs would take a hit, even those that cover only lower-income children.

States and the District would have have to pick up more of the costs of covering children whose family incomes aren’t low enough to qualify them for Medicaid — and more of some of those who are because the ACA provided the higher CHIP match for children states had to shift into Medicaid.

Or rather, they would if they decided to keep their CHIP programs as they are. States could, if they chose, shift children back from Medicaid to separate CHIP programs. This, CBPP says, would probably mean less comprehensive coverage and higher out-of-pocket costs.

More generally, states could change their laws to make fewer children eligible for CHIP because the Hatch-Upton bill repeals a so-called maintenance of effort provision in the ACA that prohibits them from doing this before the end of the 2019 budget year.

States could also impose long waiting periods — up to a year — before enrolling children in CHIP. They could do this for virtually all families who’d had — or “declined an offer of” — group health insurance.

States can now require waiting periods of up to 90 days, but not for all children. They must waive the waiting period for “good cause,” e.g., if the child loses health insurance because a parent dies or can no longer get coverage through an employer-sponsored plan. Children with special healthcare needs must also be able to get CHIP coverage immediately.

Only 14 states have opted for a 90-day waiting period. Thirty-three and the District have no waiting period at all. But who knows what they’d do if faced with the funding crunch the draft bill would create?

The MOE repeal and the extended waiting period option are, of course, other, though less direct ways the Hatch-Upton bill would cut federal spending for CHIP.

Still another is by omission, rather than commission. The bill would fail to renew Express Lane Eligibility — an expiring tool that allows states to use information they’ve already collected, e.g., from SNAP (food stamp) applications, to determine eligibility for Medicaid and CHIP.

This can not only reduce administrative costs, but boost enrollment — and get children the health insurance they need quicker, according to an evaluation for the U.S. Department of Health and Human Services.

Lest we should miss the intent, the bill also repeals a provision in the current CHIP law that offers states a higher match rate for interpretation and translation services so that language barriers don’t become barriers to enrollment.

In short, as the Executive Director of Georgetown University’s Center for Children and Families says, the “proposal comes with fine print that could reverse our nation’s progress in covering kids.”

Not only covering them, but as I earlier wrote, ensuring that they can receive the full range of healthcare services they need at affordable rates. By this measure, as well as others, the draft bill is hardly what we should wish for.


Children’s Health At Risk Without CHIP Funding, Even If They’re Insured

March 2, 2015

I came belatedly to an enlightening article on the potential end of funding for the Children’s Health Insurance Program. Learned more than I knew when I blogged about it last October.

Professor of Pediatrics Aaron Carroll, who wrote the piece, notes the concern about children who may have no health insurance whatever — about 2.2 million, according to one count. But he focuses mainly on concerns for those who will have coverage because their parents have an affordable family plan purchased on a health insurance exchange.

Or we surely hope so. As you’ve probably read, the Supreme Court has been asked to rule that the federal government can’t subsidize plans purchased on the exchange it established for people who live in states that didn’t create their own.

Many trustworthy experts think the Court won’t. But if it does, as many as five million children could wind up with no affordable health insurance, according to a friend-of-the-court brief filed by the American Academy of Pediatrics and seven other organizations engaged in healthcare services and advocacy for children.

Carroll doesn’t allude to this doomsday scenario. He instead makes several points in favor of renewing CHIP funding, even with the subsidies intact.

The first is that CHIP covers a larger portion of children’s healthcare costs — more than 90%, as compared to 70% in the mid-level silver benchmark plans the Affordable Care Act provides for.

A troublesome difference. Some parents, however, might opt for plans with rock-bottom monthly premiums, but even higher deductibles and other out-of-pockets. This could cause them to forgo needed care — for themselves and perhaps their children.

Cost aside, Carroll raises several concerns about the health care children could receive through plans available on the exchanges. They’re rooted in the fact that the plans, unlike CHIP, aren’t tailored to children’s healthcare needs.

The problem begins with the ACA itself. The law establishes essential benefits that all plans must cover, both those offered directly to individuals and those small employers can purchase. They include pediatric services, with vision and dental care specified.

