What We Need in the Next Four Years

I wrote a column in January entitled A Dime’s Worth of Difference in 2012.

The central premise of the column was that this year’s health policy debate would fall short of what we needed.  It would instead resonate with the words “Obamacare,” “Romneycare,” “government takeover,” and “individual mandate.”  That is exactly what we got – and then some.

But we needed something more.

We needed an honest debate about:

• the future of Medicare for our elders;
• the importance of Medicaid to people with chronic conditions;
• the growing mental health needs of our population – including our returning veterans;
• the essential role of public health in our lives, no matter what our socioeconomic status;
• the fact that health and social assistance providers are the real job creators in our 21^st century economy, and must play a key role in our recovery from recession.

What we experienced instead was a tsunami of concern for our more selfish instincts – that we should not have to pay anything at all for our own health and well-being, and that there is nothing of value in the lives of those less healthy or fortunate than ours.

We have just gone through a campaign with a blizzard of mostly negative advertising in a handful of swing states, but not a minute devoted to what more we might do in the next four years to help:

• children whose plunge into poverty compromises access to the food they need to grow and thrive;
• young men and women returning from war with PTSD;
• older Americans facing hundreds of thousands of dollars of long term care expenses that we fail to insure;
• communities around the country whose decaying infrastructures have proved inadequate in recent days, months, and years to hold off environmental devastation caused in part by the radical changes to our climate we created.

We have heard nothing about jobs and health care.  We have, however, heard much from demagogues around the country about the $716 billion cut to Medicare, as if that were going to determine the fate of a nation. 

Think about it.  A bipartisan, consensus item – essentially limiting the future growth in the Medicare to 5% per year instead of 5.7% - took on such a life in campaign commercials that one could conclude that no greater threat to America’s health could exist than to limit inflationary growth – while expanding benefits – in our most popular entitlement program. 

And the irony was that the proposed solution to save Medicare from this devastation was to eliminate the program as we know it.

When I was a legislator, the people of my district clearly understood that only a rare person who walked the tightrope through life could do so without a safety net beneath them. 

They didn’t blame people for falling off that tightrope from time to time, they just asked that we legislators work together to get them back up again as soon as they were able.

In the area of health, this meant that:

• we cleaned up our environmental messes with government support;
• we immunized our children with government funding;
• we built public and nonprofit hospitals and clinics and regulated the care they provided with government involvement;
• we developed long term care services financed with government dollars;
• we provided for the basic needs of people with physical and mental disabilities and diseases with government assistance.

And we didn’t think this was a bad thing, because we realized that our government was purely and simply a reflection of us.  And, by the way, the second-leading creator of jobs in our country.

Maybe some think that our uniquely American form of government no longer works for us.  I’ve heard those echoes, but I don’t see them as representing the majority view.

In the next four years, we need to insist that our governing leaders take us – and themselves – more seriously.  We need them to stand together, not fall apart, in tackling the health issues that confront us.

We need both progressives and conservatives to understand that health and social assistance providers – not small businesses in general or manufacturers – are the real job creators of the 21^st century, and drive a large share of our economy.

We need them to understand the meaning of compromise.  We do not live in an either/or, all-or-nothing-at-all world. 

And what we need most is for the pandering to end.  

When George McGovern Made Mental Health A Campaign Issue

When Senator George McGovern, who died this past weekend, decided to run for President, he did so as a World War II hero who opposed the Vietnam War. 

A respected South Dakota senator, he helped galvanize anti-war sentiment among young people and ride it to the Democratic Party’s nomination in the summer of 1972.

His election prospects that year were as remote as Senator Goldwater’s had been just eight years earlier.  From opposite ends of the philosophical spectrum, there was much to admire about both of them.  But they were also both too removed from the center of the political spectrum to be electable in the moderate America of those times.

As a vocal McGovern supporter back in 1972, I have long wondered how he felt about the one thing I admired least about his political career – the moment when he let fear about mental illness alter the course of our public policy history.

