Americans Want Medicare and Medicaid Left Alone

It turns out that our health policy still matters to us, which shouldn’t surprise anybody – except a few politicians next election.

A recent Rasmussen poll found that healthcare remains the second most important issue, behind the economy, to our people.  63% say it is very important to them in determining their vote.

And last week, a new Washington Post-ABC News poll was released.

source: Washington Post-ABC News Poll, 4/14-17/11

On the two major health care spending issues of the day – Medicare and Medicaid – the public had surprisingly strong opinions.  And it seems that some political leaders are incredibly out of touch with those opinions.

Only 21% supported cutting Medicare.  78% were opposed, 65% strongly.

Only 30% supported cutting Medicaid.  69% were opposed, 52% strongly.

This comes after an avalanche of political debate about deficits that blame them on Medicare, Medicaid, and Social Security. 

Many elected officials, led by Representative Paul Ryan, single out entitlement spending as what’s wrong with government spending these days.  They favor deep cuts to health, mental health, and other safety net programs, while favoring tax cuts for corporations and the wealthy.

From the Washington Post-ABC News poll, it doesn’t appear that the people are buying what these politicians are trying to sell.

People who follow the news regularly know that the deficit is as high as it is not because of entitlements, but because of a combination of the Bush tax cuts and Congress’s waging of wars in Iraq and Afghanistan without raising any money to pay for them.

More tax cuts and more wars aren’t going to help.

The poll results show clearly that people do not blame government-run health care programs like Medicare and Medicaid for the deficit.  After all, people recognize that they pay a dedicated Medicare tax on every paycheck they receive, but no war tax.  It’s pretty hard to miss.

So when they were asked how the budget deficit should be closed, 59% of the people said through a combination of tax increases and spending cuts.

Just as there is consensus on not cutting health care, there is a great deal of consensus about where to raise taxes.  72% thought income taxes should be increased on those making more than $250,000 a year.  54% were strongly in support of this; only 17% were strongly opposed.

Interestingly, the Affordable Care Act already contains a provision to add a new Medicare tax on unearned income for those making more than $250,000, but people would like to see regular income tax rates increased on these incomes as well.

Of course, almost 80% of poll respondents had incomes less than $100,000.  It’s always easier to support raising someone else’s taxes instead of one’s own.

However, in this instance, almost half of the people were surprisingly unselfish when it comes to pitching in to help. 

45% said they would support raising taxes on all Americans while making small reductions in Medicare and Social Security benefits to bring down the deficit.  While a slim majority – 53% - opposed this approach, only 40% opposed it strongly.

However, they are very clear that they don’t want Medicare changed dramatically, to a voucher program or privatized.  65% said they want it to remain the way it is today, versus only 34% who want it changed. 

What might be the reason? The Medicare program consistently pays out well over 90% of premium dollars in benefits.  People understand that private insurers cannot match this level of efficiency, and they don’t want to pay more money for fewer benefits, for their parents or for themselves.

Even most of the 34% supporting Medicare privatization change their minds when they factor in the cost increases associated with private insurance.  When asked if they would continue to support privatization if the value of the vouchers didn’t go up as fast as their premiums, 60% said no, leaving only 14% still in favor.

People support their government-run health programs. They want a Medicaid program that will help provide for the long term care needs of elders and people with disabilities, and provide safety net coverage for the poor.

As they’ve become more experienced with private managed care, people have become more skeptical of its benefits.  They don’t want someone making what could be a life or death decision for them or their loved ones based on cost.  And they certainly don’t want this decision made somewhere in a corporate backroom.

When people say “don’t touch my government-run health care,” they’re not trying to hold onto something we can no longer afford.  They’re keeping a firm grip on the one thing standing between many of us and misery.   

