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.


What’s Behind the Fixation on Obamacare?

October 7, 2013

I’m having withdrawal symptoms. Not symptoms that my body is craving formerly-abused substances. Rather, symptoms that I want to withdraw from following what’s going on — and not — on Capitol Hill.

I’m tired, as I’m sure you are, of the day-by-day, blow-by-blow reports and commentary on who said what, what’s really on their minds, who will do what next, what they should do instead, etc.

And I’m anxious because I can’t persuade myself that this is all a lot of kabuki theater staged to ensure that Republicans up for re-election don’t lose their primaries to candidates more radically right-wing than they.

This may be simply because I’m prone to worrying — one of the things I do best, in fact.

Wonkblogger-in-chief Ezra Klein thinks the government shutdown is really a fine thing because it makes default on the debt less likely. And bad as the shutdown is, everyone knows default would be a whole lot worse.

Noam Schrieber at The New Republic arrived at a similar conclusion, based on the political calculations he supposes House Speaker John Boehner will make.

On the other hand, Howard Gleckman at the Tax Policy Center says that for many House Republicans, Obamacare is the white whale, a.k.a. Moby Dick, that so obsessed Captain Ahab.

The end result, as you may recall, was that he and all but one of his crew members died in a futile effort to kill the creature, who wouldn’t have harmed them if left alone.

There is, to me, something apt in this analogy. Obamacare clearly isn’t just a program Republicans don’t like — different somehow from the many, many other items the House leadership planned to include in its debt ceiling bill.

It’s a symbol for diverse antipathies — not the least of which is Obama. At any rate, I don’t know how else to explain what’s appearing more and more like an obsession.

Bill Moyers & Company’s Joshua Holland, among others, argues that right-wingers feel they’ve got to stop Obamacare now because otherwise Americans will soon find out that it delivers meaningful benefits.

It will thus “provide solid evidence that government can improve people’s lives.” So, Holland says, it’s “an existential threat” to the Tea Party types, who rail against “big government.”

Also, not coincidentally, against the taxes we pay for such public goods as education, clean air and water and what we’ve got by way of a safety net.

Eduardo Porter at The New York Times also refers to “an existential threat.” For him, it’s the distinct possibility that a “large slice of the middle class” will shift its allegiance to Democrats because of the benefits of Obamacare.

In short, a shrewd political calculation, rather than “only some folks gettin’ their crazy on,” in Jared Bernstein’s priceless words.

But there is some deep hostility to social programs here.

Thus, we have Washington Post columnist George Will comparing the insurance subsidies to a heroin drip that will make Americans “instant addicts” — just as we’ve become addicted to other entitlements like Social Security.

See also Senator Ted Cruz, who alleges that the President plans to get as many of us as possible “hooked on the subsidies, addicted to the sugar.”

Ah, well. Taking the most optimistic view of things, the economy will be rescued from the devastating consequences of default. And Obamacare will continue to roll out, as the law provides.

But that doesn’t mean the hard-core opposition hasn’t done damage. Some examples in my next post.


Too Many Bad Jobs and Plenty of Blame to Go Around

December 17, 2012

“We’re better at pulling people out of the stream than walking up to see who’s throwing them in.”

Bishop Gene Robinson, who said this, was speaking about the faith community at the launch of the Half in Ten campaign’s new shared prosperity report.

But I think his twist on the oft-quoted precept of another Christian social justice advocate applies more generally.

Look at public policies, for example. The safety net surely isn’t all it should be, but it does protect a large majority from utter destitution.

On the other hand, we see a high tolerance for employment practices that effectively throw people into the safety net.

Our federal policies, for example, allow employers to pay workers as little as $7.25 an hour — even less if they’re home care workers, who’ve got no minimum wage or overtime rights at all.

Companies can duck not only the minimum wage and related overtime requirements, but their obligations for the payroll taxes that will ultimately provide workers with Social Security and Medicare benefits.

They can shift jobs overseas — either directly or by contracting out work formerly performed by employees here in the U.S. Our tax code gives them incentives for the former.

When offshoring isn’t possible, companies can still contract out essential parts of their operations to other companies or to agencies that employ workers on a short-term basis — again ducking whatever payroll tax obligations they’d otherwise have.