For reasons known best to the U.S. Department of Health and Human Services, the rules are silent on all but the two named services. And they allow for a separate, optional dental care plan — at an additional, unsubsidized cost — rather than requiring coverage in the overall plan.

I don’t suppose I need to elaborate the potential consequences for low-income children.

More generally, the failure to specify essential pediatric services has allowed states to choose as the basis for their minimum requirements plans that exclude a variety of healthcare services for children.

Carroll cites, among others, services for children with learning disabilities and autism. He also notes gaps in services expressly required, e.g., care of congenital defects, hearing aids and implants for children whom hearing aids can’t help.

Another related variation applies to plans families may purchase. Some, Carroll says, have very narrow networks, i.e., hospitals and physicians whose services the insurance company will pay for.

They’re narrow for providers of pediatric care than care for adults — and especially narrow for providers of specialty care, he adds. The narrow-network plans tend to be cheaper. And we’ve some evidence that many purchasers don’t understand the trade-off.

So parents may learn, when it’s too late, that there’s no in-network children’s hospital or other source of affordable services from doctors trained to treat children with complex, chronic conditions.

What’s rather strange about CHIP is that the ACA extends it through Fiscal Year 2019 — and sets a higher federal match rate for states’ costs beginning in Fiscal Year 2016. Yet it gives the federal government authority to spend money on the program only through this fiscal year.

States may have some leftover funding, but it’s unlikely to last through the year. There’d still be a match for low-income children who’ve been served through Medicaid, rather than separate CHIP programs, but it could be lower. It would definitely be lower for the children states shifted into Medicaid, as the ACA required.

For the rest, there’s no assurance state exchanges would have insurance plans with benefits and cost-sharing comparable to CHIP. Carroll’s analysis suggests that many don’t now. They could, but wouldn’t have to if CHIP funding dries up.

Surely it would be irresponsible to let CHIP funding lapse and see what happens. If children’s health problems aren’t promptly and expertly diagnosed and/or don’t get appropriate treatment, no one can remedy the harms by restoring CHIP or refining the ACA later.

 


What Good Is Health Insurance If You Can’t See a Doctor?

January 22, 2015

I’ve already said my piece (for now) about why everyone needs comprehensive, affordable health insurance. But that’s not the end of the story for the more than 68.5 million low-income people now enrolled in Medicaid. They’ve got to find doctors who will treat them.

This may become even more difficult than it’s been in the past — and for the same reason it’s been difficult. Medicaid doesn’t pay enough. Or at least, that’s what doctors say.

As The New York Times has reported, Congress didn’t renew a now-expired provision in the Affordable Care Act that requires state Medicaid programs to pay qualifying physicians at the same rate Medicare does when they provide primary care.

Like the now-optional Medicaid expansion provision, the Medicaid parity provision has been wholly paid for by the federal government. In other words, federal funds have made up the difference between what state Medicaid programs were paying and what they had to pay because of the ACA.

The two provisions are closely related because having more low-income people enrolled in Medicaid could otherwise make it more difficult for them to get preventive and various other outpatient services when they need them — or indeed, at all.

Before the parity provision because effective, in 2013, only two states reimbursed for the covered services at the Medicare rate or higher. The shortfall in all but 11 of the rest was at least 25%, but so much higher in many that the study I’m linking to estimated the nationwide average fee boost at 73%.

As of last October, only 15 states had said they’d use their own funds to preserve, at least partially, the so-called fee bump. Twenty-two and the District of Columbia said they definitely wouldn’t, in response to a Kaiser Family Foundation survey. Only one of them — North Dakota — had previously paid more than the fee bump required.

The Center for Health Care Strategies reports, based on we don’t know what, that six states and the District “have taken it upon themselves to extend the [parity] policy on their own.” If accurate, a far larger number of Medicaid beneficiaries could wind up with health insurance that means little or nothing if they need primary care. And who doesn’t?

We don’t for sure what will happen if Congress continues to sit on its hands. We do, however, have some indications.

A survey conducted in 2011 found that nearly a third of doctors didn’t intend to accept any new Medicaid patients. Higher percents would accept new patients with private insurance or Medicare. So it wasn’t that they were all fully booked.

