Not News, But History - A New Look at Medicaid Expansion

                لمشاهدة الفيديو كامل HD 
              والتحميل مجانا

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Now that 2014 and Obamacare are both here, there will be plenty of stories about Affordable Care Act implementation.  Some will be newsworthy; but others will just be history. 

Last week, we got our first history story characterized as exploding news.

The Washington Post reported on a newly-released Harvard study that analyzed the impact of the 2008 Oregon Medicaid expansion on hospital emergency department visits.  The study found that there was a 40 percent increase in the number of emergency department visits made by the new Medicaid enrollees.

For the Post article, an MIT health economist (I guess no Harvard ones were available!) commented  that he viewed it “as part of a broader set of evidence that covering people with health insurance doesn’t save money,” something he went on to characterize as a “misleading motivator for the Affordable Care Act.”

And Forbes went farther, claiming the study results are “undermining [the] central rationale” for ACA.

But the Oregon expansion increase wasn’t really news by itself, and it tells us nothing about the Affordable Care Act, either.

There are three reasons for this.

The first reason is that Medicaid recipients, as a group, have always been the most frequent users of emergency department care. 

I learned about this up close when I was involved in a community health project in Austin, TX, more than a decade ago. 

We compared the use of emergency departments for non-emergent reasons by privately insured, Medicaid-insured, and uninsured residents.  About half the visits made by privately insured or uninsured people were for non-emergent reasons.  But 60 percent of those made by Medicaid recipients were for non-emergencies. 

The same thing was true when that analysis was repeated in other hospitals in other parts of the country.

So the new study simply confirms what we have known to be the case for years.  Medicaid recipients use hospital emergency departments for non-emergent care more frequently than those who are not on Medicaid.

The second reason is that we also know why Medicaid recipients have historically gone to emergency departments for their non-emergency care. 

It isn’t that emergency rooms are more conveniently located than private doctors and walk-in clinics.  Or that some hospitals now use billboards, texting, or other mass media to advertise shorter emergency department waiting times.

It is simply because – unlike many private primary care providers – hospitals have historically been paid enough to take part in the Medicaid system. 

But there are new realities under the Affordable Care Act.  More federally-qualified health centers are being approved, and other private primary care providers are seeing increased rates – rates comparable to Medicare – for treating Medicaid patients.

While change won’t happen overnight, this means that over time more private providers will be signing up for Medicaid in the expanded Medicaid program, and more Medicaid patients will be choosing them over hospital emergency departments because they can.

And that makes the results of an expansion program that took place six years ago an interesting history lesson, but as poor a predictor of what will happen in the future under a different set of rules as historical stock market performance is of future returns.

The third reason is that cost-savings was not a “misleading motivator” for supporting the Affordable Care Act.

Despite the suggestion of the MIT economist and the Forbes headliner, it wasn’t actually a reason at all.  When the Act was debated in 2009 and 2010, it was clear to all that it was essentially cost-neutral. 

Both the CBO and the Administration projected that we were going to be spending about the same amount on health care overall for the next ten years whether or not we passed the law.  But the law would distribute the costs and savings differently.

Medicare and Medicaid would take on a slightly greater share of costs.  Out-of-pocket costs not covered by public or private insurance would go down (especially for those with chronic diseases and conditions who could not afford insurance in the past).  And private insurance would continue to pay just about one-third of the nation’s health care bill.

While not everyone in the media may have known this at the time, all the people voting on the law did.

That’s not news.  That’s history.

Just like the new Harvard study.

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

We've Grown Accustomed to Disgrace

It sometimes seems like policymakers go out of their way these days to pick on people with mental illness.

According to a report released last week by the American Mental Health Counselors Association, 3.7 million people with mental illness will remain uninsured because of the decisions of states not to expand Medicaid. 

And if you believe some earlier data from the Kaiser Family Foundation about the total number of people who will be left uninsured because of states' failures to expand Medicaid, then you can only conclude people with mental illnesses account for nearly 80 percent of all those who are being denied insurance coverage in non-expanding states.

This includes 652,000 in Texas and 535,000 in Florida, and around 200,000 each in Pennsylvania, Indiana, Georgia, North Carolina, South Carolina, Tennessee, and Louisiana.

The association characterizes this as “dashed hopes” and “broken promises.”

You might also call it a national disgrace.

For those of us who live in one of the non-expanding states, we’ve grown accustomed to disgrace.  Our states are often held up as examples of what not to do.  We have poorer health status, and usually spend less on mental health services.   We also have the life expectancies of Libyans.

Our policymakers often blame Washington for all of our troubles.  But Washington isn’t to blame for this one. Washington’s recent decisions on health policy did not contribute to our current staggering debt.  Fighting two interminable wars on a credit card at the same time our banking industry nearly collapsed took care of that. 

