Answering the Call

It is worth noting on this “traditional” Memorial Day of May 30^th that over 6,400 service people have lost their lives so far while fighting our two most recent wars.

Unless we put more money into health and mental health care, many thousands more will eventually lose their lives fighting the physical and mental effects of these wars.

This past weekend, we learned that 45% of returning Iraq and Afghanistan War veterans are seeking compensation for service-related injuries. 

The challenge of finding the billions of dollars needed to treat these men and women will test us as a nation. 

It will likely stoke the fires of yet another protracted battle about “public option” health care in America.

This fight is about to take place because of two reasons.

The first is that the percentage of veterans seeking compensation is twice what it was in past wars.  “Invisible” injuries with behavioral manifestations, like PTSD and traumatic brain injury, account for much of the difference.

The second is that the VA system has too little capacity to meet the needs of even the lower percentages of those who have survived past wars and made similar claims for assistance.

This usually means that we begin by denying the existence of injuries we don’t easily see. 

I remember a Memorial Day parade I attended when I was a youngster in Middletown, Connecticut.  Then, as it still does today, Middletown closed its mile-long Main Street to traffic as a collection of high school and middle school bands, children’s sports teams, public safety officers, public officials, and groups escorted war veterans past cheering crowds.

The particular parade I recall featured two of Middletown’s earliest returning Vietnam veterans.  I remember standing on the roof of a two-story building watching them as they rode in a convertible down the parade route.  They were impressive in their dress uniforms, waving to the crowd.  One, as I recall, had lost a leg in battle.  The other, an arm and an eye.

Their injuries were undeniable.

The thing about parades, though, is that once one float passes by, we always turn our heads to see what comes next. 

And with Vietnam veterans, what injuries came next weren’t always so easy to see.  Agent Orange affected thousands, addiction affected tens of thousands, and PTSD affected hundreds of thousands.  As a matter of public policy, we ignored all of these for years as the Vietnam War’s real death toll mounted. 

The ongoing lack of capacity to serve the health and mental health needs of veterans is an even bigger threat to the well-being of veterans today.

A March 2012 Gulf War Veterans’ Illnesses Task Force Report provided some recent, statistical insight into this.  It noted that of the over 500,000 service members who served in Operation Desert Shield, 152,126 filed successful service-connected disability claims.  But only half – 79,415 – received VA healthcare.  The same was true of the almost 600,000 Desert Storm service members.  165,596 filed successful service-connected disability claims, but only 87,612 received VA healthcare.

There are three times as many Iraq and Afghanistan veterans as there were Desert Shield or Desert Storm veterans.  By percentage, twice as many returning Iraq and Afghanistan service veterans are filing claims as did Gulf War-era veterans. 

Based on the current numbers of claims being filed, over 750,000 may ultimately file successful claims, and at least 400,000 already need treatment for mental illnesses.  The VA system has the capacity to provide health and mental health care to only a fraction of them.

These are wars for which most of the rest of us have been called on to make no sacrifice by public officials who dishonor the sacrifices of brave veterans when they cower in fear at the word “taxes.” 

This may seem harsh, but we were asked to pay no new taxes for these wars, in spite of the billions of dollars we spent on them and the thousands of lives we sacrificed.  Does that seem right?

We would say that we meant it when we honored the sacrifices of veterans – especially those who have died fighting our wars – when we flew our flags, visited our cemeteries, and attended our parades this week.

So here’s our choice.  Will we answer the call when asked to sacrifice more tax dollars for health and mental health care for all? 

Or will we turn our backs on our veterans once the parades have passed us by?

Wait a Minute

An accurate but off-the-mark news headline this week proclaimed that health care costs for people insured in the private sector rose twice as fast as inflation in 2010.  But it didn’t mention that health insurance premium prices rose six times as fast.

The Health Care Cost and Utilization Report, 2010 was released by the Health Care Cost Institute (HCCI).  It was based on claims data for 33 million people – one fifth of those with employer-based health insurance.

The bottom line: the consumer price index rose by only 1.6% in 2010, but health care spending was up by 3.3% for the same year.

The report summarized that “prices increased across all categories of service, with outpatient services experiencing the fastest growth.” 

This is bad news for Americans with private health insurance already fed up with low and flat salaries and the high price of health.  The cost of health care now absorbs over one-sixth of our entire gross domestic product, and just seems to grow every year.

But wait a minute.  There was a piece missing in the HCCI report.  It was related to an insured consumer’s most significant health care expensive – the cost of insurance premiums.

That would have been even more newsworthy.  The price of employer-based family insurance coverage increased by 9%, or almost six times the rate of inflation, for policies renewed in the same time frame.

You won’t find that number headlined in the HCCI report, but you will find it in an equally impressive study released by the Kaiser Family Foundation and Health Research and Educational Trust last August.

