For the 37 Percent, Stigma Trumps Acceptance

In November, 2012, a fourteen-year-old Utah boy named David Q. Phan committed suicide by shooting himself on a pedestrian bridge near his junior high school.  It was reported that he had been the victim of bullying.

In June, 2013, the New York Times published a story about three students who committed suicide at East Hampton High School during the past three years.  All three students were Hispanic.

Sam Harris, who is half-Native American and half-African American, has writtena first-person account of his own experience with mental illness that has been published on SAMHSA’s “Promote Acceptance” web site.  In his account, he reports that he lived for years with symptoms of mental illness without seeking help in part because he believed that he would be stigmatized by “going to the white man” for help.

And in a case which has attracted recent national attention in the aftermath of the Zimmerman verdict, 32-year-old Marissa Alexander – an African American and a past victim of domestic abuse – received a 20 year sentence in Florida after she fired a bullet in the direction of her estranged husband during a domestic altercation.

These diverse individuals all have had something in common. 

They all have lived in America.  They all have been among the 37 percent of Americans who are considered minorities.  And they all are or were among the 6 percent of Americans who have had a mental illness – such as PTSD, depression, or psychosis – which is considered to be serious. 

They –and others like them – are the reason that July was designated National Minority Mental Health Awareness Month.

Because while all forms of serious mental illness touch all races and ethnicities, all ages, and all socioeconomic groups, they do not touch them equally. 

For example: 

• Suicide is the second leading cause of death for Native Americans between the ages of 10 and 34.
• Hispanics living below the poverty level are three times more likely to report experiencing psychological distress than are Hispanics living above 200 percent of the poverty level.
• Up to 70 percent of Southeast Asian refugees receiving mental health care have been reported to have PTSD, and Asian American women have the highest suicide rate of women over the age of 65.
• African Americans are 20 percent more likely to report having serious psychological distress than are white Americans.

These are some of the realities Americans deal with every day, and they have been a special focus of the Department of Health and Human Services’ Office of Minority Health.

Serious mental illness is a threat to both life and liberty.

According to the Office of Minority Health, Black students are 30 percent more likely than white students to attempt suicide during high school. Hispanic students are 60 percent more likely than white students to attempt suicide. Asian American students are 70 percent more likely.  And Native Americans are an astounding 140 percent more likely to attempt suicide.

And SAMHSA has noted that over 26 percent of people who are chronically homeless have serious mental illnesses.  SAMHSA also notes that our sheltered population is disproportionately minority (only 42 percent of those sheltered are white) – and in some of our largest cities people of color comprise nearly the entire chronically homeless population.

Our jails and prisons have also become our de facto mental health facilities in recent times.  And, according to 2012 data from the Center for American Progress, 60 percent of our prisoners are people of color.  Male prisoners are 2.5 times more likely to have serious mental illness than are people in the general population.  Female prisoners are five times more likely!

We can learn a great deal by understanding the realities of mental illnesses among minorities in America.

We can learn, as a matter of fact, that mental illness often seeks its victims from among those who least able to defend themselves.

We can observe, as a matter of perspective, that the stigma associated with mental illness is harder to overcome when it is coupled with de facto discrimination.

And we can remind ourselves, as a matter of public policy, that the experiences of white males in our society are clearly not representative of the experiences of everyone in our society.

This all hits especially close to home for me.  My son is among the 37 percent, the 6 percent, those who have had suicidal ideation, those who have been imprisoned, and those who have been homeless. 

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Obamacare's Silver Surprise

There was some surprisingly good news this month about the cost of insurance under Obamacare.  It will be cheaper than expected.  But it remains to be seen – will cheaper insurance satisfy Obamacare doubters on either the left or the right?

I doubt it, but first let’s take a look at the details.

A few months ago, the Wall Street Journal warned of health insurance sticker shock when the Obamacare insurance exchanges open for business in another ten weeks. 

There could be an up-to-50 percent increase in health insurance premiums, the Journal warned.

But a report this month from the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) brought a surprise. 

Based on data from the first eleven states reporting actual premium numbers, ASPE now says that insurance costs for Obamacare “silver” plans for individuals will be 18 percent lower than originally projected by CBO.

Premiums for the least expensive plans were averaging around $321 per month – before income-based tax credits were subtracted from those costs.

