House Majority Denies Low-Income Seniors and People With Disabilies Choice of Living in Their Homes

May 12, 2017

Some followers may have noticed a long silence. I’ve just rejoined the networked world after another fall — this one, unlike the first, a complication of a complication of a condition only recently diagnosed.

As you might imagine, I’ve been dwelling on health care even more than I would have otherwise. So I was ready to launch a diatribe against major, widely-reported harms inflicted by the House repeal-replacement bill.

I’ll instead focus on another that a columnist for TalkPoverty.org ferreted out. It’s directly relevant to people in my condition, i.e., elderly and/or disabled, at least temporarily, but only those with incomes low enough for eligibility in their state’s Medicaid program.

The Affordable Care Act did more than aim to expand Medicaid eligibility nationwide. It also offered state incentives to expand Medicaid in-home services to the overlapping groups I cited above.

Among the most successful, says the TalkPoverty columnist is the Community First Choice program. It increases states’ usual federal match on their spending by 6% for services that will maximize recipients’ ability to continue living safely and as self-sufficiently as possible in their own homes.

They can receive not only help with so-called activities of daily living, e.g., bathing, eating, and health-related tasks like taking medications on schedule, but also training so they can master these tasks. They can also get equipment to assist them and training on how to use it.

Agencies may further support living at home by providing hands-on help with tasks like meal preparation, light housework and transportation.

Here’s a true win-win. We all, I suppose want to stay in our homes, assuming they’re safe and in relatively good repair.

We surely prefer living in our community to an institution where there’s no one we know and good care is far from assured. Perhaps also not one we know who cares enough and lives close enough to visit regularly.

Government agencies surely prefer this too. An in-depth AARP study found that Medicaid paid roughly three times as much for institutional care as for home-based services. The data are far from current, but there’s no reason to think the basic cost saving has significantly changed.

Another study — this one of a pilot project — found that Medicaid costs dropped by about $11,900 a year for every older adult transitioned from a nursing home back into his/her community.

The House bill would eliminate the CFC program in 2020, cutting an estimated $12 billion in federal Medicaid funding in the first six years.

It’s a minuscule fraction of the nearly the nearly $840 billion the bill would cut from Medicaid. But it would somewhat more than pay for the late-added funds states could use for high-risk insurance pools, if they opted to let insurance companies deny coverage because of pre-existing conditions.

You may have already read about this provision because it’s how the Republican leadership quelled colleagues’ well-grounded anxieties about eliminating the ACA’s guarantee against such discrimination.

People who’ve suffered injuries like mine would be vulnerable, of course. But we’re told that insurance companies have classified a wide range of conditions as pre-existing, including acne, transexuality, pregnancy and recovery from domestic violence or rape with help from therapy.

For this and other reasons, the high-risk pools probably won’t offer insurance that’s either sufficiently broad or affordable. We need only look to pools states established.

They surely won’t without a lot more money than the Medicaid shift, even if states also tap other, more broadly defined funding streams. Two conservative economists estimated the annual cost at $15-$20 billion — this back in 2010. The left-leaning Center for American Progress estimates at least $31 billion.

I’m inclined to think that some House Republicans who voted for the bill knew this, though, as we know for sure, House Speaker Ryan chose to rush it through, rather than wait for an official score from the Congressional Budget Office.

We can also, I think, be pretty sure that House Republicans know they passed a bad bill, from both the promised repeal and replace-with-something=better perspectives. They believe passing nothing would be worse, what with their valuing their re-election prospects more than their constituents’ well-being.

Happily, the Senate will start from scratch and clearly intends to take as much time as the drafters (all Republicans) feel they need.

So the story’s far from over. But broad-based research and advocacy organizations—and the rest of us interested parties—need be less focused on this one hot issue, when there are already many others.


Republicans’ Healthcare Word Choices Can’t Alter Facts

March 27, 2017

Maybe it’s because my formal education trained me to be sensitive — even hypersensitive — to words. Whatever the reason, I’m impressed and riled up when I read how House Republican leaders and some top officials in Trump administration are styling the features of their Obamacare repeal-replace bill.

Both responses because their word choices artfully appeal to widely-shared values, while obscuring basic truths that anyone who reads even a summary of their plan can see.

And just because neither the Republican House leadership nor Trump could herd enough of their cats to pass their final bill, doesn’t mean we’ve seen the end of this. Some notable examples then.

Access to Coverage. A favorite word. House Speaker Paul Ryan says it’s the Republicans’ “job to have a system where people can get access to affordable coverage.”

