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/

States Expanding Medicaid Face Challenges of Their Own

Last week, I wrote about the states that have decided not to expand Medicaid this year.  The decision will cost them in money and lives. 

But the 24 (and counting) states that have chosen to expand Medicaid will face challenges of their own.  As a new article in Health Affairs Blog reveals, expanding states will have plenty to do to assure that the benefits of expansion reach those most in need.

The article, entitled Lessons of Early Medicaid Expansions Under the Affordable Care Act, reviews the experiences of five states and the District of Columbia in expanding Medicaid benefits to additional populations using authority granted to them under Obamacare.  The five states were Connecticut, California, Minnesota, New Jersey, and Washington.

All of the states were able to capture federal dollars to support state or local low-income insurance programs.  But, according to the authors, there were seven lessons these states learned that could be warning signs to other states banking on the savings.

One lesson was that they could not predict the size of their eligible populations as well as they thought they could.

For example, when Connecticut’s expansion was approved in 2010, it was estimated that 45,000 people would be affected.  By May of 2013, over 90,000 had been enrolled.  So while Connecticut may have saved $50 million on the first 45,000; it may have spent all of that on the second.

Connecticut will still benefit in the long run – the original expansion took place under the old federal reimbursement rate.  Higher reimbursement begins in 2014.

But I spoke recently with one former state official, who echoed the concerns of others.  He said that taking into consideration all of the state’s financial difficulties in recent years, perhaps the state should have waited to expand.

Another lesson was that it was not as easy to enroll newly eligible people as the states thought it would be.

On the surface, enrollment seemed straightforward enough.  If a person’s income was below a certain cut-off – 138 percent of poverty – he or she was eligible under the expansion and could enroll.

But this presumes that people are following the news as closely as our public officials do.  And it also presumes that they can easily calculate how much income 138 percent of poverty means for them, taking into account their own family situation.  Finally, it presumes that they can get to the right place to file an application and verify their income, their address, and other information.

Beyond that, once they were enrolled, they often moved or had other changes in their status.  And that meant making certain that the state found them at their new address and captured up-to-date information.

The federal government anticipated these challenges when it provided for more navigators to assist with enrollment.  But not every state is on board with the widespread use of navigators. Even though Florida chose not to expand Medicaid, it still passed a law this year placing some unnecessary and onerous registration requirements on the new navigators.  States following Florida’s lead may discourage both Medicaid and private insurance enrollment in general.

The authors also found that expanding states were covering more people with mental illnesses than they anticipated.

To anyone following the implementation of Obamacare closely, this is no surprise.  The mental health coverage required by both Obamacare and the soon-to-be-implemented Mental Health Parity Act is far more generous – and fairer – than it has ever been.

The authors think that the jury is out on whether every expanding state will experience this.  The early expanders typically focused on very poor people, and there may be more people with mental illness in this group than in the poor and near-poor populations most affected by Medicaid expansion.  We will find out soon enough whether this is so.

Finally, the authors also noted that the political context for expansion is important. 

At bottom, states that want to provide coverage to more people will find a way to do it.  Those that do not, will not.

But in every state, the political drumbeat for better coverage is going to get louder over the next year or two.  

And, according to the authors, the drumbeat may be loudest among the safety net providers.  Hospitals and community health centers have the most to gain by expansion, and the most to lose in states where the numbers of uninsured remain the highest.

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

Grim Numbers Result from Failure to Expand Medicaid

In the aftermath of the decisions by state governors and legislators not to expand Medicaid, the grim numbers are beginning to roll in.  Failure to expand Medicaid will cost states more than 19,000 lives and over a billion dollars per year.

And that, sadly, is only the beginning.

Source: RAND Analysis, Health Affairs, June 2013

I wrote about this prospect earlier this year, when I concluded that as many as 36,000 lives could hang in the balance of the Medicaid expansion debate.

Now we have some new numbers from a RAND Corporation analysis, published this month by Health Affairs, which quantified the impact of failing to expand Medicaid in fourteen states (as of April 2013) where governors opposed the expansion.  The fourteen states were Alabama, Georgia, Idaho, Iowa, Louisiana, Maine, Mississippi, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Texas, and Wisconsin.

It found that in 2016 there would be 3.6 million fewer insured people in these states.  Collectively, the states would lose $8.4 billion annually in federal reimbursement.  And they would also need to spend an additional $1 billion annually on uncompensated care as a result of their short-sighted decision.

