The Worst States for Your Health, 2012

What do South Carolina, Texas, Louisiana, and Mississippi have in common?

They all find themselves among the worst states for your health.  And they all have governors who have already declared that they don’t want to expand Medicaid to uninsured adults in their states.

South Carolina ranks 40^th, Texas is 41^st, Louisiana is 44^th, and Mississippi is 47^th in the 2012 Our Health Policy Matters rankings of the states.

The worst state for your health this year is Oklahoma, which dropped from 47^th a year ago. 

New Mexico came in just ahead of Oklahoma, and just below Nevada, Mississippi, and Arkansas.  Rounding out the bottom ten were Alabama, Louisiana, West Virginia, Texas, and Montana.

Led by middle-of-the-pack Medicare and Medicaid community spending, West Virginia escaped the bottom of the rankings this year.  Its 43^rd place finish represents an improvement of seven places over last year’s worst-in-the-nation finish. 

On the other hand, Texas had a comparable fall into the bottom ten, plunging five places to a tie for 41^st from its finish last year, on the heels of bottom ten Healthy State and KidsCount Health rankings. 

Kentucky made the biggest jump out of the bottom ten during the past year, from 45^th in 2011 to 35^th in 2012.

The states with governors who have said that they will reject the Medicaid expansion are among those states whose citizens probably need it the most.

In addition to South Carolina, Texas, Louisiana, and Mississippi, three other states have governors who declared that they would refuse to expand the Medicaid program in 2014 – despite the federal government’s offer to pick up 100% of the cost in the first three years and at least 90% ever after.  Florida landed at the cusp of the bottom third, finishing in 33^rd place overall.  Georgia just managed to stay out of the bottom ten.  Only Iowa, which ranked 19^th, escaped from the bottom half of the rankings.

But what is most interesting about the rejecting states is that they all do a relatively poor job of directing their current Medicaid money toward home and community-based services.

• Georgia ranks last in that category, Florida ranks 43^rd, Mississippi ranks 42^nd, Louisiana ranks 35^th, South Carolina ranks 34^th, Texas ranks 32^nd, and Iowa ranks 25^th.

And as a group, their Healthy State rankings – a measure of how effectively the states support public health – aren’t any better.

• Mississippi ranks 50^th (last), Louisiana ranks 49^th, South Carolina ranks 45^th, Texas ranks 44^th, Georgia ranks 37th, Florida ranks 33^rd, and Iowa ranks 17^thon that measure.

The states at or near the bottom of the rankings should also be nervous about the changes Paul Ryan has proposed for the Medicare program.

• Medicare spending on community services is the one area in which many of these states shine.  Community per capita Medicare spending in Oklahoma, for example, is 13^th in the nation.  In Nevada it is 16^th. In Mississippi it is 10^th.  In Alabama it is 8^th.  And in Louisiana it is 3rd.  (Florida is first in this category.)

Ryan’s proposed transition of Medicare to a voucher program, with a cap on the value of the voucher, could turn out to be the first step in a long process that undermines these community-based Medicare services. 

Medicare recipients down the road might want to use their voucher money to continue to pay for these, but they might have to use it to cover hospital stays instead.

The full rankings are available here.

The OHPM rankings are a modest attempt to average rankings from several independent sources to provide an overall picture, relative to the other states, of both the health of a state’s population and the overall quality and accessibility of the state’s health care services. 

The rankings factor in:

• Public health and prevention
• Access to primary care services
• Access to home and community-based health services, especially for low income and elderly people
• Access to quality hospital care, including general and specialty hospital programs (including mental health)
• Private insurance coverage of the population

This year’s rankings incorporated three recently-released independent rankings.  These were the 2012 KidsCount Health Rankings, the 2011 Healthy State Rankings, and the 2012 U.S. News and World Report Hospital Ratings.  They also factored in the most recent CMS data on state per capita community (non-hospital and non-nursing home) Medicare and Medicaid spending on community health care services, and Kaiser State Health Facts data on the state’s prevalence of nurse practitioners and the state percentage of privately-insured individuals.     

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

The Best States for Your Health, 2012

If you want to live in the state where Medicare pays the most per capita for home-based care for elders, then Florida is the place for you.  On the other hand, if you prefer the state which does the best job of protecting the health of its children, then head to Vermont.

But if you want to live in the best state for your overall health, then Connecticut is where you want to be.

Connecticut is the new number one in the 2012 Our Health Policy Matters Best States for Your Health Rankings.  Last year’s runner-up switched places with last year’s winner, Massachusetts, dropping its northern neighbor into second.

The OHPM rankings are a compilation of seven independent rankings and ratings of states.  The sources from which the final OHPM rankings are drawn are described below. 

Connecticut made the top by scoring well across the board, finishing second in Medicaid spending on community services, third in the Healthy State rankings and in the percentage of people privately insured, fourth in access to nurse practitioners, sixth in the KidsCount children’s health rankings, 12^th in Medicare spending on community services, and 20^thin in-state access to high quality hospital programs.

Northeastern states all did well. 