Contracting out, whether here or abroad, can also relieve them of legal obligations for workers’ health and safety — and for maintaining insurance to compensate those who suffer on-the-job insurances or workplace-related illnesses.

And for the legal obligations they’d otherwise have under nondiscrimination laws.

In theory, temporary workers have the same basic protections they’d have as regular company employees — though none of the optional benefits, of course.

In reality, they’ve got to put up with whatever the agency and its client firms dish out because they’ll get fired if they complain. And they can have a lot to complain about, as this report from a former “warehouse slave” shows.

Unions used to provide a strong counterweight to such practices. Now they don’t because they represent only a small fraction of the private-sector workforce.

We can attribute some of the decline in union strength to changes in the economy, including the shift to temporary contract labor. But public policies have played a role too.

Twenty-four states, for example, have “right to work” laws that allow employees to benefit from the wages, benefits and other terms of employment unions negotiate without paying the dues unions need to effectively represent the workforce as a whole.

At the federal level, the National Labor Relations Board arguably doesn’t have the authority to keep companies from crippling union organizing campaigns or from making them effectively meaningless by refusing to bargain in good faith.

It’s easy to blame our policymakers for staying safely downstream. But that’s too simple, I think.

We’re collectively responsible for choosing them — and to some extent, for the policies they pursue.

But we also make other choices that give companies incentives to keep throwing people into the stream — or at the very least, no compelling reason to stop.

We may have joined the Black Friday boycott of Walmart, but how many of us don’t bargain-hunt, even when we know that our choice of rock-bottom prices puts companies that try to do the right things at a competitive disadvantage.

How many of us buy clothing, electronics, toys and other goods even when we know — or could know — that the companies they’re made for tolerate dreadful conditions in their suppliers’ factories?

Yet we sometimes do keep companies from behaving badly. Look at what’s just happened at Darden Restaurants — the company that owns some popular sit-down chains, including Olive Garden, Red Lobster and Capital Grille.

Word go out that Darden planned to exploit a deliberately-created loophole in the Affordable Care Act by cutting its workers hours just enough to put them under the threshold for mandatory employer-sponsored health insurance.

Next thing you know, a flood of negative feedback from customers, lower satisfaction scores at restaurants where Darden was testing its strategy and (horrors!) lower sales projections, leading analysts to drop their target prices for buying its stock.

The company does an about-face. Says it has no intention of converting full-time workers to part-time — or of cutting back on the health insurance coverage full-timers can get.

I don’t want to sound like a cock-eyed optimist. Darden has merely pushed the pause button on its workforce changes. Some other companies reportedly are moving ahead to convert full-time to part-time jobs. Still others are planning to do so.

And targeted consumer pressures alone aren’t going to transform working conditions in the lower layers of our growing service sector anyway.

But the Darden episode suggests that we’ve got some leverage if we care to use it.


DC Makes Right Choices on Health Care Reform

July 19, 2012

Reading about how states are responding to the Affordable Care Act, I feel proud to live in the District of Columbia.

Only 10 states have decided to expand their Medicaid programs by the 2014 deadline. The District has charged ahead.

It’s already lifted its income eligibility ceiling to 133% of the federal poverty line, as the ACA required — until the Supreme Court in effect said it couldn’t. The District has also requested — and received — a waiver to lift the ceiling to 200% of the FPL.

This is so fiscally smart.

Under a separate program called the DC Healthcare Alliance, the District had been paying the full costs of health coverage for people with incomes below 200% of the FPL who couldn’t qualify for Medicaid.

Now it’s shifted a majority of them from the Alliance into Medicaid. The federal government pays its regular 70% share of the costs. And as of 2014, it will pay 100% of the costs for the newly-eligible at or below 133% of the FPL.

Another cause for pride is the DC Council’s decision to preserve enough funding for the Alliance so that it can still cover hospital-based services for adults who can’t be shifted — mostly undocumented immigrants, we’re told.

Consider that some states are doing their best to drive these people out — most of them among the states that won’t admit even more poor U.S. citizens into their Medicaid programs.

And since I’m beating the drum here, I’ll add that the District has moved ahead to establish an exchange for health care insurance purchases, as the ACA envisions.

