Hypocrisy In Motion

The latest Obamacare navigator “compromise” may calm one small battle in Florida.  But it won’t end the war on Obamacare being waged by hypocritical public officials around the country.

A couple of weeks ago, I wrote about the Congressional effort to undermine the Obamacare navigation program in its entirety.  A House Committee has ordered nonprofits winning navigation grants to produce reams of material, and promises to punish those that have failed to comply. 

Source: US Census Bureau

Navigators will assist people in applying for public or private insurance to pay for their health care.  

Navigators are not a new concept, created by Obamacare.  They are as old as Marco Rubio, and Obamacare is not the first federal initiative ever to fund them.  In fact, I implemented the policy of the Nixon Administration as a VISTA paralegal 35 years ago, navigating underinsured elders to the Medicaid program.

So we know that navigators can be trusted to do their jobs.

But that hasn’t stopped some public officials from sudden “worries” that navigators hired by nonprofit agencies will disclose private information that clients voluntarily give to them.

Three weeks ago, Governor Rick Scott of Florida – apparently trying to re-establish his credentials as the nation’s leading gubernatorial opponent of Obamacare after openly flirting with it during the 2013 legislative session – joined this chorus, wondering “how the federal government will prevent personal information from being stolen” by these nonprofits.

This was quite a contrast to enrollment efforts already well underway in states like Connecticut that actually want to help people get insured.

Then Governor Scott raised the stakes last week.  He ordered that no navigators be allowed in any state health department offices.  The reason this mattered is because in Florida, county health departments are actually arms of the state government, and their employees are state, not county, employees. 

So in banning the navigators from state offices, he was in effect banning outside navigators from enrolling people in county safety net clinics, federally-qualified community health centers, and a host of other facilities staffed by state employees.

He came under immediate fire from shocked public health officials, one of whom called the edict “cruel and irresponsible,” and said that it would compromise access to healthcare for “a multitude of needy Floridians.” Florida has the second highest percentage of uninsured people in the nation – two and a half times the rate of Connecticut.

A day later, state officials backed away after having an Emily Litella moment.  They realized that the counties actually own and control the properties in which the health department clinics operate.  The state employees, like the navigators, are just outside guests in these county buildings.   

A compromise of sorts was struck.  The state acknowledged that it had no authority to keep navigators out of the county buildings so long as the counties had them work outside of the actual clinic space.

Now most thoughtful people with any knowledge of history would probably use a colorful term here to characterize the state’s position.  I’ll just call it hogwash.

Public officials like Rick Scott are not the least bit worried about navigators being able to protect the privacy of individuals. How do we know this? 

Because Rick Scott was CEO of Columbia/HCA until 1997.  Like every hospital chain in the country, HCA hospitals have worked with navigators for years to capture Medicare, Medicaid, and insurance reimbursements for uninsured patients.  The navigators are often employees of outside entities working under contract.  Many even take a percentage of the billings for every person they enroll.

I know this because I competed with these companies when I was overseeing navigation programs for community nonprofits in Texas and Florida in the 2000s.  And these outside companies had access to all the private information about which Governor Scott professes to be worried today.

But there is more. 

In Florida, my nonprofit placed navigators in state health department clinics almost a decade ago and helped capture reimbursements for the state, relieving taxpayers of the bill.  No one accused us of breaching confidentiality.  But Jeb Bush – who had some common sense – was Governor then, and George Bush was President.

Hypocrisy is always in motion, and tough to pin down.  But in this instance, certain public officials made it too easy for us to see the real reason they want to prevent uninsured people from getting help paying the bills that clinics and hospitals must, by law, present to them.

They know for a fact that this part of Obamacare will work, and they desperately don’t want that to happen.

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

The Best States for Your Health, 2013

After a year in second place, Massachusetts is once again the best state for your health in the 2013 Our Health Policy Matters rankings.

In first place in 2011, Massachusetts dropped to second last year behind Connecticut.  It edged out Connecticut this year based on the rankings of all fifty states in a combination of seven national source rankings and/or spending categories.

Here are the top ten states, with the change from last year’s ranking in parentheses.