And in five states plus the District of Columbia reporting small group plan numbers, insurance premiums for the all-important “second lowest cost” silver level plans will range from 6 percent to 36 percent less than they would have been if Obamacare were not the law of the land.

What makes a plan a “silver” plan?

Despite what you might assume from the headlines, plan categories are not based on insurance premiums.  They are based on the percentage of the total cost of health care that the plan will pay for everyone in the plan, versus what the plan’s policyholders will pay out-of-pocket.

There are four categories of plans – bronze, silver, gold, and platinum.  All plans will provide coverage for the same group of essential benefits.  But bronze plans will cover 60 percent of the cost of these benefits, silver plans will cover 70 percent, gold plans will cover 80 percent, and platinum plans will cover 90 percent.  Policyholders will pay the rest.

This does not mean that if you have a silver plan, at the end of the year you will have paid 30 percent of your total health care costs and your insurer will have paid 70 percent. 

Those are just the averages, and everyone’s individual experience will vary from the average at least somewhat.

There are two reasons that the cost of the silver plans will get so much attention.

The first is that, along with gold plans, they will be the most widely-available plans.  The second is that the tax subsidies built into Obamacare are based on the projected cost of the second-lowest-cost silver plan.

But not all silver plans will be alike.

One silver plan, for example, may charge a higher premium than another silver plan.  But that plan might cover 75 percent of hospital costs, while the other pays only 70 percent.

Other silver plans might be less expensive than some bronze plans – particularly if they provide less “first dollar” coverage for care – or more expensive than some bold plans.

But while the premium costs of the silver plans may dominate the news and public policy analysis in the coming months, I don’t think that how good you feel about Obamacare is ultimately going to be based on the cost of a silver plan. 

Here’s why.

Deductibles, co-pays, and uncovered health expenses also factor into how satisfied we are with our insurance.

If you believe that being expected to absorb, on average, 30 percent of your health care cost burden when you already have insurance is too big a price to pay, then you will not be happy with a silver plan.  You will either hope you or your employer can afford to pay extra for a gold or platinum plan if one is available, or you will complain as much as you do today about your lousy coverage.

And you will dream again of government-sponsored health care for all.

Conversely, if you think that Obamacare goes too far in requiring insurers to cover at least 60 percent of the health care costs of the people they insure, then you may decline to participate in the system at all and pay the small fine.

And you will join Eric Cantor in the march to health policy irrelevancy by asking the U.S House to repeal Obamacare for a 40^th time.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Race Does Matter

On August 7, 2012, Allen Daniel Hicks, Sr., died of a stroke.  The Hillsborough County FL resident was 51 years old.  At the time of his death, he was coaching Little Leaguers.

It is a tragedy to lose someone so young to a stroke, but it is not uncommon.  And race matters with strokes.

According to the Office of Minority Health at the Department of Health and Human Services, African Americans are 60 percent more likely to have a stroke than their white counterparts.  And African American men like Mr. Hicks are also 60 percent more likely to die from a stroke than are white men.

But Allen Hicks’s death was especially tragic because the circumstances surrounding it eerily echo those surrounding the death of a young black woman named Anna Brown a year earlier and 1000 miles away.

Both died from blood clots.  Mr. Hicks’ was in his brain; Ms. Brown’s was in her lungs.  Both died young and left children behind.  Both suffered from pain and paralysis before they died.  And both deaths could have been prevented with prompt treatment.

But here’s what really ties these two tragedies tightly together.  Both Allen Hicks and Anna Brown were taken to jail when they were taken ill, and both lay there without treatment while they suffered.

I wrote about Anna Brown’s horrifying death last year.  You can read the full column here, so I won’t rehash those details again.

But Allen Hicks’ story is also worth telling, because, along with Anna Brown’s, it raises too many questions for us to ignore.

A headline in Health News Florida directs you to the Tampa Bay Times for the details.  According to the Times, when Allen Hicks suffered the stroke in May 2012 that led to his death he was driving along a highway.  Despite experiencing sudden partial paralysis that caused him to swerve and hit a guard rail, he managed to avoid other vehicles and stop his car on the side of the road.  While he waited, witnesses called 911.

The newspaper account noted the extent of his stroke at that time, when it reported that Hicks was “speaking incoherently and unable to move his left arm” when the officers arrived.  And what was their response when faced with such classic symptoms of a stroke?  In a scene absurdly reminiscent of the movie Meet the Fockers, “Hicks was arrested on a charge of obstructing a law enforcement officer when he did not respond to commands to exit his car.”