How was it possible for HCCI to overlook so significant a cost increase? 

It might have something to do with HCCI’s funding.  HCCIwas formed just last September, “with an aim” according to its website, “of becoming the nation’s leading source of information on health care costs.” An article appearing on May 21, 2012, in Kaiser Health News makes it clear that insurance companies are the sources of both HCCI data and funding.

This bias doesn’t make the data in the report bad.  But it does suggest that the actual aim of HCCI might be better re-stated as “becoming a leading source of information on health insurers’ payments.” 

Especially if HCCI plans to continue to leave out the information about health insurance premiums.

Because when you add that into the mix, here’s another headline. 

At a time when – according to insurance companies themselves – health care costs rose by just over 3%, private insurance companies increased consumer health insurance premiums by three times that amount.

Adding insult to this injury, consumers got hit not once, but twice.  HCCI noted that out-of-pocket health spending increased by 7.1%.  In other words, insurance companies also required consumers to pay twice their fair share of the increase in health care prices.

This begs the question: where did all this money go?

If the purpose of the HCCI report was to deflect our attention away from this, it won’t work. 

The public may not have all the facts at its fingertips, but a March, 2012, survey sponsored by NPR, the Robert Wood Johnson Foundation, and the Harvard School of Public Health was released this week.  It found that 77% of all respondents, and 75% of sick ones, said that insurers “charging too much money” is a major reason for rising health care costs.

Americans don’t buy it when insurers point fingers at providers, any more than they believe major providers who just point fingers at insurers.  In the survey, consumers blamed hospitals and drug manufacturers for the rise in health care costs just as much as they did insurance companies.

So here’s the real bottom line. 

When – in the private sector – health care costs increase twice as fast as CPI, out-of-pocket costs increase four times as fast as CPI, and the cost of insurance increases six times as fast, there’s plenty of blame to be spread around.

The one entity we can’t blame for the increase is the one at which everyone usually points a finger – our government.

This in no way lets the government off the hook.

Instead, the data make a compelling case that elected officials should do more, not less, to contain all health care costs – if for no other reason than to protect the interests of the people who elected them. 

Will they do this, or will they leave us at the mercy of the marketplace?

States and Rebates

If you run a small business in Florida, are self-employed in Texas, or work for a large corporation in New Jersey (see an update below), then your state insurance regulators probably haven't been working for you.

The news that 15.8 million people can expect $1.3 billion in rebates from insurers this year because of the Affordable Care Act (ACA) underscores how weak health insurance regulation has been in states across the country. 

It may come as no surprise that Florida and Texas, two leaders in the fight against ACA, have been exposed as anti-consumer.  But they are not the only states with an anti-consumer bias.

First, the good news: last week, the federal government announced that three-quarters of us will get letters beginning on July 1 telling us that our insurance plans paid out at least 80 to 85 cents in benefits for every premium dollar they collected.

This means that under ACA they met the minimum standard for a reasonable benefit payout (which is still ten or more percentage points worse than the Medicare payout). 

But there’s bad news as well.

According to new data released recently by the Kaiser Family Foundation, 31% of consumers who purchase health insurance in the individual market, 28% who get insurance in the small group market, and 19% who get insurance through the large group market were covered by plans that failed to meet the minimum standard.

Assuming the Supreme Court upholds this most important consumer protection in the Affordable Care Act, all of these people are entitled to rebates.

The amount of the rebates will vary widely.  For example, over 2,700 Alaskans in one small group plan will get over $500 each.  Over 325,000 Floridians in thirteen individual market plans will get an average of $152.  And 46,000 Connecticut residents in three individual market plans will average almost $137 in rebates.    But people insured through the individual market in Maine won’t get anything – because they weren’t overcharged in the first place.

Until the Affordable Care Act passed, this type of insurance regulation was handled by the states. 

The new data give us a picture of which states have been looking out for consumers and which haven’t. 

Here’s a link to a tableI created from the data showing what percentage of individual, small group, and large group customers will get rebates in all fifty states (excepting California) and the District of Columbia.

The two states that have done the best job in protecting the interests of state consumers are Hawaii and Rhode Island.  These are the only two states in which every health insurance plan met the minimum standard last year.

At least one plan in every other state falls short.  But New Mexico, South Dakota, Vermont, New Hampshire, North Dakota, Alabama, Alaska, Maine, and Oregon all protect well over 90% of their health insurance consumers.

However, in Florida alone, two dozen plans don’t meet the minimum standard.  Twenty-one fall short in Texas.

By far the worst state overall is New Jersey, where 62% of people covered in the individual market, 79% of those covered in the small group market, and 67% of those covered the large group market have been overcharged for their health insurance. (See an update below.)