A deeper dive discovered that higher percents of doctors would accept new Medicaid patients in states that paid higher reimbursement rates — and conversely. Which looks like bad news for Medicaid enrollees who don’t already have — or need to change — primary care providers in a lot of states that will revert to their prior rates.

A 10-state audit conducted during the months immediately before and after the fee bump officially kicked in found that only about 58% of Medicaid patients could get an appointment with a primary care physician, though 84.7% of privately-insured patients could.

On the other hand, an Urban Institute analysis of other survey results found that only a small fraction of working-age adults who’d had Medicaid for at least a year couldn’t get an appointment — or get one soon enough.

So, as Martha Heberlein at The Children’s Health Blog observes, the access problems seem pretty well limited to new enrollees — some of them probably folks who’d gained coverage because their states expanded Medicaid.

Some doctors have said they began accepting Medicaid patients — or accepting more — because of the fee bump. A recent Urban Institute report tells us that we don’t yet have good data on whether many have done any such thing.

By the time we do, the horse may be out of the barn. And as the law stands now, it’s unclear whether either primary care physicians or Medicaid beneficiaries who can’t get needed treatment because states won’t pay enough can even get a hearing in a federal court. The U.S. Department of Justice has argued that the former can’t.

Meanwhile, a ruling that will almost surely provoke an appeal held Florida accountable for failing to ensure that children in Medicaid receive the medical and dental care they’re entitled to. Low reimbursement rates are “by far the most important factor,” the court said.

I personally find it hard to believe that rate cuts averaging nearly 43% — and over 50% in four states, including populous California and New York — will have no effect on whether Medicaid beneficiaries can get primary care when they need it.

And they’ll have suffered harms that can’t be undone — even if, as seems doubtful, the Supreme Court ultimately results in their favor.

 

 

 


Healthcare Thoughts From the Hospital Waiting Room

December 29, 2014

I started thinking about this post while I was sitting in the hospital waiting room while my husband Jesse had surgery. It’s much more difficult to write now because he died unexpectedly just before Christmas. The thoughts I had while I waited still loom large in my mind. So here we go.

Of all the things we had to worry about, paying for the surgery — and all the tests and consultations that led up to it — wasn’t one of them. Jesse was enrolled in a Medicare Advantage plan.

So most of the tests and consultations involved small copays, rather than the 20% generally required under traditional Medicare. The one exception barely broke the $100 level. And the hospital charges were tightly capped. If Jesse wasn’t well insured, these alone would have set us back more than $46,760.

Well, not us actually. (Hard to get over the plural pronoun.) I’m told Jesse’s medical debts will become the debts of his modest estate — what he hoped would make sure I was cared for when he no longer could. And it will, but wouldn’t have if he hadn’t had good health insurance coverage.

I read that Congressional Republicans (and perhaps some Democrats) want to allow people to go without health insurance again. The former are hoping that enough young, healthy (at the moment) people will opt out — and thus cause insurance purchased on an exchange to skyrocket.

The Affordable Care Act, as I’m sure you know, requires most people to have comprehensive health insurance, though they’re free to pay a penalty instead. Do we really want to enlarge the freedom to go bankrupt — or to die from conditions that could have been treated?

More to the point, House Republicans apparently favor a Medicare alternative that would shift costs to beneficiaries. I say “apparently” because Congressman Paul Ryan, who authored the House budget plans, partially revised his premium support, i.e., voucher, scheme when he was running for Vice President. Not so as to eliminate the cost shift, however.

The notion behind the vouchers, as I understand it, is that we wouldn’t go to the doctor so often, have as many tests, etc. if we had more “skin in the game,” i.e., had to pay a greater portion of the total costs of our care. At the very least, we’d shop around, as consumers do when they decide to buy, say, a car or a cell phone service contract.

This same “skin in the game” notion underlies Tennessee Governor Haslam’s proposal to require copays from the very low-income people who’d get subsidies for private health insurance, rather than coverage under Medicaid. Something of this sort is already in force in Michigan.

What might such cost-shifts have meant for us? Perhaps Jesse might not have gone to his primary care physician so soon. Then perhaps he’d have called around to price the recommended radiological tests. Then to find a surgeon.