1. Massachusetts (+1).  Among the seven components of the rankings, Massachusetts was only 4^th in the Healthy State rankings, and 11^th in the Kids Count health rankings.  But it earns its top rank overall because of consistently high placements in five other health care rankings.

2. Connecticut (-1).  Last year’s winner, Connecticut ranks 2^ndoverall in the Kids Count health rankings and in the percentage of residents with employer-based private insurance.  But it is only in the middle of the pack (20^th) in total number of high-quality hospital programs.

3. New York (+3). Never highly ranked in the healthy state rankings (18^th this year), New York has jumped from 19^thto 3^rd in two years on the strength of its hospitals, and good access to care for both younger and older residents.

4. Vermont (+3). Vermont tops the healthy state rankings and is 4^th in the Kids Count health rankings.  With an earlier investment in universal health care for its residents offsetting its lack of high-quality hospital programs, it may go higher in the future.

5. Maine. (+3). Maine tops three individual categories – the Kids Count health rankings, Medicaid access, and primary care access – accounting for its three-place gain this year.

6. Minnesota (-2). Minnesota scores highly in the Healthy State rankings, and also has high-quality hospital programs and a highly-insured population.Wisconsin (+6).  

7. Wisconsin owes its improvement in the ranking to healthy kids (3^rd) and solid performances in most other categories.  But it lags a bit in the Healthy State and primary care access rankings.

8. Utah (0). Utah scores well in the Healthy State rankings (7^th), but less well in the Kids Count health rankings (14^th).  It also has a high percentage of its population covered by employer-based insurance.

9. Washington (+7). Like Wisconsin, Washington made a big move into the top ten this year on the strength of a solid Kids Count health ranking (6^th).

10. Maryland (+2).  Maryland is in the top ten in the Kids Count ranking and in the percentage of its population with employer-based insurance.

In individual categories, Maine had the most first place rankings – the Kids Count health ranking, the primary care access ranking, and a tie for first in Medicaid access. California (19^th overall, up 3 places from last year) placed first in the number of high quality hospital programs and tied for first in the Medicaid access rankings.  Vermont topped the Healthy State rankings and tied for first in Medicaid access.  New Hampshire (11^th overall, after a 4^th place showing last year) placed first in employer-based health insurance. 

And Florida (34^th this year, down one place from last year) was first in community Medicare spending.

These rankings are the last before some significant Obamacare changes go into effect next year. For example, Vermont (ranked 4^th), Maine (5^th), Wisconsin (7^th), and Rhode Island (12^th) have all announced plans to cut their Medicaid rolls to encourage people to enroll in the exchanges, according to an article this week in Kaiser Health News.   Next year’s rankings may be adjusted to take into account insurance exchange enrollments in all the states.

Washington (9^th), Delaware (18^th), and Oklahoma (43^rd) were the biggest gainers this year.  They all gained seven spots in the rankings. New Jersey (13^th) experienced the biggest drop – 10 places. Virginia (23^rd) lost nine places, and Pennsylvania (16^th) and South Carolina (48^th) each lost eight.

Next week: the ten worst states for your health.

To see the full rankings of all fifty states, click here.

How These Rankings Are Developed:

OHPM combines seven rankings of the states to create this Top Ten.

Two of the rankings among the most highly-regarded public health or prevention-focused rankings – the United Health Foundation/APHA/Partnership for Prevention America’s Health Rankings and the Annie E. Casey Kids Count state health rankings.  The most recent America’s Health (Healthy State) Rankings were published in December 2012, and the most recent Kids Count health rankings were released in June 2013.

Because prevention and public health account for 50 percent of the gains in life expectancy over the last century, these two rankings account for 50 percent of the weight in the OHPM rankings.

The other five components of the ranking account for the other 50 percent, and are related to health care access and quality.  This year, they include the number of nurse practitioners and physician assistants per capita in the state (as a measure of the strength of the state’s primary care system), the percentage of state residents with employer-based private insurance and with access to Medicaid (as a measure of the availability of third-party payments for health services in general for the under 65 population), community-based Medicare spending (as a measure of the availability of elder health services), and, from the 2013 US New and World Report Hospital Rankings, the total number of high quality hospital specialty programs in the state (as a measure of the availability of specialty care for all chronic diseases and conditions).