In addition – and most chillingly – there would be 19,000 additional deaths in those states each year.  This is two and a half times the number of total combined combat deaths by coalition troops since the beginning of the wars in Iraq and Afghanistan, and more than the total number of homicide deaths in the nation each year.

But these numbers are already out of date, overshadowed by legislative decisions of the last month.

After the analysis was completed, several more states have moved to reject expansion.  Florida adjourned its legislative session in early May without agreeing to the expansion.  Nebraska’s expansion bill died in mid-May.  As recently as two weeks ago, Michigan’s Republican governor was calling for federal help to try to convince legislators in that state to put Medicaid expansion back into the budget.  And both the Ohioand New Hampshire Senates rejected Medicaid expansion just last week.

These decisions will cost hundreds of millions more dollars, while adding millions to the number of uninsured.  Florida’s rejection alone will account for one million more uninsured people and cost state taxpayers at least $430 million.

Failure to expand Medicaid in these states and others will also add thousands more deaths to the tally.

The irony is that all of these states have strong pro-life constituencies.  But the moral imperative of protecting lives doesn’t always extend to those who are already among the living – especially when it is the Affordable Care Act that offers the protection.

The people who will die prematurely as a result of decisions not to expand Medicaid include children with special health care needs – think of children who await organ transplants as examples – and adults with chronic diseases.  These people survive under the most challenging of physical and mental conditions, and have done nothing to incur the wrath of political leaders. 

And yet there is an undercurrent of anger toward those who are acting to save these lives that is, frankly, chilling.

Here is what the Republican Party of Benton County, Arkansas, published in its April 2013 newsletter directed at Republican legislators who supported the Medicaid expansion in that state:

“The 2^nd Amendment means nothing unless those in power believe you would have no problem simply walking up and shooting them if they got too far out of line and stopped responding as representatives.  It seems that we are unable to muster that belief in any of our representatives on a state or federal level.

“But we have to have something, something costly, something that they will fear and that we will use if they step out of line.  If we can’t shoot them, we have to at least be firm in our threat to take immediate action against them politically, socially, or civically if they screw up on something this big.  Personally, I think a gun is quicker and more merciful, but hey, we can’t.”

So we should think about shooting Republicans who vote for Medicaid expansion? 

Could the opposition to Medicaid expansion be more absurd and less grounded in reality? 

I suppose it could, if it involves giving up billions in federal dollars, costing state taxpayers billions more, throwing millions onto hospitals’ charity care rolls, and costing thousands their lives.

Come hear Paul Gionfriddo speak about what comes next for the health and mental health of South Floridians now that the legislature failed to expand Medicaid.  Sponsored by the Mental Health Association of Palm Beach County, and open to the public.  On Thursday, June 20, at noon at 909 Fern Street, West Palm Beach.  To Register: http://www.mhapbc.org/index.cfm?fuseaction=events.details&content_id=132

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

As a Medicaid Expansion Tool, Premium Support Leaves Neediest People Sitting on the Sidelines Again

It is way too early to break out the champagne over the latest Medicaid expansion initiatives bubbling up around the nation. 

States that have been reluctant to expand traditional Medicaid are ablaze with proposals to offer “premium support” to expansion populations. 

Premium support programs may differ in their details, but they have one thing in common.  Instead of offering regular Medicaid to an expansion population, the state pays the cost of their private insurance premiums.

Kaiser Health News reported last week that the Department of Health and Human Services is encouraging states to explore this approach.  MSN featured some “let’s make a deal” offers on expansion by a number of GOP legislators.  And Health News Florida reported a wave of bipartisan enthusiasm for a Florida premium support proposal that was unveiled after support for traditional Medicaid expansion collapsed.

For policymakers who don’t like Medicaid but want the federal expansion dollars, the benefits are clear.  They can prop up the private insurance market as an alternative.  They can allow children and parents in Medicaid-eligible families to be covered by the same insurance.  And they can make the Medicaid program appear smaller to the naked eye.

But based on expert evaluations, the benefits of premium support may not be so clear for today’s expansion populations.

By the early part of the last decade, at least seventeen states had premium support programs in some form, according to a 2005 report of the State Health Access Data Assistance Center.    

And from the perspectives of the states running them, the programs had some problems.

There were significant upfront costs and administrative burdens, difficulties in enrolling families, and challenges in defining the roles of employers.  And they often had to be supplemented by regular Medicaid, in which “wrap-around” Medicaid benefits were offered to close the coverage gaps in traditional insurance products.

From the perspective of potential Medicaid recipients, there were also some significant challenges. 