How in the world could he, smart has he wasy, have made informed decisions about whom to engage for what — let alone whether to engage anyone at all? “Without a lot of help,” says Austin Frakt at The Incidental Economist, “one can learn a little, but not a lot about what might be good value.” And one surely can’t learn nearly enough to know whether what a doctor recommends is truly necessary.

As things played out, our Advantage plan professionals coordinated all Jesse’s care — from the first hint of trouble through the post-op exam. Appointments were scheduled for him. And every medical professional had instant access to his records because they were all electronically stored in a single system.

Here again, less stress for us.

The ACA, which Republicans will reportedly again vote to repeal, includes several provisions to promote more coordinated and integrated care. These include financial incentives for physicians and hospitals to serve Medicare beneficiaries through networks known as Accountable Care Organizations.

They are, in some ways, like the organization that managed Jesse’s care. And notwithstanding the outcome, I believe he couldn’t have gotten better.

Kevin Drum at Mother Jones bravely blogged on his cancer diagnosis — and subsequently his thankfulness for “immediate, skilled treatment,” largely covered by “great health insurance.”

“Why wouldn’t you want that for everyone?” he asked, noting, as many others have, that the U.S. is the richest country in the world.

No doubt health care here is too costly. But people who receive it aren’t to blame. Proposals that would deny them high-quality, affordable health care — whether indirectly, by driving up insurance costs, or by cost-shifting — are, to me, not only wrong-headed, but immoral.

I don’t suppose I’ve ever felt that as strongly as I do now.


How Low-Income Americans Live (and Whether They Live) Depends on Where They Live

November 3, 2014

TalkPoverty.org recently hosted an online panel discussion on policy solutions to the economic insecurity — and downright poverty — that the latest Census figures confirm.

Toward the end of the discussion, the moderator asked panelists for their views on the “political environment” for their solutions. None saw more than the remotest chance of positive action by Congress. All noted good things happening at state and local levels — and expressed hopes for more.

There’s a flip side to these good things. They aren’t happening everywhere. And they almost surely won’t. We have a sort of inequality that’s not much talked about — the markedly unequal opportunities and safety-net supports for low-income people, depending on where they live.

Nothing new about this, of course. I’m moved to remark on it by an analysis the Urban Institute published the same day as the panel discussion.

The Institute looks at what will happen to poor and near-poor uninsured adults in the 23 states that haven’t expanded their Medicaid programs, as the Affordable Care Act required, until the Supreme Court said it couldn’t.

As you may recall, the ACA had required states to provide Medicaid coverage to non-elderly adults with incomes no greater than 133% of the federal poverty line — effectively 138% because of the way income is calculated.

The law also allows anyone in the same age bracket to purchase health insurance on an exchange if they can’t get affordable health insurance through their employer, but only if their income was at least 100% of the FPL.

What this means is that an estimated 6.3 million people have fallen into a coverage gap, being ineligible for both unexpanded Medicaid and for affordable health insurance offered on an exchange.

Needless to say (I hope) very few adults so poor can get health insurance sponsored by their employers. And there’s no way they can afford to buy it at market rates.

Their median annual income is just $9,500 — 65% of the FPL, the Institute reports. But it’s considerably lower in a number of states — 61% of the FPL in three (all Southern) and 49% in Alaska, where the median annual income for left-out residents is $7,422.

And, of course, half of the adults in the coverage gap have incomes lower, which means trying to get by on no more than $800 a month in most of the non-expansion states.

Some of these states have also done their best to limit purchases on the exchange that the federal government set up because they wouldn’t create their own.

As I’m sure you’re well aware, the exchange website isn’t altogether user-friendly. Even if it were, assessing the different plans offered and deciding which to choose wouldn’t be easy, especially if you’ve never had health insurance before.

The ACA, however, provided funds for “navigators” to inform consumers and help them through the enrollment process. And the U.S. Department of Health and Human Services established requirements to make sure they could do the job, e.g., training on a range of topics, a certification exam.

At least 13 states piled additional requirements on, according to a Health Care America Now review. Texas, for example, doubled the training hour requirements and added background checks. Can’t have ex-felons advising people on health insurance, you know.