A Republican House staffer, speaking anonymously and thus perhaps less focused on the selling the work-in progress, said, “We would like to get to a point where we have what we call universal access, where everybody is able to access coverage to some degree or another.”

Now, access isn’t the same thing as ability to buy. For example, I have access to a full-length mink coat. The coat’s in a store I can get to. I can walk right up to it. And it’s great coverage, especially when in cold weather.

So a poor person can review a health insurance policy, with ample coverage, a minimal deductible and small co-pays. Doesn’t mean s/he can pay for it.

Now that we’ve got credible estimates of the many millions of Americans who’d no longer have health insurance, Ryan harps again on access, coupled with another favorite word — and not only in the healthcare context.

Choice. For families, Ryan says, access means, among other things, “more choices.” Well, who doesn’t like having choices? Do we like being told we must do or have some specific thing — or can’t?

But the bill, as I’ve just said, doesn’t mean more choices for lower-income families, except the choice of going without health insurance — or buying one of those low-cost, high deductible plans.

Ryan touts the larger maximum people can contribute to a health savings account, avoiding the corollaries, i.e., that only people with high-deductible plans can have them and that those who live paycheck to paycheck don’t have money to stash away.

Only 6% of families with incomes less than $30,000 a year contribute anything to an HSA now. More than half the families that contribute have incomes of at least $100,000 — a tax saver for them, rather than a needed savings account.

Freedom. When Ryan was asked how many Americans would lose coverage if the Republican’s bill became law, he said he couldn’t answer. “People are going to do what they want with their lives because we believe in individual freedom.”

And indeed we do, but only up to a point. We don’t believe everyone should be able to do whatever they want, especially when what they would cause harm to others, directly or otherwise.

In the immediate case, people would be freer to go without health insurance, since the bill would eliminate the annually-growing penalty for that.

But they’d drive up premiums because most would have reasons to believe they’d remain healthy — at least for awhile. But if they then had a medical emergency, a hospital would have to eat the costs of treating them.

An immigrant from Finland cites several other instances of the Republicans’ using “freedom” as a selling point and, as her op-ed’s headline says, explains why it’s “fake,” in contrast to the freedom she had before.

Care. The Director of the Office of Management and Budget asserts that the Republicans’ goal isn’t health insurance coverage nor a plan people can afford.

It’s care they can afford. He cites his family’s high deductible when he was in the House of Representatives, earning considerably more than would qualify them for a tax credit to subsidize it, let alone one for a family eligible for the highest.

We earlier heard something, though more extreme from the Secretary of Health and Human Services — a former orthopedic surgeon and then Republican House member who proposed his own version of repeal-replace.

While in the House, he said that he “knew oh so well how the intervention of the state and federal government into the practice of medicine destroys the ability to take care of people.”

Seems fair to gather what he means from the reported views of a radically right-wing professional organization he belonged to — minimal, if any health insurance regulations or medical quality standards, e.g., that physicians be licensed to practice, no vaccination requirements and no Medicare at all.

Well, save me from care so free of intervention. But these views hardly reflect what the majority of doctors believe — even those represented by the traditionally conservative American Medical Association, which has decided that the repeal-replace is far worse than the “imperfect” law we have.

Rebuttal Story. The Washington Post recently published a column by a doctor at primary care clinic that expressly rebuts the interference with care claim — and, by example, the other negatives that the Republicans’ word choices imply.

The doctor tells the story of one of his patients. Mr. R. first came to him when he got health insurance, having had none before because he couldn’t afford it.

The Affordable Care Act changed that, enabling him to purchase a plan that cost him less than $50 a month, thanks to the subsidies low-income people receive. But that’s not all.

Mr. R can neither read nor write. So he could hardly use the online system to choose and actually apply for a plan. He had the help of a navigator — a trained, unbiased helper — whose role the ACA established.

So he’d gotten help with logging on and entering some basic information. The the system then determined he had somewhat too much income qualify for Medicaid. So it kicked him over to the health insurance exchange.

The navigator explained terms like “premium” and “out-of-pocket maximum” and helped him fill out the forms. In short, as the physician says, “the federal policies … worked synergistically.”

Mr. R had — and still has — access to coverage, freedom, choice and care from a caring doctor. What “some politicians … seem not understand,“ the doctor says, “is that without the ACA, I wouldn’t have a relationship with patients like Mr. R at all.”

They actually do, I think, just as they understand the weasely way they’re using terms like “access,” “choice” and the rest. But what’s the alternative? To acknowledge that their bill would cause nearly as many people to have no health insurance than before the ACA?