Then it got worse.  His left side paralyzed, Hicks was brought to a jail, where he was apparently given no medical screening.  He was placed face down on the floor of a cell.  “From time to time his right limbs twitched,” the newspaper reported, as he apparently tried to crawl to help using the non-paralyzed side of his body.

He waited three hours for a medical evaluation.  The conclusion?  His stroke went unnoticed, but it was recommended that he receive a psychiatric evaluation.

Two hours later, he was transferred to another jail (this is how we often treat psychosis in America – jails are our de facto psychiatric holding facilities), but did not even receive his unnecessary psychiatric evaluation until noon the next day.  He was found to be “delusional with a poor memory.”

As the old saying goes, if all you have is a hammer, everything looks like a nail.

By then, he was past the time period during which “clot buster” drugs can save the brains of stroke victims, and so his brain was probably already permanently damaged.  But his jailers did not notice this.  He was not transported to Tampa General Hospital until twelve hours later, almost 36 hours after he suffered his stroke.

He held on for three months before he died.

The Hillsborough County Sheriff’s Office gave the following statement to the Tampa Bay Times:  "It is clear that mistakes were made by Hillsborough County Sheriff's Office employees and contracted medical staff employed by Armor Correctional Health Services."

The two parties reportedly paid a million dollar settlement to the family.  I doubt that this will make their pain go away.

Nor will it resolve all the troubling questions this story raises.

How could first responders and jailers fail to recognize obvious symptoms of stroke?

When did incoherent speech and paralysis become synonymous with mental illness?

And – at a time when so many wonder if there is a different standard for whites and blacks – why were Anna Brown and Allen Hicks brought to jail in the first place?

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

What We Worry About Least in the Health Policy Debate

You shouldn’t have to worry about anything during vacation season.

So this column is my vacation gift to you. It is about all the health policy matters we seem to worry about the least. 

I have written close to 150 columns.  If you look down the right side of the page, you will find links to the ten most-read ones.  The subjects won’t surprise you – fairness in mental health treatment, Obamacare and private insurance, and cursed football players lead the way.

But do you ever wonder about the columns with the fewest readers?

Based solely and unscientifically on my numbers, here are a half dozen or so health policy matters we seem to care about the least.

Long Term Care. 

Are you worried about continuing high unemployment rates, taxes on small businesses, or another stock market crash ruining your family’s financial security?   If so, you should redirect that worry.  Because US Trust CEO Keith Banks called long term care costs “the biggest risk to family wealth” during a June 27, 2013 CNBC interview.

That’s because neither regular health insurance nor Medicare covers them.

So you can either pay $80,000 or more per year for long term care, or hope states continue to spend billions of dollars to expand Medicaid, or wait for Congress to create a national private long term care insurance program– something a new national Commission on Long Term Care has just been given three months to do.  That should get anyone’s anxiety level up.  But chances are – if you are still reading this column – your mind is wandering already, and you are ready to move on.

Medicare.

Whenever I write about Medicare, I lose 30 percent of my readers that week.  For example, I wrote two columns earlier this spring about something I found really intriguing and have never read anywhere else – that Medicare regularly pays more for men with depression than it does for women.  To me, this is blockbuster news about disparities in care.  But not to my readers. Maybe we need to be eligible for Medicare before we really start thinking about it?

Research.

Without research, there would be no modern healthcare system.  There would be no effective cancer treatments and no once-deadly communicable diseases – like polio – that ruined more than just children’s summers as recently as sixty years ago.  But the one time I wrote about why research matters – just two weeks after I wrote my most popular column ever – it was one of my least-read ones ever.

Child health.

Everybody loves children, but my columns on child health – even ones with sensational headlines – don’t seem to attract much attention.  It may be that we feel that we have solved most of our child health problems over the last few decades.  But as a brand-new Annie E. Casey Kids Count report points out, while we’re trending in the right direction, we still have a way to go.

Personal Responsibility and Wellness. 

This is another subject I have shied away from, after dipping a toe in the water two years ago.  I wrote about the way in which Connecticut, a liberal state, added a component of personal responsibility, a historically conservative concept, to its state employee health plan.  The state believes that it has saved money by doing this, and the approach has proved popular with employees.  But the column wasn’t popular with readers.  Why not?  We all want to be healthier. But maybe we don’t want health insurance to be tied to health!