No, these decisions reflect a lack of understanding and empathy on the part of elected officials.   Their decisions have consequences, and cannot always be blamed on someone else.

Perhaps those who live in more progressive states are feeling a little superior right now.  But they should not be.  Legislators in those states also didn’t clamor to expand Medicaid for all these people with mental illness before the federal government stepped in and offered to pay for it. 

So we are really all in this together.

We are all pushing nearly 4 million people even farther out on the fringes of our health care delivery system. 

These are people living with at least one serious, often life-threatening, illness.  They are living near or below the poverty line.   They cannot afford to pay for health care.  And to top it off they are often subjected to stigma and discrimination. 

This is a group of people who are frequently homeless or incarcerated. 

And when they do need medical care, this is what we say to their providers.  Treat them for free.

We ask hospitals to care for them in their emergency rooms for free.  We ask community mental health centers to provide inpatient and outpatient services for nothing.  And we ask clinicians to donate their care.

The solution for this is simple and involves us all.  If we want to do so, we can bypass those non-expanding states entirely.

All we need to do is to ask Congress to amend the Affordable Care Act to allow people living below the poverty level the option of purchasing insurance on the exchanges at the same price as those living at the poverty level. 

Right now, they cannot.  The reason is that the price of insurance for someone living below the poverty level isn’t subsidized.  But it is for everyone between the poverty level and 400 percent of poverty – over $90,000 per year for a family of four. 

There are plenty of people who think we treat people below the poverty level like millionaires with our entitlement programs.  Ironically, in this one instance they happen to be right. 

If Congress were to make this change, the immediate result would be that 3.7 million people living with mental illness could get decent basic health insurance for little or no cost. 

Of course, it would cost the rest of us something.  But Medicaid expansion costs all of us something, too – even those of us living in non-expanding states. 

And the money would be put to good use. It would reimburse providers of necessary health care, stimulating the sector of the economy that accounts for one-sixth of our GDP (and a similar percentage of our jobs).

So everyone would win if we did this.

Who could object to that?

My guess?  Many of the same politicians who don’t favor Medicaid expansion.  Because when you get right down to it, where people with mental illness are concerned, some of these politicians may in fact be our biggest national disgrace.

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/

Income Inequality, the State of the Union, and the Affordable Care Act

The President focused on income inequality in his State of the Union speech.  This is an important issue; as the gap widens between those rich and poor.

But income inequality is built into our public policy at so many levels – and even at the lowest ends of the economic spectrum sometimes the “wealthier” individuals receive better benefits than those who may need them even more. 

A case in point is how the insurance subsidies work in the Affordable Care Act in the aftermath of the Supreme Court ruling of 2012.

In these, the poorest individuals and families – those living below poverty level – fare the worst.

This is an inequality that could be repaired easily and immediately.

Here’s how this particular inequality works.  If you are a single person earning $11,375 per year, you pay the highest percentage of your income for insurance as anyone in any income bracket. 

An example:  If you want to buy “silver plan” health insurance on the open market, it will cost you $2,535 per year – or almost one quarter of your annual income.  Or you can purchase a bronze plan for $2,101.  That is still over 18 percent of your income.

In other words, you can’t afford it.

But if you earn just $230 more per year, or $11,605, then the result is almost magical.  The cost of a silver plan goes down to $232 per year – just two percent of your income.  And if you opt for a bronze plan, it will cost you nothing.

It may seem hard to believe, but it’s true.

The reason is that the first person earns just below poverty level (99 percent of poverty) and the second just above (101 percent of poverty).  And insurance subsidies begin at 100 percent of poverty.

Congress was aware that it was building this severe inequity into the law in 2010, but it was not worried about it. 

That was because it also passed a fix.

It mandated the expansion of Medicaid in all fifty states to people earning 138 percent of poverty.  With Medicaid as an option, few people living near the poverty level would need or want private insurance through an exchange.

But then the Supreme Court created a new problem.  Without acknowledging the inequality in the subsidy, it ruled in 2012 that Medicaid expansion was optional, effectively undermining the fix.

In spite of the eighteen months of political chaos that has resulted from this ruling, many states – and we can now say a majority of them – have moved to remedy the inequality in the only way they can. 

They have chosen to expand Medicaid, taking up the federal government on its offer to pay nearly one hundred percent of the cost.  And over the next several years, most of the remaining states will probably follow, but only after they’ve wasted billions of dollars of their own resources during the delay.

But remedying the inequality isn’t the same as eliminating it.  In states like Connecticut, which have embraced expansion – it just covers it over.

And in states like Florida that have not embraced expansion, it still leaves millions of people out in the cold.

There is a solution for everyone, and the federal government could move forward on it – if it is as serious about reducing inequalities as the President is.

Right now, the federal government exempts people living below poverty in states that have not expanded Medicaid from the mandate that they buy insurance.