Writing in Health Affairs in September 2005, Janet Mitchell, Susan Haber, and Sonja Hoover compared the regular Medicaid program in Oregon with a premium assistance program also offered by the state.

They found that the families enrolling in the premium assistance program:

• Were less likely to be of Hispanic origin;
• Were more likely to have at least one parent employed;
• Had higher levels of educational attainment;
• Had better health status;
• Were more likely to have had experience with private insurance programs; and
• Were more likely to receive care in a doctor’s office, as opposed to a community health center.

We can divide today’s expansion population into three groups – better educated parents of SCHIP children who have a medical home and place a premium on staying well; parents who use safety net services episodically only when they are sick; and childless, mostly single, adults with chronic conditions.

Based on the evaluations, only the first group is clearly helped by premium support – provided enrollment is encouraged and simplified.

The second group may be helped, but only if the states put additional resources into education and outreach.

As the Health Affairs authors put it:

“If premium subsidy programs are to be successful in enrolling low-income families, the results of our study suggest that these programs may need to be accompanied by efforts to educate these families about the importance of health insurance and how it works.”

The third group is one for whom premium support may be no answer at all – low-income, uninsured childless adults who have chronic conditions.  Up to 6.6 million people in the Medicaid expansion population have mental illnesses or addiction disorders.

They already often have so many strikes against them – no medical home, underemployment, no children receiving Medicaid or SCHIP benefits, and stigmatization by policymakers who equate illness with entitlement.

They don’t need insurance with all of its profit motives, administrative costs, and bureaucratic tangles.  Their providers just need someone to help pay the bills.

And states need the $20 to $40 billion Medicaid expansion would add to their revenues over the next five years if people with behavioral illnesses were added to the regular Medicaid program.

Premium support is better than nothing. 

It may ultimately win the blessing of HHS, and in some states premium support may be the only path to expansion. 

But premium support is only a partial expansion of the Medicaid program – a concept rejected by HHS just months ago. 

And this partial expansion will leave some of those most in need sitting on the sidelines again.  

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

Our Mental Health Policy Mistakes and the Sons and Daughters Who Pay For Them

We have made some big mental health policy mistakes in my lifetime.  And my son Tim is among the millions of our sons and daughters who have paid for them.

This is because he happens to be among the 6% of sons and daughters with serious mental illness.

We fail to see mental illnesses as often preventable and always treatable diseases.  And although half of us will be diagnosed with one during our lifetime and mental illnesses cost as much to treat as cancers, we more readily send people with mental illness to jails and prisons than we do to hospitals and health centers.  Meanwhile, we underfund mental health care, special education, and social services systems.

I explain what this has meant for my son in an essay just published by Health Affairs, the nation’s leading health policy journal. 

How I Helped Create a Flawed Mental Health System That’s Failed Millions – And My Soncovers over twenty years of Tim’s life in Connecticut, Texas, and California – a life now lived mostly in jail, in hospitals, or on the streets.  This isn’t because of his mental illness.  It is because of the way we treat his mental illness.

The article appears in the September 2012 issue of the print journal, but Health Affairs has also made it available free of charge online and via podcast.  There is a link at the end of this column.

In the essay, you will see that we former policymakers – along with educators and service providers – made a lot of mistakes that resulted in the isolation of people like Tim. 

And today’s policymakers aren’t just repeating the mistakes we made.  They are piling new ones on top of them.

As a Connecticut state legislator in the 1980s, I thought we had the right idea.  Close the archaic state psychiatric hospitals, and move people with chronic mental illnesses back to their homes, schools, and communities. 

There was a problem.  Closing the institutions was popular, but returning people with mental illness to communities wasn’t.  So we directed only some of the dollars we saved into services.  The rest we used to lower taxes.

We justified this because we made taxpayers happy and because we believed that whatever happened in the community would be better than the underfunded services in the institutions.

We were wrong.  Sometimes no services are worse.

Today, Americans with serious mental illnesses have life expectancies that are diminished by as many as 25 years.  They die from violence and suicide, and from ineffectively treated chronic illness.

Those who survive suffer from stigma and neglect.  This is because they often act differently from the rest of us, sometimes because of disease, sometimes because of the medications they take to manage disease, and sometimes because of the drugs they use when the medications don’t work. 

We are afraid of them. 

To make them less frightening, we use the term “behavioral illnesses” to describe what they have.  But this in turn feeds a fantasy to which unsophisticated people (some of whom serve as policymakers) cling – that mental illnesses are the same as bad behaviors, and people with mental illnesses could choose to will away their diseases if only they’d try.  As if someone with cancer or heart disease could will those away.