There is an excellent and recent brief story about this on the National Public Radio website, summarizing a book written by Joshua Glasser entitled The Eighteen Day Running Mate.

Despite growing opposition to the war, Senator McGovern’s path to the Democratic Presidential nomination was far from easy.  By the time he won his nomination, he was a polarizing figure who was behind in the national polls. 

President Nixon’s campaign machinery was also in full swing at the time, doing its damage just after the Watergate break-in.  Had people known at the time all there was to know about the Nixon Administration, any viable Democrat probably could have beaten him.

But it was still a full year before the full nature of that Presidency would come to light in the Watergate hearings.  It was more than a year before Spiro Agnew would resign the Vice-Presidency over corruption, and two years before Nixon would resign the Presidency in disgrace.

So the focus was on McGovern, who was on the defensive politically.  “A” list politicians wanted to stay off of the McGovern ticket.  At the last minute, McGovern finally settled on Senator Thomas Eagleton – a respected Senator from Missouri.  When McGovern asked him if he had any skeletons in his closet, Eagleton answered “no” and accepted the nomination for vice-president.

Within days, there were rumors that Eagleton had a “complicated” medical history.  People didn’t talk much about “complicated” medical histories in those days, but the story bled out over the next two weeks. 

Several years earlier, on three occasions, Eagleton had been treated – ultimately successfully – for depression.

That was the sum total of Eagleton’s “complicated” medical history.

McGovern initially responded by supporting Eagleton – I remember when he declared that he was behind him “1,000 percent.”  But within days, fears began to grow in the media and among the public about whether Eagleton, with a history of mental illness, could be trusted with his “finger on the button.”  Bowing to this fear and prejudice, McGovern backed away from Eagleton’s candidacy, and Eagleton gave up the nomination just eighteen days after accepting it.

How might the course of our public policy history have changed if McGovern had kept Eagleton on the ticket?

Certainly, the discourse of the 1972 campaign would have been different.  Eagleton’s continued presence on the ticket might have stripped away at least some of our prejudices.  We all would have been educated about the nature of treatable mental illness.

And it would have shown an entire nation that mental illnesses were not to be feared, and did not need to prevent people from lives of amazing accomplishment.

It might have changed the course of actual public policy, too. 

If Senator Eagleton were more than just a quiet footnote to Presidential campaign history, would the Community Mental Health Centers Act still have been repealed back in 1981 and replaced with a block grant?

Would fewer people with serious mental illness today be in jail – a percentage that is three times greater than the prevalence in the general population and also three times greater than the prevalence among those incarcerated at the time of the 1972 campaign – and more have access to treatment?

I don’t know the answer to these questions, but I do know this.  Senator McGovern – whom I otherwise admired until his death – had just a moment on the stage when as a candidate for President he could have permanently altered the way we think about illness and disease.

And he squandered that opportunity.  

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.

Pushing for Mental Health Parity

Former U.S. Congressman Patrick Kennedy was in South Florida last week pushing the radical idea that all people, including those with mental illness, are created equal.

What makes this idea radical in 2012 is that we continue to discriminate against the 6% of Americans who have serious mental illnesses.  Patrick Kennedy understands this, and is devoting his life after Congress to fighting on their behalf.

It is a fight that affects him personally, as it does the one-fifth of all children and the one-fourth of all adults with a diagnosable mental illness each year.

Discrimination against people with mental illness takes on many forms – arrests for loitering, incarceration instead of treatment, and perhaps most commonly in the unequal coverage by insurers for mental health conditions.

This last form of discrimination was supposed to have ended with the passage of the Mental Health Parity and Addiction Equity Act of 2008.  But the federal “rule” implementing this law has never been finalized.

At a field hearing hosted by Rep. Kennedy on October 9^th, a speaker from the American Psychiatric Association talked about the effect this has had.  In late 2011 Florida Blue (formerly Blue Cross Blue Shield of Florida) terminated its contracts with nearly every behavioral health provider in the state.  Providers had to sign new contracts for significantly less reimbursement.