To see the full rankings of all fifty states, click here.

Source links:

http://www.americashealthrankings.org/mediacenter/mediacenter2.aspx

http://www.statehealthfacts.org/comparetable.jsp?ind=125&cat=3

http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=7248

http://kff.org/medicaid/state-indicator/medicaid-enrollment-as-a-of-pop-fy09/

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsStateHealthAccountsResidence.html

http://health.usnews.com/best-hospitals/area

http://data.bls.gov/oes/search.jsp?data_tool=OES

http://samhsa.gov/data/NSDUH/2k11State/NSDUHsaeTOC2011.htm

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

The Ten Best and Ten Worst States for Your Mental Health

Connecticut spends four times more per capita on state mental health services than Texas.  In Florida, 25 percent fewer people report having mental illnesses than in Washington.

Across the nation, there are significant differences in the amounts states spend on mental health services.  Connecticut spends $189 per capita, while Texas spends only $39.

But there are also significant differences in the reported prevalence of mental illnesses.  For example, fewer than 18 percent of Floridians report having a mental illness during the past year, but in Washington almost 24 percent do.

But what happens when you put spending and prevalence together?  Some new rankings emerge that give you a measure of each state’s real commitment to protecting mental health – and treating mental illness – in their population. 

This week, I have ranked all fifty states using both spending and prevalence data.      

I have taken per capita mental health spending from Kaiser Family Foundation’s State Health Facts data, and prevalence data from SAMHSA’s Summary of the National Survey on Drug Use and Health (NSDUH).  Both data sets are from the 2010-2011 time period.

It turns out that some states spend more than ten times as much as others on behalf of people with mental illness.

You can review the full list of the states along with the full set of the data I used here. 

But for now, if the commitment of state government is your measure, here are the ten best and ten worst states for your mental health.

The Best:

1. Maine.  Maine spends almost $1,900 per person with mental illness – 25 percent more than the next closest state.  It is tops in spending per capita, and but also 7^th best in percentage in percentage of people reporting mental illnesses.

2. Alaska.  Alaska is middle-of-the-pack in prevalence, but it is second in spending per capita.  The result?  Alaska spends just under $1,500 per person with mental illness.

3. Pennsylvania.  Pennsylvania is 3^rd overall in spending, but only 16^thbest in prevalence.  That still results in spending of over $1,400 per person with mental illness.

4. New York.  New York is 4^th in spending, and middle-of-the-pack in prevalence.  It spends over $1,200 per person with mental illness.

5. Vermont.  Like New York, Vermont is 23 places higher in spending than in prevalence.

6. New Jersey.  New Jersey is 3^rd best in prevalence, but still spends over $1,100 per person with mental illness.

7. Arizona.  Arizona is only 36^th best in prevalence, but it invests well in mental health services, spending $1,044 per person with mental illness.

8. Connecticut.  Connecticut is one of eight states that spend at least $1,000 per person with mental illness.  It pays off for a state that is tied with Georgia for 9^th best in prevalence.

9. North Carolina.  North Carolina’s high ranking is driven by a 4^th best ranking in prevalence, and top twelve spending per capita.

10. Hawaii.  Balance is the key to Hawaii’s ranking – 15^th in prevalence and 10^thin spending.

And the worst:

41. South Carolina. South Carolina ranks 23^rdbest in prevalence, but is 43^rd in spending.

42. Louisiana.  Louisiana is 35^th in prevalence, but it is not enough to nudge up its overall ranking.

43. Utah. Utah is 49^th in reported prevalence of mental illness – a surprise for a state that regularly ranks near the top in other health categories.  It spends only $263 per person with mental illness.

44. Kentucky.  Kentucky is middle-of-the-pack in prevalence, but spends only $259 per person with mental illness.

45. Georgia.  Georgia is tied with Connecticut for 9^th best in prevalence, but it by spends only one-quarter as much per person with mental illness.

46. Oklahoma.  Oklahoma earns its ranking by placing 40^th in prevalence and 45^th in spending.

47. Florida.  Florida ranks second in prevalence, but only 48^th position in spending per capita.  As a result, it spends just $222 per person with mental illness.

