The Top Health Policy Stories of 2011, Part Two

Last week, I shared four of the top policy stories of the year that told us something about how health policy has been trending over the past decade or more.  This week, I’m offering four more to close out the year that tell us a little about where health policy is going in the future.

4.  Connecticut Employees Choose Health.  Back in the early days of managed care, when HMOs were not yet a four-letter word and they emphasized wellness as much as health care cost containment, they proved to be popular with members.  In August, the State of Connecticut revived the concept, giving its employees the choice of a lower cost health insurance plan that emphasized wellness or their traditional comprehensive plan.  It expected 50% to choose the new wellness plan.  But the state got a big surprise.  When the dust settled in October, 97% had opted for the wellness plan.  This will cost the state much more in the first year, but will also produce more than the $100 million in health care cost savings the state originally projected for the future.

The implication for future policy – people want do more for their health, and will if they see a direct financial benefit.

3. The Florida Legislature Puts the NRA In Charge of Medicine.  During its 2011 legislative session, the Florida legislature attracted some national attention when it decided to include the National Rifle Association (NRA) in the doctor/patient relationship.  The NRA asked the legislature to prohibit pediatricians from even asking parents if there were firearms in the house so they could counsel them about firearm safety – despite well-known evidence that children are more likely to die from unintentional injury than any other cause.  The bill passed, and the pediatricians were eventually forced to go to court to stall its enforcement.  With big lobbying organizations being allowed to sit in the doctor’s office with us, is it any wonder that people wonder whose side government is on?  

The implication for future policy – Patient privacy protections will erode if “smaller government” cedes more power to private entities.

2.  The Attack on Public Health.  After the loss of almost 30,000 public health jobs nationwide between 2008 and 2010, the Association of State and Territorial Health Officials (ASTHO) headlined an April press releasewith the words “Cuts to Essential Public Health Services Jeopardize Americans’ Health.”  The proof came in an article published in Health Affairs in August, which showed that a 10% change in public health funding changed infant death rates, as well as death rates from cancer, diabetes, and heart disease. 

The implication for future – we and our children will be less healthy tomorrow because of the cuts our policy leaders have made today.

1. The Implementation of the Affordable Care Act.  The implementation of the Affordable Care Act (ACA) was once again the health story of the year.  The public is still divided.  A plurality supports it, but the combined numbers of those opposing it either because they believe it did too little or too much comprise the majority.  Meanwhile, the law has begun to affect significant numbers of Americans.  For example, in September, CMS announced that 1.3 million Medicare recipients had received drug discounts averaging over $500 per person, and another 1.3 million had gotten a free wellness visit as a result of ACA.  And this month, the National Center for Health Statistics reported that 2.5 million young adults had insurance because of ACA provisions enabling them to stay on parents’ policies.    The election campaign and the expected May or June Supreme Court ruling on its constitutionality guarantee that this will be the story of 2012, too.

The implication for the future – government’s role in determining our health care future is going to grow, not diminish.  Policymakers will continue to struggle with our expanding $2.5 trillion health care economy and the public will continue to try to figure out whose side they’re on.

In early December, Our Health Policy Matters was averaging over 2,500 readers per month, and had recorded its 20,000^th reader – not too bad for the first year of a once-a-week column focused entirely on health and mental health policy.  I appreciate you all, especially those of you who printed and shared columns with your friends, used them with your students, and offered them to readers of your own electronic journals and web sites.

I’m always interested in your ideas about how to improve the column, and how to get it in front of more people.  Please let me know (gionfriddopaul@gmail.com) if you have any suggestions for me. 

And thank you all for engaging in the health policy debate, and my best wishes for a happy, healthy, and prosperous 2012!

The Top Health Policy Stories of 2011, Part One

Public policy attacks on public health and mental health, intrusions in doctor/patient privacy, the continuing fight over the Affordable Care Act, and our collective loss of faith in private health insurance were among the top health policy story lines of 2011.

This year, eight stories make my short list.  Not all of these stories made big headlines during the year.  But they have had, or will have, an outsized impact on our lives.

I’ll begin the countdown this week with four that capture and continue some of the major trends of the recent past.   Next week, I’ll offer four more that hint at where health policy may go in the future.

8.  The Shooting of a Congresswoman.  In January, the first big health policy story of the year was about violence and mental illness – the horrible wounding of a member of Congress, and the murder of several people around her.  As the media struggled to make sense of this, it raised once again the relationship between mental illness and violence.  What it failed to do was to report that, while this particular shooter seemed mentally imbalanced, most perpetrators of violence are not, and many victims of violence either already have mental illness, or will develop it as a result.

The continuing trend – Our jails are our nation’s largest mental health institutions, and will remain so until we invest more in prevention and treatment of mental illness.   