Before that action, a psychologist was receiving just under $52 for a full counseling session, already far less than the average hourly rates paid to carpenters, plumbers, and electricians. 

After the action, the same psychologist received just $46 per hour.

The Florida insurance commissioner said that he had no jurisdiction over this. 

This isn’t just Florida’s problem.  I point out in testimony being presented today (October 17^th) at a public hearing on behavioral health parity hosted by the Connecticut Office of the Healthcare Advocate that actions like this affect every state.  Because there is no federal rule, a Connecticut insurer covering mental health care given in Florida also pays that pitiful amount – because the Florida insurer sets the reimbursement for others.

Insurance discrimination affects everyone.  But people with serious, chronic mental illnesses face worse today. 

As low income, single adults, they were all supposed to become eligible for Medicaid benefits in 2014 to cover mental health services.  But the U.S. Supreme Court said earlier this year that states could opt out of that Medicaid provision.  As homeless people, they often end up in jails and prisons because there are not enough places of care.  And as returning veterans – or “returning heroes,” as Rep. Kennedy prefers to call them – they often wait months to receive treatment through the VA.

There is still another way we deny people with mental illness fair treatment for their disease – ironically, by hiding behind their “civil rights.”  Local police officers and sheriffs known as mental health officers have become gatekeepers to emergency mental health services, and judges often make decisions about treatment.  A mental health officer once denied my son emergency care at a time of severe crisis because he didn’t think the crisis was severe enough to “deny his civil rights” by bringing him to a hospital for 24 hours.  So he didn’t get care that day. 

But he was jailed six times over the next three years. 

People with chronic mental illness, Kennedy noted at a reception my wife and I hosted at our home, don’t have a big political constituency. 

That’s why states have been able to cut $4.6 billion in mental health funding since 2009.

We can change this nightmarish reality if we want to. 

Here are just two examples of how.

In recent months my son has been involved with a behavioral health court in San Francisco.  Behavioral health courts take into account a person’s mental illness in devising treatment strategies to reduce recidivism.  There’s evidence that they work.

And instead of just playing catch-up long after a disease has ruined lives, we can begin with equal treatment – including parity in insurance coverage – for a set of chronic diseases that take as big a health toll each year as cancers.

Rep. Kennedy is optimistic that the tide will turn soon.  He believes that this time we will not repay war heroes with neglect, and that what we do for them will lift up everyone with mental illness.

I sure hope he’s right.

Because there are elections around the corner, and something has got to change. 

Ending the Medicare Debate

If you care about Medicare, then who lost last week’s Presidential debate?  Perhaps we all did.

That’s because both candidates favored some cuts in the Medicare program.  And cuts translate into a real impact on real people.

But no cuts could mean something even worse - unsustainable levels of spending in the Medicare program.

The question is what’s the lesser evil – a cut in payments to providers or a cut in benefits to individuals?  That’s the choice President Obama and Governor Romney gave us.

President Obama favored cuts in payments to providers.  Governor Romney favored cuts in benefits to individuals.  The difference in their positions became clear as Romney pressed his point about the $716 billion in “cuts” that Obama supported in the Affordable Care Act.

The “cuts” Obama favored actually fell into two categories that are built into the law – provider rate reductions and cuts to private insurers offering Medicare Advantage plans. 

The provider rate reductions arguably hit doctors the hardest, because ACA presumed that the so-called “doc fix” won’t happen anymore beginning next year.  The “doc fix” has had bipartisan support every year since 2002, because it corrects a provision in the Medicare reimbursement formula that would immediately reduce reimbursement by around 30%. 

The other provider cuts are realized by limiting the increase in future Medicare reimbursements to 5% per year – less than the 5.7% health care costs are expected to grow.

Romney was emphatic during the debate that as President he would restore not just these provider dollars, but the private insurers’ administrative dollars, too.

