California Screaming

I first heard about James McGillivray, Lloyd “Jim” Middaugh, and Paulus “Dutch” Smit about a month ago, though not by name.

A tiny news crawler reported that three men were victims of a serial killer in southern California.

James McGillivray’s body was found near a Placentia, CA, shopping mall on December 21^st.  53 year-old McGillivray hung out almost every day at the mall.  Regulars there called him humble, unobtrusive, and a “nice guy.”  A 17 year-old commented “I don’t know why someone would kill him.”  McGillivray was sleeping when he was attacked and stabbed to death.

Jim Middaugh’s body was found along a riverbed trail in Anaheim on December 28^th.  He was also stabbed to death as he slept.  After his death, his mother – to whom Middaugh was exceptionally close – described her six foot, four inch son as a “gentle giant.”

Dutch Smit was 57 years old when his body was found outside a Yorba Linda public library on December 30^th.  He left three children and 10 grandchildren.  He was described by his daughter as “an honest and sincere soul.”  He enjoyed the library, often sitting and reading quietly for hours on end. 

McGillivray, Middaugh, and Smit had one thing in common.  

They were targeted for death because they were homeless.

The police considered McGillivray a “loiterer,” but his homelessness may have been tied to his drinking.  According to the National Coalition for the Homeless (NCH), a 2008 survey identified substance use as the leading cause of homelessness among single adults.

Smit, who called himself a wanderer, not a transient, was a hoarder who left his home when it became too unsafe to live in.  Hoarding is a symptom of mental illness.  Mental illness is the third leading cause of homelessness among single adults.

Middaugh lost his transitional living apartment for sex offenders after he had lunch with a friend at a Chinese restaurant that was too close to a public park where children might be playing.  He had been convicted for “lewd and lascivious acts on a minor under the age of 14.”  But the crime for which the 42 year old was still being punished had occurred more than twenty years in the past.

80% of crimes of violence against homeless people are committed by people under the age of 30. 

The suspect in the executions of McGillivray, Middaugh, and Smit is 23 years old.  Itzcoatl Ocampo, of Yorba Linda, CA, is a former Marine who served in Iraq.  As a Marine, Ocampo was reported to have earned at least four medals and commendations.

Ocampo was caught with blood on his hands on January 13^th, while executing a fourth homeless man, John Berry, a 64 year-old Vietnam Veteran.  Ocampo targeted the others simply because they were homeless, but apparently attacked Berry as retaliation after Berry spoke out in the media about the murders.  During the assault, a Good Samaritan intervened and chased Ocampo down. 

Police and prosecutors seem certain that Ocampo does not suffer from PTSD or other mental illness, but his attorney is not so sure.

There is no doubt that the Good Samaritan, 32 year old Donald Hopkins, now does.  He is receiving counseling after witnessing the violence because the scene keeps playing over and over again in his head.

This story – and the relative lack of national news attention it has received – bothers me a lot. 

Perhaps it is because of the way we treat homeless adults.  Of 235 cities surveyed by NCH, 33% prohibit “camping,” 30% prohibit “sitting or lying,” and 47% prohibit “loitering,” all of which are often selectively enforced against homeless people.  Of the ten "meanest cities" toward people who are homeless, three are in California, but my home state of Florida is home to four – St. Petersburg, Orlando, Bradenton, and Gainesville. 

Or maybe it is because we ostracize even children with behavioral health conditions, setting many of them on their path toward isolation and homelessness as adults.  The school district in my old Connecticut home town of Middletown made news last week for forcing such children into cell-like “scream rooms.” The federal government is now investigating.

Or maybe it is because my son also happens to live in California, and is homeless, has mental illness, and self-medicates.  He has been beaten up, cited for “sitting or lying” on a sidewalk, and been in jail, but he also loves reading in libraries, has an honest and sincere soul, and has been described as a gentle giant.

But I think what screams out most to me is that these executions call attention to our deeply flawed views about homelessness, behavioral health diseases, and the victims of violence in America.  

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.

The Curse of the Super Bowl Chargers

Are the 1994 AFC Champion San Diego Chargers a cursed team, or just a reflection of a growing trend toward chronic disease and early death in America?

Led by running back Natrone Means and linebacker Junior Seau, the 1994 Chargers won the AFC West with a record of 11 wins and 5 losses, and beat the Miami Dolphins and Pittsburgh Steelers to reach the Super Bowl.  The 53 players on the active roster averaged 26 years of age.

According to 1995 life expectancy tables, a 26 year old male could expect to live to the age 75.

But when 42 year old Lew Bush – a linebacker on that Super Bowl team – died on December 9, 2011, he was the 7^th member of the team to die more than 30 years prematurely.