Only 14 states have even established the necessary legal framework. Mayor Gray signed the District’s law in January — after what seems to have been a good bit of work by an interagency task force, including efforts to get public input.

Virtually all states have gotten grants to plan exchanges, as has the District. But 17 of them decided to stop or slow down planning until the Supreme Court ruled on the ACA. Another six hadn’t really gotten started.

Now these states are behind the eight ball. If they don’t have a “blueprint” ready by November, the federal government may decide to run an exchange for them — just the kind of “takeover” conservative ACA opponents deplore.

Rhetoric aside, the laggard states may, for various reasons, wind up with a health care system that’s less satisfactory than what they’d otherwise have.

Six states have nevertheless decided not to even try to establish exchanges. Seems we’ve got a new legal strategy for making the health reform plan crash. Or maybe two.

Some ACA opponents, including a bunch of Congressional Republicans, now claim that the ACA doesn’t allow the federal government to impose penalties on employers who won’t provide adequate, affordable health insurance except in states that operate their own exchanges.

Others argue that the federal government can’t provide subsidies to households who purchase health insurance on exchanges that state inaction constrains it to create.

So we can look forward to more brawling in Congress — and perhaps another round of lawsuits.

But, as things stand now, these attacks on the ACA won’t affect District residents because our policymakers have viewed the law as an opportunity to “ensure  … access to quality, affordable health care” for all of us.

You’d think this would be a no-brainer. It’s a testimony to our times that it’s worth a shout-out.


Supreme Court Medicaid Ruling Worst for Very Poor People

July 5, 2012

Analysts and pundits have dug into the Supreme Court’s ruling on the Affordable Care Act, including the part that addresses Medicaid.

What we’re learning is very bad news for very poor people because millions — especially the poorest — are likely to remain uninsured.

Here’s why.

As I earlier wrote, the ruling essentially lets states retain their current Medicaid eligibility restrictions.

They’d forfeit the extra federal funding they’d get if they expanded their programs to include all residents (except some immigrants) with incomes at or below 133% of the federal poverty line.

But they wouldn’t lose the funding they get under the regular formula — 50% up to 73.4% of costs in the upcoming fiscal year.

We’ve had a lot of speculation about what state governors will do, especially those heading up the 26 states that challenged the law.

Some say it will be hard for them to turn down so much extra money, especially when their constituents see how other states are benefiting — and from their federal tax dollars too.

Governors will also be under pressure from their in-state hospitals — a powerful lobbying force, as the final shape of the ACA shows.

Others point out that some right-wing governors have already rejected extra federal money, e.g., some of the stimulus grants created by the Recovery Act.

And some of their states would incur quite large additional Medicaid costs — not initially, but as 2020 approaches and thereafter. A big reason is that, at this point, their programs exclude so many people an expansion would cover.

In Texas, for example, non-working parents qualify for Medicaid only if their incomes are below 12% of the federal poverty line. The cut-off for working parents is 26% of the FPL — just over $4,960 a year for a family of three.

Not surprisingly then, the combined caseloads for Medicaid and the Children’s Health Insurance Program* would initially increase by an estimated 1.2 million if the state adopts the ACA expansion criteria.

This alone, says the state’s Health and Human Services Commission, would cost the state $2 million, increasing to $1.4 billion by 2020.

What it would get from the federal government would be exponentially larger, however — total of $52.5 billion through 2019.

Florida Governor Rick Scott claims that it would cost his state about $1.9 billion to “implement a massive entitlement expansion of the Medicaid program.”

In this case too, though he doesn’t say it, the cost in part reflects the state’s very low income eligibility cut-off — 58% of the FPL for parents.

Think Progress reports that Scott and nine other governors have said they’ll definitely not accept the expansion funding. Twenty-two are still on the fence, including 15 whose states signed on to the lawsuit.

So it seems we’ll indeed see a goodly number of states with no Medicaid expansion — at least initially. We’ll thus still have millions of people with no health insurance. And they’ll be among the poorest.

The problem, as the Center on Budget and Policy Priorities explains, is the way the ACA structures tax credits to subsidize health insurance purchased on the exchanges states will establish — or the federal government establish for them.

