Why Our Health Policy Matters More Than Ever in 2014

A single health policy issue will decide who controls Congress after the 2014 election.  Here’s why.

You may have noticed the relative dearth of partisanship emanating from Washington over the past couple of months. 

Congress approved a budget with little fanfare and passed a debt ceiling increase with no hint of strings attached.

There is a reason for this newfound spirit of bipartisanship, and it is not what you think. 

Congress isn’t suddenly taking to heart its relentlessly low approval ratings in 2013.  And it hasn’t just become aware of how unproductive it has been.

Barring an unforeseen catastrophe like 9/11, Katrina, or Sandy, it’s just that members of Congress already know which issue will swing the upcoming election.  And they are not interested in muddying the waters at this relatively late date. 

The Democrats know that they have an advantage in the improving economy, their stand on women’s issues, and their strong support among minorities.

The Republicans know that they gain support because of a still-too-high unemployment rate, unbalanced budgets and the increasing national debt, and an unpopular foreign policy.

But the issue that will swing the Congressional elections in November is the one in which the political advantage then is a little less clear today.  It’s Obamacare.  And that’s proof that our health policy matters more than ever in 2014.

The partisan Congressional lines are arguably drawn more sharply over Obamacare than any other public policy.  We all know of the dozens of party-line Obamacare “repeal” votes that have been taken in the House since its equally partisan passage in 2010.  No other issue comes close for purely partisan controversy.

So what might this mean in the fall?

The current generic Congressional ballot reflects a near dead-heat for the 2014 election, which (because of gerrymandering) would keep the make-up of Congress roughly as it is for another two years.  And the parties have been pretty even on the generic ballot since last October.

What happened in October was that the Democrats lost ground quickly when the initial Obamacare web site problems overwhelmed the news cycles for a month.

As a result, recent polling data suggest that Obamacare is less popular now than ever, with an unfavorability rating 12 points higher than its favorability rating as of February 15. 

From Republicans’ perspective, this is all they can hope for.  Obamacare is the issue that can protect the Republican majority in the House and give the party a fighting chance of picking up the Senate.  Republicans do not want to squander this opportunity by picking new fights they can’t win (and might even cost them their primaries) over deficits and debt ceilings in particular.  So they’ve stopped talking about these for now.

But the Democrats are standing pat because they’re betting that Obamacare will be much more popular in six months than it is today.

The reason is that we’re all beginning to see who is benefiting from the new law – people over the age of 55.

This is a high-voting constituency that went heavily Republican during the 2012 election.  Romney won the 45 to 64 year old demographic by 51-47 percent, and the 65+ demographic by 56-44 percent.

Ever since that election, people on Medicare have been enjoying free annual physicals and improved prescription drug benefits.  And they have not experienced the collapse of the Medicare system that some feared.

As it turns out, baby boomers are flocking to Obamacare, too.  According to one source, 31 percent of the new Obamacare enrollees are 55 years of age or older.  Until now, many of these people had no reason to vote for a Democrat this year.  They had lost their jobs and their insurance during the recession. But now they have insurance again.

Democrats are banking on the fact that they will not risk losing their insurance a second time by voting for a repealing Republican in 2014.

While most people may never understand Obamacare in its entirety, they are just beginning to understand how it affects them personally.  That’s ultimately what matters.

There may still be hand-wringing over fewer than 7 million Obamacare sign-ups this spring or too few young, healthy people in the exchanges, but that will just be background noise to actual voters in the fall. 

What will matter is what this election means for them personally, and that’s why Obamacare may still spring some November surprises.

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

For Better Health, Why We Need Integration of Care

I was asked recently why I didn’t actively seek out a specialized school setting many years ago in which to educate my son.

My son has a serious mental illness, one which first manifested when he was a child.  I’ve written about this before in Health Affairsand will write about it again in a book scheduled for publication later this year.

The argument is this.  If you put children with a special condition – such as serious mental illness – into a classroom with other children with the same condition, then you can adjust your educational services to meet the needs of those children all at the same time – and you will get better outcomes.

That’s essentially how our health care delivery system has often been built, too.  Through most of the twentieth century, people with mental illnesses were treated in one set of hospitals (usually state hospitals). And people with most physical conditions were treated in a different set of hospitals.

I wrote “most” above because we even segregated regular health care sometimes.  For example, we had specialized TB hospitals through most of the twentieth century, remnants of which still existed in some places as we turned the page to this century.

But segregating services like this did not lead to better outcomes. 