7.  The End of the Iraq War.  The War in Iraq may have ended this month, but its health effects will be with us and our veterans for many years to come.   A GAO report released in Octobergot little mainstream media attention, but was blunt in its description of the effects of this war and others on veterans’ mental health.  The 2.1 million unique veterans who received mental health treatment in the five year period between 2006 and 2010 represented over 30% of the veterans who received any type of health care.  The fastest-growing groups of veterans receiving mental health treatment during this period were the 213,000 Iraq and Afghanistan veterans with mental health needs.  And 38% of all Iraq/Afghanistan veterans who received health care during that time required mental health care. 

The continuing trend – So long as we remain at war, veterans’ health and mental health services will need to be expanded significantly throughout the foreseeable future, and, as taxpayers, we will need to pay for them.

6.  The Death of the CLASS Act.  What does it say when the first major provision of health reform to be killed off in a bipartisan way was the one provision that had enjoyed bipartisan support for a generation?  There are at least two things about long term care most of us don’t want to face.  The first is that most of us will need it someday.  The second is that practically none of us can afford it on our own.    Rather than coming up with a meaningful public/private partnership to pay for it after almost thirty years of trying, the Administration and Congress quietly killed CLASS in October, choosing once again to keep the current, broken system in place.  This is the one where we first impoverish people when they get old and sick, and then let government pay the whole bill.

The continuing trend – Medicaid will remain the default payer for long term care.  Costs will continue to skyrocket, we’ll all continue to complain, and long term care insurance won’t gain a greater foothold in the market any time soon.   

5.  Low PCIP Enrollment Numbers.  The most compelling evidence in 2011 that we may have finally lost our faith in private insurance was found in the late summer reports of the low enrollment in the Pre-Existing Condition Insurance Program (PCIP).  This is a program that eligible uninsured people were supposed to embrace, because it pretty much guaranteed that it would pay out far more for their health care than it collected in premiums, saving each of them lots of money.  But when only 30,000 of the 4 million eligible people enrolled as of July, most of the rest seemed to be saying that they would rather take their chances on permanent financial ruin than insurance.  Or that they were already so impoverished by illness that they no longer had anything to lose.

The continuing trend – If the health insurance industry cannot restore our trust, even the people who need it most will opt out, relying only on safety net government funding.

Next week:  The final Our Health Policy Matters column of the year looks at four more big stories of the year, and their implications for the future. 

Echoes of Scrooge

Except for summertime humidity, the Florida and Connecticut “climates” don’t have a lot in common. 

For example, Connecticut has one of the best climates for health and health care, while Florida’s is in the bottom half.  On the other hand, Florida has one of the best business tax climates, while Connecticut’s is near the rear.

Their political climates are also polar opposites.  Florida’s governor is a Republican, and its Legislature is overwhelmingly Republican.  Connecticut’s governor is a Democrat, and its legislature is overwhelmingly Democratic.

And the difference in their policy climates is reflected in the way they handled their 2011 budget crises.  Connecticut raised taxes and cut spending, while Florida just cut spending.  As a result, Connecticut’s budget now balanced.  Florida, meanwhile, extended its crisis by another year.  And its Governor has just proposed cutting $2 billion from health services alone in his proposed new budget.

But for two states with so little in common, their emerging 2012 Medicaid cost containment strategies are remarkably similar echoes of the ghost of Ebenezer Scrooge.

They both want to “decrease the surplus population” of needy people on the program.  Florida is targeting kids; Connecticut young adults.

In Florida, Health News Florida reported last week that nearly 800,000 Florida residents could be forced off of Medicaid because of a new co-pay Florida has asked the Federal Government to approve.  The vast majority would be children. 

While he awaits the decision of the Feds, Florida’s governor is also proposing massive cuts in Medicaid reimbursements to a host of safety net hospitals.  Jackson Memorial Hospital in Miami would be cut by $133.5 million, Memorial Hospital in Ft. Lauderdale would be cut by $58 million, Shands Hospital in Gainesville would be cut by $52 million, Miami Children’s Hospital would lose $35 million, and Tampa General would be slashed over $32 million. 

Shands, Jackson Memorial, and Tampa General all have been ranked among the best hospitals in the country by U.S. News and World Report.   This would greatly limit poor people’s access to them.

Meanwhile, in Connecticut CT News Junkie reported that a “reduction in health care benefits, asset tests, and a potential cap on enrollment” are all under consideration by the Department overseeing its Medicaid program.

The reason is because its caseload is growing too quickly.  In 2010, Connecticut was the first state to shift 45,000 state-only medical assistance program clients – many young adults – to Medicaid under a provision of the Affordable Care Act.  The Federal Government paid 60% of the cost and the state saved millions.   But the number of people signing up for the program has grown to 70,000 in the last eighteen months, erasing the savings.

So Connecticut has sent a letter to the Federal Government asking permission to change the eligibility requirements for the program and the benefits package.

Even though Connecticut acknowledges in the letter that the poor economy is a reason for the unexpected growth in the program, its solution, like Florida’s, is to deny some of its neediest people access to care.