Environmental health. 

While environmental health is a huge part of public health, environmentalists and public health officials often go their separate ways in policy advocacy.  I wish it were different.  But even when I wrote about the environmental devastation in the immediate aftermath of the Japanese nuclear disaster in March 2011 and put it in a broader public health context, not too many people paid attention.  The column drew fewer readers than almost every other column I wrote that spring.

Eric Cantor.

Don’t ask me why, but the least-read of my 150 columns was the only one that used the words “Eric Cantor” in the title.  If you have forgotten who Eric Cantor is, I am not going to remind you.  But once upon a time, he was actually relevant to the health policy debate in this country.

Lately he seems to be taking a vacation.  A long one.  As we all should be!

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

100 Days and Counting; 10 Things You Need to Know About Obamacare

In fewer than 100 days, the Obamacare insurance exchanges will be open for business.  Fifteen states will be running their own exchanges.  Thirty-five will be relying on the federal exchange.

Vangent, which is running the federal call center, is preparing for 200,000 calls per day between now and the first of October.

The federal government has also re-tooled its site, www.healthcare.gov, to provide up-to-date information about the exchanges.

These are parts of a massive consumer education campaign, which is badly needed.  Because as of two months ago – three years after its enactment and a year after the Supreme Court affirmed almost all of it – according to a Kaiser Family Foundation poll, 42 percent of Americans did not even know that Obamacare was the law of the land.

Obamacare is and will remain the law of the land.  And here ten things you need to know today as you prepare for it to take full effect.

One, if you are part of a family of four and your household income is between approximately $24,000 and $92,000 per year, and you have to buy your own health insurance, you will be eligible for a tax subsidy beginning on January 1.  Small employers already are, but most are not taking advantage of the credit. If you are insured through your employer, very little will change for you. 

Two, a family of four with a household income of $50,000 will receive a subsidy so large for an average insurance plan that the net cost of the premium for family coverage will be only $280 per month.  And if that is too much, there will be a less expensive choice.  A lower cost “bronze” plan will cost only $140 per month.  You can calculate your own costs by using the Kaiser Family Foundation calculator.

Three, if you are under the age of 26, then as of January 1, 2014 you will have the option of remaining on your parents’ insurance – even if your own employer offers you coverage.  But if you stay on your parents’ plan and can only pick up your employer’s during an open enrollment period, you may need to enroll in the year before you turn 26 or risk a lapse in coverage and a possible tax penalty.

Four, if you earn less than 138% of poverty and your state has expanded Medicaid, then you will have Medicaid coverage.  But if you live in one of the 20+ non-expanding states and have an income that is at or just above the poverty level, then you will be eligible for a “bronze” plan at no cost to you.  (I have an updated list of where states stand on expansion on my State Rankings page.)

Five, under Obamacare you will still get your health insurance from companies you recognize – not from the government.  Blue Cross Blue Shield will be participating in exchanges throughout the country.  United and Aetna will each be participating in a dozen or more states.  Smaller local companies will also be offering plans.

Six, pre-existing conditions will no longer disqualify adults for insurance.  The transitional health insurance program for adults with pre-existing conditions, called PCIP, has ended.

Seven, mental health benefits will finally be on a par with physical health benefits.  This isn’t just because of Obamacare.  The administration has promised that the Mental Health Parity Act of 2008 will finally take full effect before the end of the year.

Eight, soon everyone will know what an “accountable care organization” is, and chances are that at least one of your providers will be participating in one.  Although it is hard to summarize what this means in one sentence, the bottom line is that you’ll see more emphasis on preventive services, and your providers will get paid more for keeping you healthier.

Nine, the number of uninsured people will begin a march downward from over 50 million to between 25 and 30 million, and then remain at that level.

Ten, widespread opposition to Obamacare will die down over the next two years.  Part of the reason is that years of Obamacare-bashing have set the success bar pretty low.

And by 2016, the opposition may be effectively gone.  Most people will be used to paying lower net amounts for health insurance, most states will be reaping the benefits of the expanded Medicaid program, and young people coming of voting age will have never known a time when Obamacare was not a part of the national landscape.

We will be ready to move on.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/