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Mental Health Budget Cutters on the Wrong Side of Reality

How do we help political leaders understand that the actions they take can have a profound, long-term effect on the mental health of our population?



copyright Mental Health America, 2011

David Shern, CEO of Mental Health America and one of the nation’s leading mental health advocates, has an answer.  Arguing that “the next century of mental health in the U.S. needs to be fundamentally different” from the last one, he makes the case for a new “vision for mental health now within our grasp.”

Speaking at an April 13th seminar sponsored by the Mental Health Association of Palm Beach County, FL, Dr. Shern offered a glimpse into a policy future that could reverse the epidemic of mental illness in America. 

“The United States has the highest rate of mental illness in the world,” he began, as he laid out the present state of mental health in the United States.

·         One in four of us have diagnosable mental illnesses each year.  Half of us will have diagnosable mental illness in our lives.

·         By 2002, serious mental illness cost us $193.2 billion in lost earnings per year, an amount greater than the annual revenue of every Fortune 500 company except one.

·         The mean age of onset of mental illness in America is 14, but treatment for mental illness is typically delayed for up to ten years.

·         Chronic disease, or disability, accounts for 70% of death.  Diabetes accounts for 3% of disability, arthritis 4%, cancers 12%, cardiovascular disease 15%, and mental illness over 20%.

Dr. Shern believes that we have accepted this current state of affairs for far too long.

Serious mental illness robs people of 25 years of life, but as he pointed out, “these are not death sentences.”  With proper diagnosis, care, and rehabilitation, even 50% of people with schizophrenia can largely or fully recover.

Dr. Shern says that there is a lot we can do about mental illness.  He believes that a 21^st century mental health system should focus on both prevention and treatment. 

Mental illness prevention strategies should be modeled on the hugely successful 20^th century public health program. 

He cited compelling evidence from a 2009 IOM report that addressing environmental factors, including child abuse and assault, neighborhood and family violence, and substance-abusing caregivers, can prevent mental illness.  He used as an example a long-term Seattle-based study, which found that at-risk children whose parents received training had a 38% reduction in mental illnesses 15 years later.

To illuminate the point some more, he presented data showing that when immigrants arrive in America, they have the lower rates of mental illness of their former nations.  After several years in this country, they experience mental illness at the higher rate of the rest of our population. 

His treatment strategies are modeled on inclusion and integration. 

In his talk, he advocated for a reversal of the 20^th century practice of segregating mental health care from other health care.  He promoted collaborative care models, in which primary care and mental health professionals practice side by side.  It’s a good investment, which one insurance company found saved $2 for every dollar spent.    

He sees hope in both the Mental Health Parity Act and the Affordable Care Act, which provide for better treatment coverage and more prevention dollars for mental health.  But he observed that it took more than a decade for Congress to pass the Mental Health Parity Act, despite strong public support for it.

He derives inspiration about the future from Dr. Julius Richmond, former Surgeon General, who said that societal change requires three elements – science, the ability to implement, and political will. 

We have the science to identify the best methods for preventing and treating mental illness, he said, and the ability to implement them.

But what of our political will?

Around the country, political leaders are making people with mental illness budget scapegoats.  In a recent blog, I wrote how states are pushing huge cuts to mental health. The same day Dr. Shern gave his talk, the U.S. House voted to repeal the ACA prevention dollars he referenced. 

It is as if they believe people with mental illness are responsible for unbalanced budgets. In the face of overwhelming evidence to the contrary, they act as if nothing they do for, or to, people with mental illness will make a difference.

If they listened to Dr. Shern, they would know that they were on the wrong side of reality.  Mental illness prevention and treatment programs are working and should be expanded. 

If legislators are not careful, a new mental health catastrophe may be just around the corner from the cuts they make. 

This is an important message for every American.  And every American, Dr. Shern concludes, must play a role in creating the political will we need to change our mental health trajectory for the better.

For more information, contact Mental Health America at www.nmha.org, the Mental Health Association of Palm Beach County (www.mhapbc.org) or your local Mental Health America affiliate.  You can also get information about mental health and mental health advocacy through NAMI (www.nami.org) or your NAMI affiliate. 