The most generous subsidies are for people at 100% to 133% of the federal poverty line. I infer that Congress included this income bracket to extend assistance with health care coverage to documented immigrants who aren’t eligible for Medicaid.

Other people in this income bracket could purchase health insurance if their state decides not to expand its Medicaid program.

The coverage would cost them more than Medicaid would have, but the premiums would be fairly modest — at most 2% of annual income.

No subsidies, however, for people below the federal poverty line — people who can’t possible afford to buy insurance at market rates. They’re about 80% of all uninsured people who’d have become eligible for Medicaid before the Supreme Court ruled.

Congress could, of course, fix the ACA to make health insurance for these people affordable if their states won’t open Medicaid to them.

Lot of luck. Republican Congressional leaders insist that the law must, as the House Majority Leader John Boehner put it, “be ripped out by its roots” and replaced with …. Well, they’re still not saying.

This much we know. Senate Minority Leader Mitch McConnell thinks that coverage for the well over 30 million people uninsured now “is not the issue.”

As the New York Times explains, Republicans may have difficulty dismantling the ACA in its entirety. But this is cold comfort to the poor people whose only hope for health care is Medicaid.

* CHIP is part of the calculation because Texas had planned to shift some children out of the program and into Medicaid in 2014.

UPDATE: PolitiFact has just awarded a False rating to Governor Scott’s claim that expanding Florida’s Medicaid program would cost $1.9 billion. Estimates from the state’s health care agency, it says, indicate that costs for new patients added under the expansion would be about $500 million, but not until 2020.  At least, one advocacy organization has called the estimates “hyper-inflated.”


Health Care Reform Survives, But With Low-Income People at Risk

June 29, 2012

I don’t know about you, but I breathed a huge sign of relief when the first tweets announced that the Supreme Court had upheld the individual mandate in the Affordable Care Act.

I’d been thoroughly convinced by arguments that the whole ACA framework would ultimately collapse if people could go without health insurance until they needed costly care and then were entitled to it — and at the same price the company charged people who needed only routine preventive care.

What’s problematic, however, is another part of the Supreme Court decision, which may limit low-income people’s access to affordable health care. Here’s why.

Under the ACA, all individuals with incomes at or below 133% of the federal poverty line were supposed to become eligible for Medicaid in 2014, when the health insurance purchasing exchanges and subsidies for not-so-low-income people also kick in.

All, that is, except undocumented immigrants and others who’ve been in the country for less than five years.

The federal government will initially pay the full costs states incur for Medicaid caseload increases due to the higher eligibility ceiling and the expansion of coverage to adults who don’t qualify now, e.g., those without disabilities or dependent children.

The extra federal support will phase down after the first three years. Beginning in 2020, states will get only 90% of coverage costs for their newly-eligible Medicaid participants.

Still a high percent, but likely to leave them with a total of about $73 billion more to pay by 2022.

Or maybe less. As the Center on Budget and Policy Priorities notes, this estimate doesn’t factor in what state and local governments will save in health services for the uninsured, e.g., emergency room care.

Twenty-six states nevertheless filed a lawsuit claiming coercion because, under the law, they’d lose all federal funding for their Medicaid programs unless they expanded them as described.

This is really no different from the way a vast number of federal programs operate. If states want federal funding, they have to meet certain standards.

For safety net programs like Medicaid, this generally means that they have to provide certain types of benefits to people the federal law has targeted.

The Supreme Court majority, however, ruled that states can opt out of the Medicaid expansion without losing their regular share of Medicaid funding.

It seems reasonable to suppose that many, if not all of the 26 states will do just that.

Other states might follow, since they’ve been struggling with rising Medicaid costs — and paring back optional benefits — since the recession set in.

What’s going to happen to the millions of uninsured people who aren’t poor enough to qualify for Medicaid under their states’ existing laws, but plenty poor enough to make market-rate health insurance policies unaffordable?

To the able-bodied, childless adults, some of whom are poor as the proverbial church mouse — homeless even?

Well, maybe this is an idle worry. As economist-blogger Jared Bernstein observes, anti-poverty advocates won’t be the only ones fighting against state opt-outs. Health care providers have interests in Medicaid expansion too.