It also requires community groups to secure liability protection, e.g., an insurance policy, for the navigators they retain and to comply with a bunch of additional rules. More costs clearly intended to hamstring the groups’ activities.

Indiana and several other states did something similar through licensing requirements that reportedly cost as much as $175 per navigator. Florida barred navigators from its public health offices.

We can see the results in the latest American Community Survey figures. In Texas 22.1% of the population had no health insurance last year. In the District of Columbia and Hawaii, just 6.7% of residents didn’t. Only Massachusetts, whose own healthcare reform gave it a jumpstart, had a lower rate.

We see similar divides in other state-level policies that affect the lives of low-income people, e.g., minimum wage rates, welfare benefits. I single the ACA pushback out because it’s so egregiously political, perverse and consequential.

Political because the state governors and/or legislative majorities want the ACA to fail — and more importantly, to ensure they don’t get beaten in the next primaries by candidates even further to the right.

Perverse in part because expanding Medicaid wouldn’t cost the states one thin dime until 2016 and only 10% of the costs of health care for the newly-eligible from 2020 forward.

Some of these costs would be offset by savings on care for people without insurance, however. So the extra states would have to spend would be a miniscule percent of what they have to spend anyway — 0.3%, on average, another Urban Institute analysis found.

And some states, the Institute concluded, would probably come out ahead. Another of its studies estimated states’ total savings at $12 billion to $19 billion a year, beginning in 2020.

We don’t need number-crunching to know that states gain nothing by deterring their residents from purchasing health insurance on an exchange. If anything, they’re stiffing their hospitals, virtually all of which must provide emergency care, whether patients can pay for it or not.

But people without health insurance generally don’t get much else by way of medical care. No routine checkups to detect so-called silent health problems like diabetes and hypertension. No screenings that can detect certain types of cancers.

Nor do people without health insurance generally have the wherewithal to follow recommendations they may get, e.g., to take prescribed medications at prescribed intervals, to get followup tests.

There’s been a lot of back-and-forth among experts over how many people will die because their states haven’t expanded Medicaid. The truth is we don’t know (yet).

But it seems as clear as day that low-income people — and some not-so-low — can look forward to longer, healthier lives in some states and will die unnecessarily in others. And if that’s not inequality, then I don’t know what is.

 


Congress Fiddles While Children’s Health at Risk

October 23, 2014

More than two million children may soon have no affordable health insurance — perhaps no health insurance at all. They’re at risk because federal funding for the Children’s Health Insurance Program will expire next year, unless Congress extends it — or fixes the so-called family glitch in the Affordable Care Act.

The number rises to 2.7 million if one also counts children who are eligible for CHIP, but not enrolled and others in Medicaid because some states and the District of Columbia used CHIP funding to expand eligibility, rather than create an altogether separate program.

More than 400 organizations that advocate and provide services for children have urged Congress to keep CHIP fully funded until at least 2019 — even if, as seems unlikely, Republicans agree to fix the glitch.

But say they did. First Focus, which has been pushing hard for renewed CHIP funding, argues that the program would still be needed. First some background, then the reasons why and finally the reasons the issue is more urgent than it may seem.

What is CHIP?

Congress created CHIP in 1997 to close a gap not unlike the one that could soon open. While very poor children qualified for Medicaid, families with somewhat higher incomes couldn’t afford health insurance, especially because relatively few could get it through their employers.

At the time, 23% of children in families below twice the federal poverty line were uninsured. Last year, all but 7.3% of children had health insurance — well over half through CHIP or Medicaid, according to Families USA.

Insurance coverage is far from the whole story. CHIP is designed specifically for children’s healthcare needs. States that operate CHIP through their Medicaid plans must provide a prescribed battery of early and periodic screening, diagnostic and treatment services.

States that have standalone CHIP programs must also provide a wide range of preventive services, as well as outpatient treatment and in-hospital care.

How is CHIP funded?

CHIP is sort of like Medicaid in that the federal government pays a share of the costs states incur in providing health care for those enrolled in their programs. The so-called match varies according to a formula, just as it does with Medicaid. It’s generally higher — on average, 71%.