For information about this blog, or to subscribe to the Our Health Policy Matters weekly email, contact gionfriddopaul@gmail.com.     

What's at Stake for Health in the Budget Debates

The President, the Congress, and State Legislatures are struggling mightily through their budget debates as if the health of the nation is at stake.  It is. But not in the way they think.

Whether wealthy people will pay more or less taxes, young people will get fewer social security benefits, and the governments will get smaller are important considerations.

But they are only important to people who are healthy enough to care about them.

What about those who aren’t? 

source: County Health Rankings, 2011

If someone were to tell you right now that you had a medical condition that was going to take 25 years from your life, would cutting spending and giving corporations tax breaks be your top legislative priority?  Would you vote for anyone who made those a bigger priority than your health?

Here are some of the people whose life expectancy today is 25 years less than the norm:

• A person born with Down Syndrome.
• A person born with Cystic Fibrosis.
• A young person diagnosed in his/her late teens with a serious mental illness.
• A person who played professional football in his 20s. 
• A woman in her thirties with Stage 4 breast cancer.
• A man in his forties diagnosed with Lou Gehrig’s disease.
• A 50-year-old man or woman with advanced congestive heart failure.

I don’t imagine these people see the budget debates the way politicians do.  Many rely on public programs and government spending for their health.  Whether they are for or against health reforms, there is a reason they are so passionate.  It’s not the money.  It’s literally life or death for them.  The sicker they become, the more they choose life.

Most of the politicians voting to privatize Medicare and cut Medicaid, or to cut $600 million from community health centers as members of Congress agreed to do last week, don’t rely on these programs to help them live well.  Terms like “medically needy” mean nothing to them.  For people who are medically needy, on the other hand, the stakes are much higher. 

Significant percentages of Americans are living with serious chronic conditions that cost a huge percent of their monthly income and most of their savings.  These Americans witness government leaders who don’t realize that when they say share the “pain” of cuts, it’s a cruel joke on people feeling real pain. 

Health spending cuts come at a real price.

This year’s county health rankings were released a couple of weeks ago.  Palm Beach County, my home for the last six years, is ranked 11^th among 67 in the State of Florida – pretty impressive.  Only 12% of us are in poor health and, based on a calculation that adds up the overall harm this does to our life expectancy, we lose only 7.5 years of life to premature death for every 100 people.

Other south Florida counties also do well.  Broward County, which ranks 10^th in the state, loses only a little over 7 years of life for every 100 residents, and Miami-Dade, ranked 8^th, does even better, losing only 6.5 years.

By contrast, northern Florida counties have some of the lowest scores in the state.  24% in Baker County are in poor health, and they lose 11.5 years of life for every 100 residents.  Union County residents fare worst of all, ranking 67^th.  They collectively lose over 21 years of life to premature death for every 100 residents.

I was feeling pretty good about my county’s ranking until I compared it to the two counties in which I lived before I moved to Florida. 

Middlesex County, CT, ranks 2^nd of Connecticut’s eight counties, and its residents lose only 4.8 years of life to premature death for every 100 people.  Despite its harsh winter climate, only 10% are in poor health.

 Travis County, TX, ranks 6^th out of 223 Texas Counties.  Even though 14% of Travis County residents are in poor health, its people lose only 5.6 years of life to premature death for every 100 people.

Why should the health of Palm Beach County’s residents be demonstrably worse than that of Middlesex County and Travis County residents?  We’ve got our fair share of fine hospitals, clinicians, and public health services.  Historically, we’re not poorer than either of these two other counties – in fact, 10 years ago per capita income was about the same for all three. 

We also have lower taxes and less government.  Connecticut has a state income tax, and property taxes there and in Travis County are much higher than they are in Palm Beach County. 

But lower taxes and less government wouldn’t account for our poorer health status.

Or would they?