They can’t. 

I can’t defend what we did in the 1980s to shackle people with mental illness with neglect.  But it seems to me that today’s policymakers are doing worse.

They can see with their own eyes the results of neglect – people sleeping in our parks, lying on our sidewalks, and standing on our street corners begging.  So how can they possibly defend the $3.4 billion in cuts they’ve made to state mental health services in the last three years, or some of the other horrible policy decisions I write about in the essay?

Maybe they just choose to look the other way.

That’s what most people do who see my son Tim – and all our sons and daughters who are like him. 

And when they do, they miss seeing a gentle soul with an easy smile, a good heart, and an imperfect history who has accepted humbly the hand he has been dealt and graciously consented to me writing about it.

But what they miss most isn’t who they choose not to see, but an essential part of what makes us human – empathy.  We were made to do better than this.

To read the full Health Affairs Narrative Matters essay, click here.

For links to the sources of data cited in this column, please see the mental health section of my data links page.

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.

Public Health Spending Prevents Deaths

If you are as grateful as I am that the nonstop coverage of debt ceilings and deficits is behind us for a while, and want to talk about something even Congress should be able to agree is worthwhile, then just repeat after me these two magic words. (No, not those two!)

The words are "public" and "health."  There is a new article out entitled Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths. 

Source:  Mays and Smith, Health Affairs, 7/11

The article has been published online by Health Affairs, and is in the August 2011 edition of the print journal.  It was written by Glen Mays and Sharla Smith.

Spending on public health has long been one of our government’s great success stories.  It keeps our water clean, our air free of pollution, our food pure, our children immunized, and our homes and neighborhoods free of lead, rats, and violence.  It also promotes our health. 

I wrote in a previous column about what this means for individuals like you and me.  Our life expectancy in America grew by 30 years during the last century.

The Health Affairs article makes it clear that public health is still getting the job done today.

Here’s the bottom line.  When more money is spent on public health, death rates go down.  When less money is spent on public health, death rates go up. 

It can’t be much clearer than that.  The authors studied public health expenditures and death rates in a number of communities between the years of 1993 and 2005. 

Local health departments whose spending increased by an average of 10% per year during those years experienced significant declines in infant deaths, deaths from heart disease, deaths from diabetes, and deaths from cancer.

These declines were not inconsequential.  For each 10% increase in public health funding, there was a decrease of 3.2% in deaths from heart disease, a decrease of 1.4% in deaths from diabetes, and a decrease of 1.1% in deaths from cancer.

There was also a 6.9% decrease in infant deaths.

These percentages may seem small, but consider this.  In a county of one million people, a 10% increase in public health funding per year for twelve years means a decrease of over 1,000 deaths from heart disease alone. 

These are not avoided deaths among people who had heart attacks and were saved by advanced medicine.  These deaths usually occur among people who seem healthy.  If it weren’t for public health, these thousand people wouldn’t be playing with their children and grandchildren, walking and jogging along our streets, working at jobs, dining in our restaurants, shopping in our stores, and even serving as elected or appointed officials.   

It seems a no-brainer to invest in public health.  However, one-third of local health departments actually had their funding reduced during the twelve year time period of the study.  The communities they serve had an increase in deaths equivalent to 430 for every one million people.

We’ve all heard how tight our public budgets are as public officials work to reduce spending.  Can we afford to save this many people through public health?

The short answer is yes, and the longer one involves some embarrassment that we don’t try harder.  The average community spends about $40 per person per year on public health.  Increasing this expenditure by 10% would average out to $4 per person per year, about the cost of one movie rental or one beer per year.  

Local people have also already delivered a message about this to state and federal officials.  They don’t mind giving up a movie rental or a beer every year to save 1,000 lives. 

In states where counties or cities control their own local health departments, the authors note that public health spending is 24% higher than it is in states where the states themselves control the local health departments.  It turns out that local people are willing to give up a movie rental and a beer for public health.

The authors calculated that the ten percent increase in public health spending per community would increase local public health budgets by an average of only $312,000 per community each year.  Compared to the billions and trillions of dollars our elected officials have been talking about – or even the $9.2 million one hospital recently charged the estate of a dead patient – $312,000 doesn’t seem like a very big number to me. 

Public health is responsible for 50% of the gains in life expectancy in the United States during my lifetime.  We can certainly do better than to give it less than 5% of all health funding, as we do today.

Public health doesn’t need a lot to do its job.  Just 5.05% would make a measureable difference.  And 5.5% across the nation could save the lives of millions.   

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