But unlike Medicaid, CHIP is a block grant. In other words, the federal government gives states just so much, rather than a percent of their annual costs.

If that’s not enough, states can put children on a waiting list. Or they can require families to share more of the costs, though the law puts strict limits on premiums, copays and the like — the strictest for the lowest-income families. Or they can cut reimbursement rates — a cost-saver that tends to limit access to care.

How did the ACA deal with CHIP?

The ACA requires states to shift children whose incomes are at or below 133% of the federal poverty line into Medicaid. For technical reasons, the threshold is effectively 138% of the FPL — currently $27,310 for a parent with two children. The Supreme Court’s ruling that states can’t be compelled to expand their Medicaid programs has no affect on this child coverage mandate.

At the same time, the ACA prohibited states from lowering their CHIP eligibility standards — or changing their applications procedures to reduce enrollment — until the end of Fiscal Year 2019.

It provided for a higher match, beginning in Fiscal Year 2015. But it authorized funding only till then. Seemingly another glitch resulting from the haste to get the ACA passed.

More than half the states and the District cover children in families with incomes at or above 250% of the FPL — and 19 states and the District, with incomes of at least 300% of the FPL.

So it might seem that most states and the District would have to pick up the full cost of health care for a great many children enrolled in their programs unless Congress renews CHIP funding. We thus see the Washington Post editorial board warning of a “potential unfunded mandate.”

Not so, the Vice President for Health Policy at First Focus advised me. States will have no obligation to maintain their CHIP enrollment standards and procedures if Congress doesn’t come through with federal funding.

Why do we still need CHIP?

As I’ve already noted, there’s the family glitch in the ACA. The term refers to an ambiguous provision that the Internal Revenue Service has decided bars families from getting subsidies for health insurance purchased on an exchange if a working member’s employer offers health insurance that’s affordable for him/her alone.

Family coverage, as I’m sure many of you know, is considerably more expensive than coverage for only a worker. So some children — other dependents too — will probably be priced out of the market.

It’s not just premiums we need to be concerned about. A healthcare consulting firm crunched the cost-sharing numbers in 35 states, i.e., the premiums, deductibles and copays, that families are responsible for.

The experts found that families at 160% of the FPL would face out-of-pocket costs averaging seven times what they currently pay if their children were insured through a health plan purchased on an exchange rather than CHIP.

Bigger shocks to the pocketbook for families whose children have special healthcare needs like asthma and diabetes — as much as $5,200 a year per child.

At the same time, the experts found that certain services most CHIP programs provide at no cost to the family would either not be covered at all or require cost-sharing. Only 37% of the health plans reviewed covered hearing exams, while all the CHIP plans did.

And in most cases, families would have to pay an additional premium, plus some further costs for their children’s dental care — a benefit required in CHIP.

What’s so urgent?

The federal fiscal year began only weeks ago. So it might seem that Congress has a lot of time before it has to come to grips with further funding for CHIP.

Most states, however, begin their fiscal years on July 1. Only two and the District begin theirs as late as the fed. So budget drafting is already underway. A big problem when there’s a big question mark about funding for CHIP.

Googling around, one finds many warnings of potential disruption. States unwilling, for obvious reasons, to renew their contracts with health plans. The plans, therefore, not renewing their contracts with pediatricians and other providers. Providers reluctant to accept CHIP-insured patients because they don’t know whether they’ll get paid.

And as Say Ahh! blogger Elisabeth Wright Burak adds, parents in acute anxiety because they don’t know whether their children will have affordable health insurance come fall.

Healthcare lobbyist Billy Wynne foresees troubles ahead in our fractitious Congress — worse as the months go by. We just might help create a proper sense of urgency if enough of us weigh in. A MoveOn.org petition makes this quick and easy to do.

UPDATE: Shortly after I published this, First Focus posted a new letter to Congressional leaders, signed by some 1,200 organizations. It urges them to include a four-year extension of CHIP funding in the next “legislative vehicle” that moves during the lame duck session that will begin soon after the November elections. It says that an estimate 10.2 million children could otherwise have” their health coverage disrupted.”


Lower Healthcare Spending, Better Health for Low-Income Americans

March 20, 2014

Now, here’s an interesting idea. We’re spending so much on health care because we’re under-spending on programs and services that make for a healthy population.