48. Texas.  Texas – which has the lowest prevalence of mental illness – still spends only $221 for each person with mental illness.

49. Arkansas.  Arkansas is one of only two states spending less than $200 per person with mental illness.  It is among the worst in both spending and prevalence.

50. Idaho.  Idaho is far and away the worst state for your mental health.  It is worst in reported prevalence and worst in reported spending.  How bad is Idaho?  At $143 per person, it spends less than one-tenth as much per person with mental illness as do Maine, Alaska, and Pennsylvania.

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

A Long Road Back To Sanity - States Finally Reversing Cuts to Mental Health

All over the country, governors are finally beginning to propose new mental health services funding in the aftermath of last year’s mass shootings in Aurora and Sandy Hook.

Notes: OH funding is from existing OHT appropriation.
CT funding is bond money, some of which may
be used by non-MHSA providers.

There will be a long road back to policy sanity.  We have to dig ourselves out of the mess caused by $4.6 billion in state mental health cuts over the last few years.  But these governors give us hope that the funding-cut nightmare over which many of them have presided may be finally coming to an end. 

In recent weeks, both Republicans and Democrats have announced new community behavioral health funding initiatives, typically ranging between $5 million and $20 million.  

But support for community mental health services is not universal.  In states with the worst track records in funding mental health services, their governors continue to be sadly out of step with their colleagues across the nation.

In Idaho, which has recently dropped to the bottom of mental health services spending, Governor Butch Otter’s major mental health initiative in the aftermath of the Sandy Hook shooting is for $70 million to construct a 579-bed “secure mental health facility” on the grounds of the state’s prison south of Boise.  That would be considered progressive by late 19^th century standards.

At least Otter’s proposing to do something.

Florida has been at or near the bottom of mental health spending for years.  But Governor Rick Scott – whose administration just cut millions more away from community mental health services in October – seems to think that if he just ignores the problem it will go away.  He requested no new dollars for mental health services in his 2014 budget.

But in the rest of the country, the emerging news is much better.  In the last month or so:

According to the Lansing State Journal, MichiganGovernor Rick Snyder said he will seek $5 million in new funding for mental health services to identify young people with mental health needs.  Michigan has cut $124 million from community mental health programs since 2004.

In Missouri, where eighteen months ago Anna Brown’s death in a St. Louis jail after she was refused care in a hospital emergency room drew national attention, Governor Jay Nixon is proposing $10 million in new mental health funding, primarily for a hospital emergency room diversion program.

In Colorado, Governor John Hickenlooper, whose state suffered through the Aurora mass shooting last summer, has proposed spending $18.5 million in new funding, including over $10 million for five urgent care centers for people with mental illness and a statewide 24-hour hotline.

In Connecticut, the site of the Sandy Hook massacre, Governor Dan Malloy proposed $20 million in new bond funding to assist community behavioral health providers with infrastructure projects that providers say have either been set aside because of budget cuts or have been draining money needed for direct services.

Kansas Governor Sam Brownback, saying that he was committed to strengthening the state’s community mental health system, announced his support for an additional $10 million to increase funding to 27 community mental health centers and to establish a regional system of peer support, intensive case management, crisis intervention, and other evidence-based services.

Oklahoma Governor Mary Fallin announced that she will seek $16 million in new mental health services funding - $8 million for existing programs and $8 million for new programs, including early intervention programs for children and a new state-supported mental health crisis center.

And in Ohio, Governor John Kasich reported that he was authorizing the expenditure of $5 million from an Office of Health Transformation discretionary fund to support children’s crisis intervention services.

These represent just a handful of states taking action, but a cross-section as well. 

The reasons the governors made these proposals may vary.  Some governors may be avoiding gun control debates.  Others may still erroneously equate mental illness with violence. 

The mental health funding initiatives the governors are proposing, however, are needed. 

The governors are working to improve community mental health systems.  They are calling for early identification and treatment of mental illnesses in children, adding new crisis intervention services, and addressing other neglected priorities in their own states. 

And while the numbers may pale in comparison to the cuts made in recent years and won’t undo the damage overnight, they are steps in the right direction. 

These steps should be embraced by legislators in their states, and in states with less understanding governors.  

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

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.

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