Several other states aspire to New Jersey’s low standard. 

South Carolina and the District of Columbia have even worse consumer protection records than New Jersey in two of three areas.  And in Oklahoma, Arizona, and Texas, more than eight out of every ten consumers were overcharged in at least one of the three areas.

Who specifically is paying the price for this?

In Texas – where over 90% of those insured in the individual market were overcharged for insurance – it is people who are either self-employed or have chronic conditions which disqualify them from group coverage.

In Florida and Missouri, it is small business owners and employees.   In Florida, 73% of those covered in the small group market were overcharged for health insurance, and in Missouri, 72%.

Florida’s numbers are worse than the nation’s across the board – in addition to 73% of those in the small group market, 38% of those covered by individual plans and 37% of those covered by large group plans have been overcharged.

And Connecticut – home to the insurance capital of America – was worse than the nation as a whole in both the individual market and the large group market, where 42% and 28% were overcharged, respectively.

So should ACA consumer protections trump states’ rights?  In this case, I can think of 1.3 billion reasons why they had to.

Click here to see the full list of the states in the Kaiser rankings.

Update:  HHS released its final list of the states in June (available at this link).  The final national rebate numbers were amended downward somewhat - to 12.8 million customers receiving $1.1 billion in rebates.  As was pointed out to me by a New Jersey reader, some of the individual states' information changed dramatically in the final analysis - New Jersey's among them. The final New Jersey numbers were significantly lower than the initial Kaiser Family Foundation numbers.  $7.5 million in rebates will be given there - none in the small group market - placing New Jersey in the upper tier of states. 

Confused and Confusing

President Reagan gave his first speech on the AIDS epidemic almost twenty-five years ago on May 31, 1987.  This was after 36,058 Americans had been diagnosed with AIDS, 20,849 had died, and over a quarter of a million had been infected with HIV.

For years, he had been criticized for ignoring and underfunding the worst public health crisis of the late 20^thcentury.  

So he began his speech with a joke:

“A charity committee approaches the wealthiest man in town for a contribution.  ‘Our book shows that you haven’t contributed any money this year,’ they tell him.  ‘Does your book also show that I have an infirm mother and a disabled brother?’ he replies.  ‘Why no,’ they say, ‘we didn’t know that.’ ‘Well, I don’t give them any money.  Why should I give any to you?’”

The bad joke was an inadvertent punctuation mark on a presidency too fondly remembered by both republicans and democrats today.

On matters of health, Reagan took us backwards.  He was neither in touch with the nation’s growing needs nor successful in addressing them.

His inattention to the AIDS catastrophe in particular and public health in general were just two examples.

He also helped create a new generation of chronically homeless people when he significantly cut federal mental health funding as part of the Omnibus Budget Reconciliation Act of 1981.  During his two terms as President, he also cut funding for safety net community health centers by over 25%.

Suggesting that Reagan would be too liberal by today’s GOP standards – as both some progressives and conservatives have done – is too liberal a stretch where health policy is concerned.

It was the Bushes who were progressives by today’s standards. 

Both delivered on campaign promises to expand the government’s role in health.

“Compassionate conservative” George W. Bush doubled funding to community health centers during his term and added a prescription drug benefit to Medicare.

And George H.W. Bush significantly expanded the federal Medicaid program.

Long before blogging, those of us who wished to express our opinions publicly used the “Letters to the Editor” forum in our local newspapers.  When I was in the Connecticut Legislature in the 1980s, I communicated regularly with my constituents through my local newspaper.

Here’s something I wrote about presidential health policy in October 1988: 

“When health insurance is necessary to pay for health care, how do we ensure that everyone has access to affordable insurance?  Both presidential candidates talk about this.  Governor Dukakis believes that the answer lies in the private sector, in all employers providing health insurance to their employees.  Vice President Bush believes that the answer lies in the public sector, in expanding the state and federal financed Medicaid program.  I know this looks like a classic role reversal, but solutions to health care dilemmas defy ideology.”

You can read the full text of what I wrote here.  If you do, you’ll be either fascinated or fatigued by how little health policy progress we have made in the last 25 years. 

Today, Mitt Romney, another former governor from Massachusetts, has a position on health care more similar to Michael Dukakis than to either Reagan or Bush.

Dukakis wasn’t very persuasive arguing for the private sector solution then, and Romney hasn’t been very persuasive arguing for it now – possibly because both headed a state with a long and solid reputation for making significant public investments in health.

At least President Barack Obama, the most vocal Democratic opponent of the individual mandate in 2008 who is now its leading proponent, recognized the importance of government funding for health when he said this past weekend:

“I refuse to pay for another millionaire’s tax cut by eliminating medical research projects into things like cancer and Alzheimer’s disease.  I refuse to pay for another tax cut by… eliminating health insurance for millions of poor and elderly and disabled Americans on Medicaid.”