In addition to Connecticut and Massachusetts in the top two places, New Jersey, which took 3^rd, and New Hampshire, which tied for 4^th, also placed in the top five.  New York came in 6^th, Vermont 7^th, and Maine tied for 8^th with Pennsylvania.  Rhode Island finished just outside the top ten, placing 11^th.

The two states that broke up  the northeast’s logjam at the top were Minnesota, which moved up two places from 6^th place last year into a tie for fourth, and Utah, which went from 5^th last year to a tie for 8^th in 2012.

New York, Maine, and Pennsylvania all made big moves into the top ten.  Buoyed by top-six rankings in community Medicare and Medicaid spending and access to high quality hospital programs, New York jumped from 19^th place last year to 6^th. Maine moved up from 18^th on the strength of strong Healthy State and KidsCount children’s health rankings.  Pennsylvania, led by a 3^rd place finish in the number of high quality hospital programs, moved all the way up to the top ten from 22^nd.

Washington and Hawaii dropped out of the top ten, falling to 16^th and 17^th place.

Five states including Florida and Vermont shared first place honors in the seven categories.

In addition to topping the states in the KidsCount health ranking, Vermont finished first in the Healthy State ranking.  New Hampshire took first in the percentage of the population privately insured and in the number of nurse practitioners per capita.  California, which finished 23^rd overall, led all the states in the number of high quality hospital programs, and Alaska, which finished 30^thoverall, was first in per capita Medicaid community spending.

Florida finished 33^rd overall, down three places from last year.  While it was in the top ten in two categories – Medicare community spending – which it led for the second straight year – and in-state access to high quality hospital programs where it placed 9^th, it was near the bottom in two others – 43^rdin Medicaid spending on community health services and 47^th in percentage of people with private insurance.

The full rankings are available here.

The OHPM rankings are a modest attempt to average rankings from several independent state ranking sources to provide an overall picture, relative to the other states, of both the health of a state’s population and the overall quality and accessibility of the state’s health care services. 

The rankings factor in:

• Public health and prevention
• Access to primary care services
• Access to home and community-based health services, especially for low income and elderly people
• Access to quality hospital care, including general and specialty hospital programs (including mental health)
• Private insurance coverage of the population

This year’s rankings incorporated three recently-released independent rankings.  These were the 2012 KidsCount Health Rankings, the 2011 Healthy State Rankings, and the 2012 U.S. News and World Report Hospital Ratings.  They also factored in the most recent CMS data on state per capita Medicare and Medicaid spending on community (non-hospital and non-nursing home) health care services, and Kaiser State Health Facts data on each state’s prevalence of nurse practitioners and percentage of privately-insured individuals.      

Next Week: The Worst States for Your Health, 2012

Paul Ryan's Magical Thinking

A Medicare exchange in which private plans compete with a public option?  A Medicaid program unshackled by federally determined program requirements and eligibility criteria?

Now that Governor Romney has chosen Rep. Paul Ryan as his running mate, these new visions of Medicare and Medicaid will become part of the health policy debate in every state.

They are both part of Vice-Presidential candidate Ryan’s now-famous Path to Prosperity proposal published earlier this year.

In his vision, Ryan attacks an “open-ended, blank-check” Medicare subsidy that in practical terms means a government that will pay providers what it costs to treat diseases even for the most expensive seniors. 

In his own words: 

“Medicare subsidizes coverage for seniors to ensure that coverage is affordable.  Affordability is a critical goal, but the subsidy structure of Medicare is fundamentally broken and drives costs in the wrong direction.  The open-ended, blank-check nature of the Medicare subsidy drives health care inflation at an astonishing pace, threatens the solvency of this critical program, and creates inexcusable levels of waste in the system.” (p. 48)

In his new Medicare program – which would apply to everyone under the age of 55 – Medicare would no longer be a government-run insurance program for all. 

Instead, it would be transformed into a voucher system, in which every person at the age of 67 would be given a certain amount of money to spend making a choice among “private plans competing alongside the traditional fee-for-service option on a newly-created Medicare exchange.” 

Ryan envisions that “all plans, including the traditional fee-for-service option, would participate in an annual competitive bidding process to determine the dollar amount of the federal contribution.” 

Here’s the most important part.  The plans with the best coverage won’t determine the amount of the 

Medicare subsidy.  Instead, the second-cheapest plan would; Medicare beneficiaries would be responsible for anything above this.

There’s more.  The Medicare subsidy payment would also have a “hard cap” of no more than one-half of 1% more than GDP.  If medical inflation were higher than that – as it is nearly every year – the Medicare recipient would pay the difference.

From a consumer perspective, Ryan’s Medicare exchange will be like the Affordable Care Act’s health exchange on steroids – except that it will still have a public option.

It will save the federal government money in direct care subsidies, but not through medical cost containment strategies like capping rates.  Instead, it fills in a number on the formerly blank check sent to seniors, and if this number is too small makes seniors responsible for rationing their own care. 

And if higher out-of-pocket costs aren’t enough, those seniors will also have to spend 15% or more of their payment on the administrative costs and profits of the private insurance plans they will now be offered. 