But Obama pointed out that these savings were used in part to finance the closing of the Medicare donut hole and new Medicare prevention benefits.

More significantly, they also change the trajectory of Medicare spending significantly over time.  According to the 2012 annual report of the Medicare Trust Fund trustees, even with the savings the overall cost of Medicare will grow from just under 4% of GDP today to just over 6% in around thirty years, and then grow a little higher through 2085 (those are the green lines in the chart). 

So Obama just cuts away at the increase.

Romney’s position is more extreme.  Because without the savings, the cost of Medicare will grow to 7% of GDP by 2040, and then skyrocket to over 10% (those are the red lines in the chart) by the time babies born today hit retirement age.

If we had to borrow to cover that, it could bankrupt America.

Romney obviously doesn't want to bankrupt America.  But he did say that he favored leaving Medicare alone for people age 60 and above. (Note: The Ryan plan says 55, but Romney said “60” in the debate.)

For everyone else, Romney wants to reduce the projected cost of Medicare by changing it to a voucher program. 

He would give a health insurance voucher to everyone when they turn 65, and let them use it to purchase either “traditional” Medicare or private insurance through a federal Medicare exchange. 

The value of the voucher will be tied to the second-cheapest plan available, and won’t keep up with health care inflation.  The Medicare recipient will have to pay the difference out of pocket, negotiate with a doctor to accept less, or ration their own care.

Romney made a good argument for at least doing the “doc fix” again by arguing that many doctors won’t be able to absorb a huge rate cut, and will drop out of Medicare if the rate reductions are put into place.  But Obama made an equally valid point that the vouchers could be even worse for recipients. 

If the arguments are left standing there, as they were in the debate, then something has got to give, and everyone's going to lose.

So why not give voters a different choice – one that could end the debate with everyone a winner?  Because there is another option that could save Medicare for our grandchildren without resorting either to borrowing or to huge provider cuts or to Medicare vouchers. 

We have all enjoyed a 2% payroll tax “holiday” for the last couple of years to help stimulate the economy.  When this holiday comes to an end, all we need to do is to dedicate 1.33% back to the Medicare Trust Fund.

If we did this, then Medicare would be solvent for the next seventy-five years.

That's a choice about taxes we all should be offered.  Maybe we’d vote no, but at least we’d be voting with our eyes open.

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

Florida's Medicaid Expansion Rejection Will Cost Residents

There was a fascinating news report out of Arizona this past week that embracing the ACA Medicaid expansion will result in $8 billion in new federal dollars flowing into the state over four years – in return for an investment of $1.5 billion from the state.

That looks pretty good on the surface, and the 435,000 people who will become insured as a result are a nice bonus.

What many people don’t recall is that Arizona was the last state to enroll in the Medicaid program.  So a report such as this from a state whose embrace of Medicaid was a long time coming is especially noteworthy.

After seeing numbers like that, I can’t help but wonder what might happen if the state decides not to expand Medicaid.  Its residents could lose a lot of money in return.

This is what Florida is facing.

We can calculate just how much money every resident of Florida will lose by reviewing what Florida Attorney General Pam Bondi wrote to the Supreme Court this past January:

Florida estimates that, as a result of the ACA, its share of Medicaid spending will increase by $1 billion annually by the end of the decade. 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.

Setting aside for the moment the $574 million she attributed to currently eligible people – who will be entitled to Medicaid whether or not the expansion goes through – let’s accept her calculation that the expansion population will cost the state $351 million annually “by the end of the decade.”

This means that the federal government will be sending at least $3.2 billion to Florida annually in 2020 if Florida accepts the Medicaid expansion.

That comes to $168 Florida will forfeit per person per year if it rejects the expansion, which represents a 90% share of the cost of the expansion.  And the forfeit is even higher in the years before 2020.

These are dollars that Florida residents will have to pay out of pocket if the federal funds don’t flow.

Here’s why.  Estimated Medicaid expenditures represent just that – projected actual health care expenditures, not insurance premiums or some other indirect cost.