But this hasn’t stopped President Obama from initiating or agreeing to multiple raids on public health funding.

Are you confused by all this?  You should be.  Presidents and presidential candidates have long taken confused and confusing positions on health policy with dire consequences for the public’s health.

Need some evidence?  Connecticut had over 250,000 uninsured people when I wrote my letter back in 1988.  Today, it is one of the states with the lowest percentage of uninsured people.  It has 384,000 uninsured.  Mental illness prevalence is up, autism is epidemic, obesity and its related effects have skyrocketed, and HIV still infects over a million Americans.

And our children, we all know by now, could be the first generation to live shorter lives than their parents.

An additional note on three sources:  I took the Reagan speech anecdote from the book And the Band Played On by Randy Shilts (1988 Penguin edition). My constituent letter was published in the Middletown (CT) Press on October 7, 2008. Kaiser Health News provided the Obama quotation on May 7, 2012.  

Iraq and Back: Veterans Experience Tragic Delays in Obtaining Mental Health Care

A newly released report found that hundreds of thousands of veterans experience excessive delays in trying to obtain mental health services from the Veterans Administration (VA).  This is especially sad to consider today, both because May is Mental Health Month and the President has just renewed our troop commitment to Afghanistan.

William Hamilton was a 26 year old Iraq veteran when he died in May 2010.

One of five siblings, he joined the army when he was nineteen.

He experienced his first symptoms of mental illness while serving a tour in Iraq in 2005. He was diagnosed with PTSD and an anxiety disorder. 

He was discharged honorably later that year and sought treatment at a VA Center.

For four years, as his condition worsened, Hamilton bounced from one VA treatment setting to another. 

In 2006, he was diagnosed with major depressive disorder.  Chemical dependency complicated his treatment.  He was hospitalized at the VA on several occasions over the next two years, and had several unsuccessful VA transitional housing placements.

In 2009, he was diagnosed with schizoaffective disorder.  He had two extended stays at the VA hospital and another at a rehabilitation center. 

In 2010, he was also diagnosed with psychosis, and by then it seemed to his parents that the VA didn’t want to see him anymore. 

Three times in 2010, his parents contended, Hamilton was denied admission to a VA medical center. 

The first was early in the year after he was found running in and out of traffic and hospitalized in a community hospital.   The second was after he was hospitalized a month later after being found walking the streets naked.  

In both instances, hospital personnel documented that the VA center reported that there were no beds available those days. 

The third was a few days before he died in May.  Community hospital personnel said that when they spoke by phone with the VA center at 4:20 p.m. they were told that the VA did not accept transfers that late in the day.  So they found a Department of Defense hospital to admit him.  His parents expected him to be transferred to the VA center from there, but instead he was released three days later. 

His parents said that he was unstable.  He died four hours later when he stepped in front of a train.

Did the VA center’s failure to accept and treat William Hamilton contribute to his death that day?

His parents thought so, and the Office of the Inspector General of the Department of Veterans Affairs agreed to investigate.  It released the report of its findings a little over a month ago.

It determined that the VA center did have beds available on the first two dates in question, and should have admitted him.  However, it could not determine whether he had been denied admission in May, too. 

That’s because when it tried to verify the 4:20 pm phone call, the VA center records showed that “no outgoing calls were recorded from any VAMC extension to anywhere on the subject day.” No one could say why, but the OIG suggested that “it would not be plausible” that no outgoing calls were made during that entire day.

This tragic case is an exclamation point on a bigger story.

According to a new reportissued by the OIG just last week, hundreds of thousands of veterans experience delays in obtaining mental health evaluations and care from the VA.

The VA mandates that all initial mental health evaluations for veterans seeking mental health care from the VA for the first time be completed within fourteen days.

Over 373,000 veterans sought such care in FY2011.  Only 49% had their mental health evaluations completed within 14 days.   An estimated 28,000 evaluations were never completed at all.

The VA also mandates that patients new to a specific mental health clinic be granted appointments within fourteen days of when the veteran wants to be seen.

Out of 262,000 appointments, only 64% met this deadline.  94,000 veterans waited longer.

In Denver CO, the average wait was 19 days.  In Milwaukee WI, it was 28 days.  In Spokane WA, it was 80 days, and in Salisbury NC, it was 86. 

One of the things that jumps out at me about William Hamilton’s tragedy is that as his symptoms of mental illness became more and more serious, his treatment never seemed to catch up with his disease.

And what jumps out at me about the VA data is that where veterans’ mental health is concerned, playing catch-up seems to be the norm.

Comments are welcome on this and other columns.  If you have questions about this column or would like to receive an email notifying you when new OHPM columns are published, please email gionfriddopaul@gmail.com.