Source:  ESPN Official 2011 Roster Information

There is talk that these 1994 Chargers are cursed.  The first player to die, linebacker David Griggs, was 28 when his car slid off an expressway ramp in Ft. Lauderdale and crashed into a pole in June, 1995.   The second, running back Rodney Culver, died in a plane crash in 1996.  He was 26.

Young people most often die of injuries.  So those two deaths, while untimely and tragic, didn’t make anyone think “curse.”

The third one did. In 1998, linebacker Doug Miller, also just 28, died when he was struck twice by lightning while on a camping vacation.

For the next decade, “curse” talk faded as the surviving 50 players went about their lives and careers.

Then, in 2008, two more Chargers died.  Center Curtis Whitley was 39 when he died of a reported drug overdose, and defensive lineman Chris Mims was 38 when he died of heart failure.  Mims – a relatively svelt 288 pounds for a six foot, five inch lineman in 1994 – was reported to weigh 456 pounds when he died.

Defensive lineman Shaun Lee was the sixth to die, on March 1^stof last year.  He was 44 when he lost a battle with pneumonia.  He was reported to weigh over 300 pounds and suffer from diabetes at the time of his death.

And when Lew Bush died of a heart attack in December, these seven men together had lost 280 years from their expected life spans when they played in their Super Bowl – the equivalent of nearly four full lifetimes. 

Are the untimely deaths of these young men a curse or a reflection of what causes premature death in America?

According to the NFL Players Association, the average life expectancy for an NFL football player is under 60 years.  Traumatic football injuries, such as concussions, are blamed for this.  They are a factor, but the common conditions of life in America today – including obesity, chronic disease, and non-football injuries – have been the “curse” of the Chargers.

Even if all 46 remaining members of the team now live to their normal life expectancy, the team as a whole will still have lost 5.3 years of life per player to premature death. 

NFL football players don’t have a life expectancy that is approximately 20 years less than the norm just because they played football. 

Like many other young people in our society, their lives are being claimed before their time by the cardiovascular diseases, behavioral illnesses, and other chronic conditions that result from poor diets, stress, and unhealthy habits.

This problem is real, and isn’t going to go away on its own.

The average weight of the 44 linemen, excluding tight ends, on the 2011-2012 AFC Champion New England Patriots and the 2011-2012 NFC Champion New York Giants is 306 pounds.  They are a year older than the 1994 Chargers were.  But they also weigh an average of 17 pounds more than the twenty Chargers who played the same positions in 1994.

To what do they have to look forward as they age?  If you believe the NFL Players Association, they will be walking advertisements for premature death.

They are not the only ones. 

According to AHRQ data, 60% of all Americans have at least one chronic condition, 38% have two or more, and 16% have at least three.  In this one way, we are all just like the Chargers.

Like most Americans, I enjoy watching the Super Bowl and celebrating this unique American holiday.  But we should embrace not just the game, but the light it can shed on the real curse that affects us all.  That is the curse of both men and women dying young for reasons we could have, and should have, prevented.

Update:  When Junior Seau died on May 2, 2012, he became the eighth member of the 1994 Chargers to die before the age of 45.  His death was an apparent suicide. There is widespread speculation as to whether the suicide was brain trauma related.  Suicide is also commonly linked to mental illness - another significant cause of premature death in America, known to reduce life expectancy by over 25 years.

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

The Medicaid Elephant in the Supreme Court Room

States’ Medicaid elephants are being dragged into the courts this year.  States had better be careful, or they just might get trampled under the weight of people they’ve failed to enroll.

Last week, CT News Junkie reported the story of a class action lawsuit filed on behalf of almost 7,000 potential Medicaid recipients in Connecticut as of November 2011 whose applications were not processed within the 45 days mandated by federal law.  

And Health News Florida, among others, reported that Florida’s Attorney General Pam Bondi filed a brief with the Supreme Court on behalf of twenty-six states (Connecticut is not one of them) alleging that Congress exceeds its authority when it “coerces states into accepting onerous conditions” of participation in the Medicaid program –even when it pays 90-100% of the costs of those provisions. 

The two battles raise similar questions about how states avoid Medicaid costs today.

The Supreme Court brief is supposed to be an argument against the Affordable Care Act-mandated Medicaid expansion to cover everyone up to 133% of poverty beginning in 2014.

Bondi builds her argument around a simple point.  States depend so heavily on Medicaid money from the federal government that they can’t afford to drop out of the program.

And the ACA-mandated expansion, she argues, will cost Florida almost $1 billion.

But then there’s a stunning revelation in her brief.

Most of the costs she cites have nothing to do with ACA.  They represent the cost of enrolling currently eligible people in the Medicaid program, not those who will become eligible as a result of the Affordable Care Act. 