So the $3.5 billion will be spent, one way or the other.  In the absence of Medicaid expansion, it will be paid by state and local taxes, offset in part through charitable giving, or financed through private insurance premiums (with an additional 15% administrative overhead). 

In other words, the $3.5 billion won’t just disappear into the atmosphere somewhere.

When Mitt Romney, who along with Florida Governor Rick Scott opposes the Medicaid expansion, was asked for an alternative, he must have felt put on the spot.  Because he suggested that hospital emergency rooms could take up the slack, although he knows that hospital ERs are the last place a community wants to provide indigent care.  This is because the cost is so high. 

I’m not happy about having to cough up $1,244 over the next seven years so that my governor can make a point that he doesn’t like a federal law. 

I already get that, and understand that he and the six other governors who are thinking like him are probably a lost cause to my way of thinking.

But most of our state legislators are running for office this fall, and they may actually care what we think.  I think we can do a lot of good with $3.5 billion.  So I’ve got a question for them. 

Who’s got a better idea than expanding Medicaid for paying this $3.5 billion bill? 

ACA and the Collapse of Capitalism

Here is a question I’d love to see candidates answer before the election.

Source: NY Times

Does the continuing activity around the implementation of the Affordable Care Act signal the collapse of American capitalism – at least as it pertains to health and health care?

The myth of American capitalism is so powerful that I imagine they won’t touch this one with a ten foot pole – or even a ten-foot long poll!  In the politics of our $2.6 trillion healthcare economy, however, capitalism takes a back seat.

The recent activities of the Connecticut health exchange board explain why capitalism in health care is about as relevant as a Democratic voter in Utah. 

Connecticut is one of the dozen or so states embracing ACA, and is making an impressive effort to implement its health insurance exchange on time in 2014.  By contrast, more than half the states have yet to even declare their intentions, even though the deadline for doing so is mid-November.

According to a recent, well-written article in CT News Junkie, its health exchange board, tasked with the job of approving the “essential benefits package” for the state, did so last week.  The essential benefits package will become the standard in each state for what must be offered by insurers after the law takes effect.

The board voted to base Connecticut’s essential benefits package on one of its most popular health insurance plans.  The plan is offered by ConnectiCare, an HMO.  ConnectiCare has offered good health insurance packages for many years – I was insured by ConnectiCare for many years when I was a resident of Connecticut.

So far, so good.

But here’s the ironic twist that makes you wonder if capitalism can survive health care, and if health care can survive capitalism. 

The one member of the board voting against the package was the former CEO of ConnectiCare.  His reason was that the plan will provide to be too rich for many small businesses and individuals to afford.

He was quoted as saying that small businesses would have to drop insurance.  According to the report, here is how he put it:  The essential benefits were supposed to set a floor for insurers “but it’s like we’ve taken an elevator to the 12^th floor.”

Think about it.

If an insurance plan that provides fair coverage for emergency services, mental health services, prescription drugs, pediatric services, pregnancy services, and rehabilitation has become too rich for all the people who need those services the most to afford – even with thousands of dollars in tax credit subsidies – then what kind of an insurance market is that?

And if Connecticut’s comprehensive, but essential, benefits cost too much, then what’s your alternative?

As a Florida Congressman once got in political trouble for asking, “dying quickly?”

If the ACA essential benefits approach doesn’t work then there are really only two options left to consider.

The first is to regulate the price of healthcare as aggressively as you can. 

The second is to create a Medicare-for-all system with the leverage and muscle to decide how much it will pay for healthcare services no matter what a provider wants to charge.

Both require significant governmental intervention.  And neither is an endorsement of the kind of market-driven capitalism favored by some candidates this year.

So why can’t all this still be part of our national campaign dialogue about health care?  Is the myth of capitalism and “free” enterprise so strong that politicians can’t even talk about how important the role of the government is in subsidizing our care and regulating and managing the marketplace?

I’m just asking.