Florida's $11 Billion Medicaid Gamble

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Treating the public policy arena like a casino is never a good idea.

Florida is placing an $11 billion bet on Medicaid this year.  If the state loses, we’ll all be emptying our pockets for lower services.

The bet involves moving all Medicaid recipients to managed care.  As reported in an article by Jim Saunders in Health News Florida last week, passage of this legislation this year is as close to a sure thing as there is in government.

Florida hopes to save $1 billion the first year, and $2 billion by 2013 – nearly 10% of the total State Medicaid budget.

There are three problems with this calculation.

The first is that the projected savings from moving to managed care might be too high.  In a 2009 report prepared for America’s Health Insurance Plans, the Lewin Group found that savings in 24 different state Medicaid plans ranged from half of one percent to 20% after a switch to managed care.  Savings tended to be low at first, and most were still in the single digits after several years.

The second is that the savings will be offset by lost federal revenues, because the federal government will reimburse at least 55% of Florida’s Medicaid costs the next two years.  The actual savings to taxpayers is under $1 billion in FY2013, less than half of what the Governor and legislators are claiming.

The third problem is that to achieve these savings, Florida has to include elders and people with disabilities – who together account for 70% of Medicaid expenditures – in managed care.

To many people, “managed care” means the same thing as “care delayed or denied.” If $700 million of Florida’s Medicaid savings come from denying care to nursing home residents, cutting back on treatment services to people with mental illness, and delaying care for people with mental retardation, legislators fighting Medicaid growth won’t exactly be hailed as conquering heroes.

Together, these factors leave at most $300 million in savings associated with the non-long term care Medicaid program.

But the savings may not be even that high.

The reality is that Florida had a much slower growth rate in its Medicaid program from 2004 through 2009 than did the nation as a whole. The cumulative savings in Florida over this period was 10% compared to Medicaid spending in the nation as a whole.  Florida may have already squeezed the savings from Medicaid without resorting to managed care. 

Also, there is a new cost associated with turning the program over to the private managed care companies.  Unlike the state, these companies have to make money, which has to be added into the cost calculation.

Finally, reports authored by Jack Hoadley and Joan Alker of the Georgetown Health Policy Institute and released yesterday by the Jessie Ball DuPont Fund suggest that Florida’s own Medicaid managed care pilot program has disrupted care for Medicaid recipients while saving little or no money. 

In the face of all this evidence, saving even $300 million in Medicaid non-long term care is a long shot. 

So on what is Florida wagering $11 billion? 

Senator Joe Negron, the Senate legislation’s sponsor, says that Florida will drop out of the Medicaid program if the Federal Government refuses to go along with Florida’s managed care plan.

That’s an $11 billion gamble – the annual Federal reimbursement that Senator Negron says Florida will give up if the federal government doesn’t let it switch to managed care.      

Obtaining federal approval for unpopular Medicaid changes which could disproportionately and adversely affect elders is no sure thing.     

If Florida drops out of Medicaid, 3 million Medicaid recipients will become uninsured.  This will bring the total number of uninsured people in Florida to close to 7 million – more than 35% of the population.

Hospitals, nursing homes, independent physicians, community health centers, mental health centers, and other providers do not have the capacity to absorb care for 7 million uninsured people. 

Instead, Florida would have to create and fund a new plan to pay for the care of all 7 million people.  To do this, it would have 9 billion state Medicaid dollars with which to work. 

$9 billion – or $1,300 per person – may seem like a lot of money to provide care for these 7 million people.  But they aren’t young and healthy – remember, 70% of the Medicaid dollars go to long term care – and one nursing home bed alone can cost fifty times this amount.

$9 billion could disappear in a matter of weeks.

Florida can’t afford the gamble.  If saving $300 million in the Medicaid non long-term care program is the state’s goal, it should either find out in advance if the federal government is willing to approve or find another way to do it.   

After all, Florida’s not playing with house money, but ours.