On page 17 of the brief, she writes that “Florida anticipates spending approximately $351 million on its share of the cost for newly eligible program participants who are presently uninsured and $574 million on the currently eligible but unenrolled.”

In other words, 62% of the costs she’s claiming will result from ACA are actually costs the state should be paying today, but avoids by failing to enroll Medicaid-eligible residents.

The Connecticut class action suit attacks essentially the same issue – failure to enroll currently eligible people.

In paragraph 25 of the complaint, the plaintiffs allege that Connecticut “has set up a system to circumvent the federal timeliness requirements by making it appear that the applicant has failed to provide required documentation.” 

Throughout the nation, these practices result in the avoidance of billions of dollars of costs at the expense of elders, low income children, and people with chronic diseases and conditions – and the health and mental health providers who serve them.

Bondi’s brief suggests that new Medicaid enrollments could cost Indiana about $2 billion over ten years, Arizona and Louisiana over $7 billion, and Texas close to $25 billion.  But these numbers all appear to include the currently eligible populations.

States understandably and justifiably want to contain their Medicaid costs.  But they cross the line when they do it by turning away literally millions of people who already belong on the program.

Bondi works hard to make the currently eligible group relevant to the Affordable Care Act by stretching a silken thread of the individual mandate around them. 

She writes that “the considerable cost for the [currently eligible group] reflects the fact that, unlike for the newly eligible, Congress has not increased federal funding for those newly enrolled (but previously eligible) by virtue of the ACA’s individual mandate.  As a result, the States will continue to pay for up to half of the costs generated by the latter group’s now mandatory enrollment.”

But she stretches the thread to the breaking point.  The individual mandate doesn’t apply to the group of people currently eligible for Medicaid.  Their Medicaid enrollment is “mandatory” by virtue of existing state and federal laws that pre-date ACA.

So what happens when the Supreme Court makes its ruling this spring?

If the Court finds the Medicaid expansion constitutional, then the states will have to implement it in 2014 – and also enroll those currently eligible without further delay. 

But even if it doesn’t, the currently eligible group isn’t going away – and we now know what they will cost.  Florida will still owe at least $574 million and Connecticut will still have to enroll up to 7,000 more eligible people.

That’s the best case scenario.  The worst is that such a ruling could induce the federal government to reduce its role in the Medicaid program to avoid the “coercion” argument in the future.  Then states might have to provide coverage and care to the poor and elderly all by themselves.  

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.

What the New Mitt RomneyCare Would Mean for Health Care Costs

“States and private markets, not the federal government, hold the key to improving our health care system.”

Those are the words of Presidential candidate Mitt Romney, as he articulates his health reform vision on his campaign web site.

U.S. health care costs are around $2.5 trillion. This money buys a lot of care, and pays a lot of salaries.  One out of every six workers in America relies on the health care industry for a paycheck. 

Romney thinks that’s too big a cost for care.

“At its core of this debate,” he writes (jarringly inarticulately for an official campaign web site), “is the question of what creates better patient outcomes and more efficiency: free enterprise and consumer-driven markets, or government management and regulation?”

I realize that he wants us to answer “free enterprise and consumer-driven markets.” But in this case, that doesn’t happen to be true.

The reasons why we have even a semblance of an affordable health care system in America are government management and government regulation.  Relying on free enterprise and consumer-driven markets in their place would lead to an unmitigated (sorry about the pun) health care financing disaster.

It is the salaries of professional athletes that may best illustrate why.

In a free enterprise system akin to what Mitt Romney proposes, the salaries of the most highly skilled health care professionals might be similar to the salaries of the most highly skilled professional athletes.   In fact, they once were.  In 1950, family physicians earned an average annual salary of $12,480.  That was before Medicare, Medicaid, and a whole lot of governmental regulation. 

In 1950, the average salary of a major league baseball player was comparable - $13,300.  That was before television advertising. 

Let’s look at what has happened to health care salariessince then. 

Today, the average salary for a registered nurse is just over $67,000.  Pediatricians make almost $166,000.  Psychiatrists make $168,000, and anesthesiologists make $336,000 a year to ensure that we undergo surgery without pain and without losing our lives to a drug overdose. 

Governmental management and regulation have a great deal to do with those salaries, because the Medicare system drives the prices providers can charge to patients and private insurers.

Are they too high?  When valued public sector employees such as police officers are making $55,000 and firefighters only $47,000, it may seem so.

And in the private service sector a house painter who makes $37,000, a janitor who makes $24,000, and a child care worker making $21,000 may wonder if health care professionals would really be ten times more valuable in a free enterprise system than they are.

The answer is yes, they probably would be.  We demand highly-skilled, highly trained professionals to tend to our health.  We can’t perform surgery on ourselves, but if we had no alternative most of us would do our own painting, clean up our own messes, and give up school and work to raise our own children.