The best data to support this conclusion come from a study of life expectancy of people who were in state psychiatric hospitals in several different states.  The study found that, on average, the life expectancy of people in those hospitals was reduced by up to twenty-five years or more.

To get a sense of how significant this is, consider this.  It is greater than the overall life expectancy reduction attributable to cancer.

The problem with segregating health care services was this.  When you segregate treatment, you often forget about the rest of the person.  The people with mental illness who died young were not usually dying because of their mental illness, they were dying because they had other medical problems that were undertreated, too.

This is the argument against segregating educational services, too.

When we did move my son into a private school for children with emotional disturbances, it focused almost entirely on managing his emotional disturbance, and he received few, if any, educational services.  He arguably didn’t get a better health outcome, nor did he get a better educational outcome.

This is not to say that we should educate or treat everyone “in the mainstream.”  That’s too simplistic, because it too often implies that a “one size fits all” standard should be the norm, when that is not what children (or adults) with serious chronic conditions, like mental illness, need. 

What people need are services tailored to their own needs that take their “whole person” into account.

There is really only one way to do this – by integrating care and services. 

For everyone, this means that the right thing to do is to integrate general health treatment and services with behavioral health treatment and services. 

It means screening for behavioral health in the annual check-up, just as we screen for weight, vision, hearing, blood pressure, heart, and lung function.  It also means connecting the work of behavioral health specialists to primary care providers in the same way that we want obesity care, cancer care, diabetes care, treatment for hypertension, and pain management connected to primary care.  We want good communication, and each treatment strategy considered in the context of all the others.

This gets meaningful results, as reflected in the chart that accompanies this column.

But it also means making the changes necessary to integrate health and behavioral health services with non-health services.

In the case of children, this means integrating them with educational services, and actually making community-based care a part of the overall instructional plan.  The million dollar question (literally) is “who should pay for this – the educational or the health care system?”

In the case of adults, this means integrating health and behavioral healthcare services with housing, employment, and social and peer support services, and recognizing that recovery is only possible through integration, and only meaningful if it can be measured by an increase in life expectancy.

Otherwise we’re just spinning our wheels and repeating our past mistakes.  

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

A CBO Full of Surprises: Obamacare Will Insure 2 Million Fewer in 2014

Obamacare will insure 2 million fewer people in 2014 than previously reported.  That number is in a new report just released by the Congressional Budget Office (CBO).

That may come as a surprise to you.  But it isn’t the biggest surprise in the report for me.  I’ll explain why later. 

First, let’s review the new numbers.

Last May, the CBO estimated that seven million people would sign up for insurance through exchanges this year.  That number is not a surprise – it has been reported widely in the media.

It also estimated that nine million previously uninsured people would be enrolled in Medicaid or CHIP.  In other words, a total of 16 million people would obtain coverage this year through Obamacare.

But last week, CBO released updated estimates.  It now says that only 6 million will sign up through the exchanges this year, and only 8 million will enroll in Medicaid or CHIP. 

Because some of the people who would have signed up are already insured, that means that the number of uninsured people will grow by 1 million over the CBO’s previous estimate.

Is that really a surprise?

It has been evident for some time that getting 7 million people to sign up for insurance through the exchanges was an ambitious target.  And the early glitches sure didn’t help.  But enrollments have been going much more smoothly lately, and reaching 6 million would still be impressive.

Also, taking into account the new enrollments in Medicaid and CHIP, the overall number of uninsured would still be reduced this year by 13 million.  That would reduce the total number of uninsured people from 58 million in 2013 to 45 million – halfway to Obamacare’s 2016 full-implementation target of 31 million.

That is still a pretty good result, and about what could have been expected.

And there is a little more good news on the fiscal side.  Lower enrollment numbers mean a little less spending for ACA each year, and in a program this big, that comes to $18 billion saved over ten years.

That would be enough to fund the prevention fund again, but I guess we shouldn’t go there.

So where’s the surprise?

The first is, of course, could be in the perception.  Much as the headline from the CBO report last week that Obamacare would cause the loss of over 2 million jobs was pretty surprising, another headline that it has fallen 2 million people short of its 2014 insured targets could be just as shocking. 

Of course, last week’s headline didn’t mention that the jobs “lost“ come about largely from among people who feel too sick to work, and who hold onto a job solely because they need the health insurance that comes with it.   The next headline may also not mention that the newly insured people also will come from among those who perceive that they need health insurance the most.