This is the thesis of a new book entitled The American Health Care Paradox. It’s not for the casual reader, and I confess I haven’t read it.

But public health professor and Health Stew blogger John McDonough provides a summary of the main argument, with eye-popping graphs. And we get another, broader overview of the research in slides the coauthors prepared for a conference last September.

The paradox the title refers to has been often discussed. The U.S. spends much more per capita on health care than any other highly-developed country — 50% more than the next two biggest spenders, according to recent figures from the OECD (Organisation for Economic Co-operation and Development).

But the outcomes don’t show it. Life expectancy is below the average for the OECD countries — lower, in fact, than all but eight of them, none nearly so wealthy as the U.S.

The U.S. also ranks very low on some other common health indicators — both maternal and infant mortality rates, for example, and the rate of infants born weighing dangerously little.

It’s common to attribute these, as the OECD does, to the fact that the U.S. is one of the very few developed countries without a universal healthcare system and to our extraordinarily high obesity rate – a function, the OECD suggests, of the many “disadvantaged” among us.

The American Health Care Paradox coauthors don’t dismiss these factors. But they’ve got a different explanation. Basically, we spend a lot on curing illnesses — or keeping people alive when we can’t, even when they’re almost sure to die very soon.

But we scrimp on what they call social services, e.g., education and job training, housing assistance, cash benefits for jobless workers and people with disabilities, support services for seniors and “family supports,” by which I suppose they mean things like high-quality affordable child care.

We spend less on these than any other OECD country. And our ratio of social services to healthcare spending is the lowest too. This, said ex-Wonkblogger Ezra Klein, helps explain why 5% of the population accounted for about half our healthcare spending in 2008.

Well, we’re moving bumpily (and imperfectly) toward an expanded, publicly-subsidized healthcare system. And we already have some evidence that the Affordable Care Act is slowing the growth of healthcare spending.

But at the same time, we’re in a cost-cutting mode on social services. The recent budget deal doesn’t alter this, since real-dollar spending for non-defense programs that depend on annual appropriations will be 15% lower this year — and 17% lower next year — than in 2010.

Spending isn’t the only issue. Our healthcare services move on one track and our social services on another — actually, on many tracks.

A child may show up in an emergency room on a regular basis, gasping for breath, despite the medications for her asthma. The treating physicians may suspect that mold in the home and/or fumes from the highway outside are triggers.

They’ll tell the parents, one supposes, if they’ve taken the time to talk about the home environment — and know how to listen. But linking them to a nonprofit legal service that will go after the landlord or to a public agency that could provide the assistance they’d need to move is generally not how a hospital operates.

There are some exceptions. As I’ve written before, a nonprofit called Health Leads fills “prescriptions” for food, heating and other assistance as a partner with physicians in the clinics where it’s located.

It aims, its website says, to “align the forces necessary” to change our healthcare system to one that “addresses all patients’ basic resource needs.” Forces do seem to be aligning in various ways.

Hospitals, for example, have begun tackling hunger as a health issue, as U.S. News reports.

A dozen in an Ohio-based system have been feeding local residents. The system itself has opened a grocery store with fresh produce, whole grains and the like in a food desert where one of its hospitals is located.

And some of its hospitals now screen patients for food insecurity and sign those at risk up for SNAP (the food stamp program) or give them a supply of groceries when they’re discharged.

Massachusetts General Hospital also screens for food insecurity and helps with SNAP applications, as do two of its primary care clinics. The clinics also enroll pregnant women and mothers of young children in WIC, operate food pantries and offer healthy meals cooking classes.

The Affordable Care Act provides incentives for hospitals to address public health issues like food insecurity, says the former executive director of one in Connecticut that serves low-cost meals to seniors.

Links to unaffiliated social services still seem limited, however, even though the American Health Care Paradox coauthors found that both healthcare and social service providers want the more holistic approach that linkages could provide.

They’ve got barriers to overcome, including insufficient resources. But investing in systems that would support collaboration — and in the social services themselves — would pay off in lower healthcare costs.

More genuine well-being for low-income patients too.


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