So in a free enterprise system, how highly might we value health care professionals?

There are only 4,600 neurosurgeons in the entire country.  It just so happens that there are also just over 4,600 elite professional athletes playing in the National Football League, Major League Baseball, the National Basketball Association, and the National Hockey League combined. 

Neurosurgeons are at least as highly trained and as elite a group of professionals as major league athletes.  Neurosurgeons make, on average, around $220,000 a year, though in some areas of the country the number is higher and the best can earn upwards of three-quarters of a million dollars annually.

However, major league professional athletes, who sixty years ago earned what doctors earned, now make, on average, $2.7 million dollars each, more than ten times what neurosurgeons make.  That’s the effect of free enterprise.

If we turned our health care system into more of a free enterprise system, would a professional athlete still be worth ten times as much to us as a highly-skilled surgeon and forty times as much as a nurse? 

Probably not.  The salaries of health care professionals would undoubtedly go up.

Mitt Romney’s new health care vision for America is far different from the one he envisioned as Governor of Massachusetts.  In a consumer-driven, less-regulated market, the high demand for health care would increase, not decrease, health care costs.  There isn’t really any question about this. 

In fact, the only question is why is Mitt Romney pretending otherwise?

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.

A Dime's Worth of Difference in 2012

With the Iowa caucuses finally behind us, the Presidential campaign of 2012 now begins in earnest, and will dominate our news and lives for the next year.  I predict we will hear words like "Obamacare," “Romneycare,” “government takeover,” and “individual mandate” (usually in sentences following the word “repeal”) until we can’t stand it anymore.

If this is to be our fate in the New Year, then perhaps we can take some comfort in knowing that the debate probably won’t make a dime’s worth of difference about where most of us get our health care over the next few years or how we pay for it.

This is because the 2010 Affordable Care Act and the individual mandate were not really health reform.  They were efforts to preserve health insurance as we know it, by getting more people who can afford it to purchase private insurance, and more who cannot onto the Medicaid public insurance program.

So maybe we should take a minute between caucuses, primaries, and the general election to imagine what real health reform in America would look like in 2012.

It isn’t hard.  We just have to keep in mind a few facts.

First, governments already pay approximately $1.8 trillion of our roughly $2.5 trillion annual national health care bill.  Individuals pay another $300 billion out-of-pocket.  These numbers aren’t going down, whether the Affordable Care Act is upheld or repealed by the Supreme Court in June.

Second, there is plenty of money in our health system to delivery high quality health care to everyone who needs it.  We just need to target it to prevention as well as treatment.

Third, for the relatively small amount of money they put into the system, insurance companies have been given an outsized role in determining when, where, and how our health care is delivered.

Fourth, we woefully underfund our most important health services.  Public health and prevention activities have accounted for half of the gains in life expectancy during the last century, but receive far less than 5% of health care funding. 

And fifth, we criminalize instead of preventing and treating much of mental illness, and have made jails our nation’s largest mental health institutions.

With those facts in mind, we should acknowledge what real health reform isn’t.

It is not Romney’s or Obama’s “individual mandate” to buy private health insurance people don’t want and won’t trust.

It is also not Ron Paul’s notion of leaving people to fend for themselves in some non-existent “health care marketplace.”  No civilized nation does this and we are not going to be the first.

Here’s what a true American health reform – one that would result in healthier citizens, better access to care when it is needed, lower long term costs of care, and better quality – would look like.

1.       We would rebuild our health care delivery system around the federalized funding that already dominates health financing.  Medicare would be our basic national health insurance program, and be available to everyone.

2.       Medicaid would become a federal program like Medicare, and cover only long term care needs including chronic mental illnesses.  There would be no means-tested eligibility. States would not have to pay for it or administer it, so they could lower their state taxes accordingly.

3.       Private insurers, which are already such a small part of the overall health financing market, would play a role to which they are more suited.  They could offer supplemental insurance products covering first-dollar deductibles, co-pays, and additional, discretionary consumer services (like private hospital rooms and gourmet meals) at whatever prices they could get, for whatever profit they could make. 

4.       The Medicaid program could still require that people spend down a considerable portion of their own resources before it covered the remainder of long term care costs.  But we should allow everyone to set up tax-deferred long term care savings accounts to use for themselves, members of their families, or anyone else they designate.

5.       We would double the percentage of health dollars in public health and prevention over the next ten years.

How could we finance such as system of care?  The reality is that this system probably wouldn’t cost us any more than the current one does, and would probably cost less.

Of course, we won’t get this reform, but we can dream.  And I’d much prefer such a real policy debate about health reform in 2012 to the one we’re scheduled to receive – Mitt Romney attacking the individual mandate he invented and Barack Obama defending the individual mandate he opposed. 

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.