The second is also in the perception.  If Obamacare falls short of its targets, and those targets are recast as promises, then this will be perceived as another Obamacare promise broken.  People always seem surprised when they hear about politicians breaking promises, and they often make them pay at the polls.

But what may be the biggest surprise of all in the new numbers? 

It is this: that Obamacare is working almost exactly as it was intended, and appears to be having almost exactly the result that was intended. 

We are actually getting from the Affordable Care Act almost exactly what the President and Congress said we’d be getting way back in 2010.  And whether you like the law or not, this does suggest that members of Congress were a whole lot more knowledgeable about what they were voting for back in 2010 than most people give them credit for.

In other words, this law was put together out in the open.  The provisions in it were put together in a thoughtful way.  And those who made promises about what it would do were, in fact, telling the truth.  

And while a few of us may be surprised by how it has affected us personally, as a whole we all do know where we stand with this program.

I wish that were the case with all public policy initiatives. 

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

Policymakers Cannot Deny What Medicaid Expansion Means to Survival

It is never easy to absorb unpleasant information.

And when I was a policymaker, if someone told me that my decisions were going to cost innocent people their lives, then I usually chalked it up either to hyper-sensationalism or hyperbole. 

After all, would passing a small increase in a business tax really force an employer to imperil workers by cutting corners on safety?  Would gun registration really leave a homeowner defenseless in the case of a break-in? Would cutting back welfare a few dollars actually result in a choice between eating or heating in the winter?

In most instances, it was hard to see the direct connection.

But the more I learned about health issues, the more I understood that there really were some decisions that were a matter of life and death.  These were the issues that taught me humility.  These were the issues that taught me that I needed to set aside my political ideology and embrace both theology and hard data whenever they stared me in the face together.

One of those issues was Medicaid. 

Back in the late 1970s, I saw Medicaid as a safety net program for seniors and people with developmental disabilities to help pay for skilled nursing or intermediate care.

And so when Ronald Reagan and, later, George Bush agreed to expand the program to cover children and families, I admit I was skeptical.  Wouldn’t it burden taxpayers who were already paying far more for Medicaid than they ever expected?  Wasn’t private insurance enough? And what would happen if we did not go along – would anyone die without the expansion?

That was always the billion dollar question – who dies without the help of government?

We knew that people caught in fires, victimized by criminals, or trapped by natural disasters died.  We also knew that those who couldn’t get into hospitals, who couldn’t get emergency services, and who were given substandard care in institutions also died as a result.  But we did not know how Medicaid fit into this.

Fortunately, we voted to expand Medicaid anyway, taking it mostly on faith that it was the humanitarian thing to do.  And now we know the result.  We saved a lot of lives, just as if we had disarmed potential killers or rescued people from fires burning out of control,

We do not have to assert this as a matter of faith anymore.  We also have compelling hard data.

I wrote about this in February 2013 in a column I provocatively entitled Failure to Expand Medicaid: Just another Death Penalty?   If you are interested, you can read the full column by clicking on the title, but the essential point was this: Based on a study published in the highly-respected New England Journal of Medicine, it did not take a rocket scientist to calculate that as many as 36,000 lives nationwide hung in the balance of the Medicaid expansion. 

It may not be hard for a policymaker to dismiss the results of a single study; I did it myself in my day.

But it is not quite so easy to dismiss two.  

And there was a second study, conducted by the prestigious RAND Corporation, published by the equally reputable Health Affairs in June of 2013.  I wrote about it in another column entitled Grim Numbers Result from Failure to Expand Medicaid.  By then, we could all come up with a first set of estimates of the numbers of people who would die in just those states that failed to expand Medicaid last year – up to 19,000.

But last year’s sessions were over by the time people saw the report.  And so they likely threw it into the bottom of the circular file and forgot about it.

But can similar evidence be denied a third time – much as Peter denied knowing Christ?

Health Affairs blog published a new report just days ago, entitled Opting Out of Medicaid Expansion: The Health and Financial Impacts.  It found that up to 17,000 lives still hang in the balance in states that have refused to expand Medicaid.

As Health News Florida pointed out: “More than 1,100 Floridians will die prematurely if the state Legislature continues to refuse to expand Medicaid.” As will more than 1,800 in Texas, 500 in Georgia, 400 in North Carolina, 350 in Pennsylvania, and 200 in Missouri, Alabama, Virginia, Louisiana, Tennessee, South Carolina, and Indiana.

Policymakers in those states – and others – can continue to vote against Medicaid expansion, but they had better be willing to embrace what they are doing.  They are sentencing innocent people to death, and they will own this forever.   

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