So here’s the question that both Florida and Connecticut must answer.

If they make these cuts, where do they think these people will go, and who do they think is going to pay the bill?

Workhouses, a favorite of Scrooge’s?  Prisons, which are already the largest mental health providers in the country? 

Or perhaps they want them to go to the hospitals from which Connecticut took $32 million in 2011 and Florida wants to take millions more in 2012? 

Of course, in both states there are good, local alternatives to cutting and slashing, and wishing and hoping that poor people will recover from disease and disability on their own. 

Connecticut could offer the same wellness and disease management program to these Medicaid recipients as it offers its 50,000 state employees.  The State projects that it will save over $100 million this way – close to what it hopes to save in Medicaid cuts. 

And Florida could stop slashing public health and prevention – which already took a $56 million hit in 2011 – and instead increasefunding to local public health departments by 10%, giving them the flexibility to spend the new dollars anyway they want.

A Health Affairsarticle this past summer showed that this approach leads to reductions in cancers, heart disease, and infant deaths (here’s a link to a related article and chart I created from the data).   

Wouldn’t these cost-saving options be preferable to a Scrooge-like denial of care to desperate children and destitute young adults? 

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Socialized Medicine in America

If there were an award given for the worst health policy exaggeration of 2011, it might well go to Newt Gingrich, Mitt Romney, Rick Perry, and a chorus of others who call the Affordable Care Act “a government takeover of health care.”

They make this charge to capture votes from a constituency that fears what life would be like if we had “socialized medicine.” 

The problem with the rhetoric is this.  It isn't true.  If you look at who pays the bill, the United States already has socialized medicine. We just get less for our money than practically anyone else in the world.

According new data from the Organisation for Economic Cooperation and Development (OECD), no other country spends close to what our government alone does on health care.  Right now, the total government share of our annual per capita health care bill is around $6,000, or over 70% of the total. 

Norway is next most expensive, but its total per capita bill is $5,352.  The government share is $4,501.  In Denmark, the government pays only $3,696 annually, and in the United Kingdom, our poster child for socialized medicine, it pays just $2,933.

There are more relevant comparisons to make, too.  According to OECD, the Canadian government’s share of its annual health care bill is 71% - exactly what ours comes to when you add in all our government costs (the OECD does not in its data reporting, which makes our government share – though still second-highest among the nations – look artificially small).  Health care costs much less in Canada than it does here, however.  The Canadian government spends only about half ($3,080 per capita) as much as ours on health care.

What are we getting for all this government spending?  Fewer doctor visits, shorter hospital stays, and less access to mental health care.

We get an average of 3.9 visits to doctors each year here, compared to 7.7 in Germany, 5.5 in the United Kingdom, and 5.5 in Canada.  People in Italy, Switzerland, and Denmark also get more doctor visits than we do.

Our average length of stay for an acute care hospital visit is 5.4 days.  In Canada, they get 7.7 days, in Germany and Switzerland, they get 7.5 days, and in the United Kingdom, they get 6.8.

And we share 2 psychiatric care beds for every 10,000 people.  Canada has 4, Germany has 5, Denmark and the United Kingdom have 6, and Switzerland has 10.

Perhaps we need less health care because we’re healthier in America. 

Only 16% of our population smokes every day, the same percentage as in Canada.  This compares favorably to Norway, Germany, and the United Kingdom, where over 20% of the population are daily smokers.

And while we consume almost 9 liters of alcohol per person per year, citizens of Germany, the United Kingdom, Switzerland, and Denmark all consume far more alcohol than we do.

But if we take better care of ourselves, have shorter hospital stays, and fewer doctor visits, shouldn’t our overall cost of care be lower, not higher, than other countries’? 

Could we be paying for quality?

We have access to a lot of medical technology, but not so much more as to explain why the cost of care is so high here.  For example, we have more MRI machines than any other country in the world, but countries like Greece, Iceland, Korea, and Finland are all beginning to catch up with us. 

And we are in a tight competition with this same set of countries in the availability of other technology.  We have less radiation therapy equipment available to our population than Iceland, fewer mammogram machines than Greece, and not as many CT Scanners as Korea. 

Of course, we don’t usually compare our health care to that in Iceland, Korea, Finland and Greece – and we shouldn’t.  Iceland’s annual total per capita health care expenditure is $3,538, Finland’s is $3,226, Greece’s is around $3,000, and Korea’s is $1,879.

So why is socialized medicine such a mess in America? 

It isn’t, and won’t ever be, on account of the Affordable Care Act’s phantom “government takeover.” 

It’s more likely because politicians pretend that private insurers play a bigger role in financing health care than they do, and give them too much power over transactions between patients and providers.   

And – unlike other countries with socialized medicine – it’s because we treat health care more as a commodity off which private businesses should profit than a public service we all need.

That’s what exaggerating politicians are really defending.

If you have questions about this column, or wish to receive an email notifying you when future Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.