Finally, none of this comes without added federal bureaucracy.  Because the existing Medicare bureaucracy – which has little fat in it – will still be needed to manage the public option, the government will need to grow a new Medicare bureaucracy to manage and regulate the Medicare exchange.

It is magical thinking to believe that an approach that shifts costs to seniors, skims dollars for new bureaucracies, and has no direct health care cost containment features will result in better care at a lower cost.

Current seniors may be breathing a sigh of relief after considering all this, knowing that Ryan preserves Medicare as we know it for everyone over the age of 55.

But it’s too soon for a victory dance.  The biggest health care challenge a good portion of the 55+ group faces is how to pay for long term care.  Ryan has $810 billion of cuts over ten years in mind for the Medicaid program on which they will rely.

He wants to reform Medicaid “by converting the federal share of Medicaid spending into a block grant indexed for inflation and population growth…. States will no longer be shackled by federally determined program requirements and enrollment criteria.”

In other words, if a state chooses not to cover nursing home “room and board” or name-brand pharmaceuticals to absorb its portion of the $810 billion cut, it won’t have to. And if it chooses to count all of the non-institutionalized spouse’s income and assets toward the Medicaid eligibility of an institutionalized spouse, it will be allowed to.

Ryan is right that we need a debate about the future of Medicare and Medicaid.  He is wrong, however, in believing that reducing benefits can happen without pain.

Our Health Policy Matters published early this week because of the selection of Paul Ryan as Mitt Romney's running mate.  It will return to its regular publication schedule next week, with a new column on Wednesday, August 22.

Denying the Inevitable

If 243 members of Congress knew that they were going to develop Alzheimer’s Disease or related dementia, would it change the way they make Medicaid and long term care policy?

Or would they continue to deny the inevitable?

When Congress convened in 2011, the average age of a House member was 57, and the average age of a senator was 62.   They were approaching the prime years for dementia.

If you don’t already have Alzheimer’s Disease or related dementia by the time you turn 65, then your chances of developing it between the ages of 65 and 74 are greater than one in 20.  Your chances of developing it between the ages of 75 and 84 are almost one in 7.  And after that your chances of developing it are one in 4.

At today’s prevalence rates, 28 members of Congress will develop dementia between the ages of 65 and 74, 91 between the ages of 75 and 84, and 124 later on.

The only thing that will change this trajectory is if they die sooner of something else.

If I were a younger elected official today, this might get might attention, and it also might get my attention that the number of people with dementia will increase from 5.2 million today to at least 11 million during my lifetime.

Representative Aaron Schock of Illinois and Senators Mike Lee of Utah and Marco Rubio of Florida all fit this bill.  They were the youngest members of their respective chambers (at 39, Senator Lee was a week younger than Senator Rubio), and they had remaining life expectancies of at least 40 years. 

So while we might forgive 87-year old Representative Ralph Hall of Texas and Senator Frank Lautenberg of New Jersey if they feel they don’t always have the luxury of taking the long view in policy-making, we should wonder a little more about Senators Lee and Rubio and Representative Schock.

They are all likely to be around when the fruits of their recent healthcare work ripen over the coming decades. 

And they may find some of them especially bitter.  

According to the Alzheimer’s Association publication 2012 Alzheimer’s Disease Facts and Figures, the cost of caring for people with Alzheimer’s Disease and other dementias – in today’s dollars – will increase from $200 billion to $1.1 trillion per year by 2050.

These $1.1 trillion are not inflated by forty years of GDP growth or the increased costs of medicine.  They represent what dementia will cost us down the road even with no inflation simply because there are more of us and we’re living longer lives.

Dementia is an adversary worthy of battle at the highest levels of government.  But neither Senator Lee nor Senator Rubio nor Representative Schock mentions it on his website. 

Instead, Senator Lee champions what he calls “saving the American dream,” which rolls back Medicaid funding to 2007 levels and caps it there.  Senator Rubio has endorsed the same approach.  Medicaid currently pays $36 billion a year of the $200 billion cost of care for people with dementia.  Under Senator Lee’s plan, it will pay even less than that toward the $1.1 trillion cost of care in 2050.

And Representative Schock goes one step further.  He touts a bipartisan effort last year to repeal the CLASS Act, which ironically would have offered private insurance for dementia-related care to take some of the burden off Medicare and Medicaid.

Dementia hits close to home for all of us.  A member of our family has it, and it has been progressing relentlessly for several years.  This is a pretty scary thing to witness.  It’s like watching a blackboard filled with facts and figures being erased, one giant sweep at a time, until all the information fades.

Senator Lee wants to save the American dream, but does he really want to do it by substituting a national nightmare of disease with no relief?  And whose dreams is he really saving?  Not the ones of our family members with dementia, nor the ones of their caregivers who already shoulder so much of the burden, nor even the ones of the 243 members of Congress who may someday join the ranks of those with dementia. 

Senator Lee, Senator Rubio, and Representative Schock are, of course, entitled to pursue the policies they choose.  But I hope they will never say that no one could have foreseen what they chose to ignore.

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.