Mother Jones blogger Kevin Drum thinks that some state agencies will also press for expansion since they’re “already on the hook for indigent healthcare.” Better to get those indigents into Medicaid and the federal government picking up the costs.

On the other hand, Wonkblogger Ezra Klein reminds us that the Supreme Court decision is hardly the end of the story.

Both Congressional Republicans and Presidential candidate Mitt Romney have vowed to repeal the ACA.

Say they’ll replace it, but can’t (or won’t) tell us how. Clearly, however, not with anything like an individual mandate or a mandatory expansion of Medicaid.

An across-the-board sweep in November, including a 60-vote Republican majority in the Senate, could thus put us right back where we were before the ACA.

As many as 33 million people who would have had health care coverage — including as many as 17 million through Medicaid — would still be at risk of untreated illnesses and injuries or bankrupting medical costs.

One reason that 2012 is, as an op-ed in the New England Medical Journal says, “a watershed election for health care.”


Medicaid Block Grant Not The Only Threat To Health Care For Low-Income People

July 7, 2011

Economist Jared Bernstein reminds us that cost shifting is not cost saving — this in connection with Congressman Paul Ryan’s plan to convert Medicare to a voucher system.

I wonder whether the President and his White House advisors have their minds around this obvious fact — or frankly, how much they care.

What’s got me wondering is a new brief from the Center on Budget and Policy Priorities that takes us through the complexities of a proposal for Medicaid savings that the White House has offered up as part of its deficit reduction plan.

It’s called a blended rate because what it would do is create a single rate for the federal match that each state gets to help cover the costs of insuring low-income adults and children under Medicaid and CHIP (the Children’s Health Insurance Program).

Basically, the federal government now pays a fixed percentage of states’ regular Medicaid costs and a higher percentage for their costs of insuring children enrolled in CHIP.

Under the Affordable Care Act, it will initially pick up the full costs of ensuring people who become newly eligible in 2014, when the minimum federal income cut-off rises in 2014 and childless adults gain a right to coverage. It will then cover somewhat lower percentages, bottoming out at 90% in 2020.

States that expanded Medicaid coverage to childless adults before the ACA was passed will still get a match for them, even though they’re not newly eligible. This match phases in, reaching 100% in 2020.

In short, we’ve got a mix of matching rates — some higher than others. The blended rate would replace them with a single match. Which may sound okay until we learn that states would get significantly less than they would under current law.

Back in April, the White House issued its overall framework for deficit reduction. Savings from Medicaid totaled $100 billion over the first 10 years. CBPP President Robert Greenstein says that as much as $65 billion would have to come from the blended rate.

States would apparently realize some modest savings in administrative costs. But they’d be stuck with the rest of the loss from the replacement of their current and prospective matching rates.

This doesn’t mean they’d make up the difference out of their own revenues. Anyone who wonders what they’d do need only look at what they’ve already done to reduce their Medicaid costs.

They’d cut payments to health care providers, though current reimbursement rates are already so low that many physicians, particularly specialists won’t treat Medicaid participants.

They’d scale back benefits they don’t have to provide to get federal funds, e.g., dental care, eyeglasses and hearing aids, home health services, organ transplants (!).

The President apparently opposes the House Republicans’ Medicaid block grant proposal. “Not on the table” in the deficit reduction talks, says his top Medicare-Medicaid administrator.

But the impacts of the blended rate could be much the same, though probably less drastic.

The federal government would spend less, but not by reducing the costs of providing the health care that low-income people need. It would save by dumping a bigger portion of the rising costs on the states.

The states would then try to minimize the shifted costs. They too would probably rely more on cuts than on genuine cost-reduction strategies, e.g., better quality control, coordination and preventive care.

Ultimately low-income people, including children, would pay — with their health, in some cases their lives — to reduce the federal deficit.

This, I trust, is not what the President had in mind when he embraced “shared responsibility and shared sacrifice.”

NOTE: This posting and my recent cross-posting from Laura’s Life are part of  a Medicaid blog-a-thon organized by MomsRising — a virtual grassroots community that acts on issues that affect mothers and families.

UPDATE: MomsRising now has an online listing of all the blog-a-thon postings, with links. You can find it here. More member Medicaid stories are available in a story map.


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