But there is a better alternative.  It could offer everyone living below poverty the option of “purchasing” a bronze plan at no cost.  In other words, it could extend the same subsidy to them (when they are not otherwise eligible for Medicaid) as is available to those earning just above poverty.  It would probably also have to waive the deductibles in those plans for this group, and there are ways it could do this.

This would cost the federal government no more than paying for Medicaid expansion.  It would get millions more people covered – many of them adults, and many with chronic conditions.  And it would spare us endless debates in reluctant states.

There are legislators in some of these states who have proposed using new federal Medicaid dollars to purchase private insurance for low-income individuals.  That’s an idea, but expanding subsidies would be a simpler solution.

It would cut out the reluctant state middle man, and reduce inequality directly.

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

In 2014, the Gap Will Widen between the Health and Mental Health "Haves" and "Have Nots"

Let’s open 2014 with four health policy predictions.  Here are the first three:

• Obamacare enrollments will top 5 million.
• Uninsured rates will come down.
• Health inflation will tick up.

Here’s why you can count on these.  

First, 1.1 million people have already enrolled in Obamacare.  The Administration hopes for 7 million by March.  That may be optimistic, but there will be another burst of enrollments in a couple of months.  And there will be another open enrollment period toward the end of the year. 

So at least 5 million enrollments seems reasonable.  And here is a bonus prediction.  If that many sign up, the politics of Obamacare in the half of the states that have embraced it will probably shift during the 2014 election cycle.  Their people will, too.

Second, the number of people who are uninsured will go down.  A 1 or 2 percent decline will be attributable to Obamacare.  The improving economy will also help.  And this means that the numbers will be better even in the states that did not embrace Obamacare.

Third, because more people will be insured and getting care, health inflation will go up again.  Both the Congressional Budget Office and the Administration have been predicting this for 2014 ever since the passage of Obamacare. 

In fact, if it doesn’t happen, this will probably be the health policy news story of the year.

But the fourth prediction may be most significant of all.  The gap will widen between the states with better health and mental health care and those with worse. 

And this has everything to do with Medicaid money.

As of December, the states were literally divided down the middle between those that decided to expand Medicaid in 2014 and those that did not.  If you compare the 26 states (including the District of Columbia) that decided to expand Medicaid to the 25 states that did not, the expanding states already have a decided advantage in supporting health and mental health care.

And with hundreds of billions more dollars flowing into those states over the next few years, that gap will probably widen.

Consider how these Medicaid dollars could widen the gap in just two areas – the number of nationally-ranked hospital specialty programs in a state and mental health spending. 

First, think about the high-quality hospital specialty services we all want and sometimes need.  Hospitals rely on Medicaid dollars for a significant portion of their revenue.

Medicaid-expanding states already have significantly more nationally-ranked hospitals and specialty programs, according to the U.S. News and World Report 2013-2014 rankings, than states that do not.

Seven of the ten states with the greatest numbers of nationally-ranked specialty programs decided to expand Medicaid.  And consider the advantage already enjoyed by California (ranked #1 in number of nationally-ranked specialty programs) and New York (#3) over the two most-populated states that decided not to expand Medicaid – Texas (#6 in number of nationally-ranked specialty programs) and Florida (#11).

California and New York, with 678 hospitals between them, are home to a total of 28 hospitals with at least one nationally-ranked specialty, with a total of 154 nationally-ranked specialties overall.

Texas and Florida, with 895 hospitals between them, are home to a total of 16 hospitals with at least one nationally-ranked specialty, with a total of 70 nationally-ranked specialties overall.

Texas and Florida are leaving as much as $100 billion on the table over the next ten years, much of which would have ended up on hospitals’ bottom lines.

The same point can be made regarding funding for care for people with mental illnesses – on whose behalf many of those Medicaid expansion dollars will be spent. 

The 26 states expanding Medicaid already spend much more on mental health services than those are not.  And the disparity is striking.  According to the Kaiser Family Foundation, the average state spends $120 per capita on mental health agency programs. 

But the states expanding Medicaid spend $139, on average, compared to $116 by states that refused.

And even these spending numbers look artificially close because of high per capita mental health spending in states like Alaska and Maine, which have small populations.  When population size is taken into consideration, as is clear from the pie chart above, the expanding states account for nearly twice as much of the nation’s per capita mental health spending as do the non-expanding states. 

And that gap – like the gap between the “haves” and “have nots” – will only widen in 2014.

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

Six More Reasons Why Obamacare Won't Be Repealed

The House of Representatives voted to repeal the Affordable Care Act for the 40^th time last week.  It did this before balancing the budget, passing a jobs bill, reforming election laws, or anything else that might actually improve its standing in the eyes of the general public.

So what began for some members of Congress as principled opposition to federal “overreach” has turned into a political punch line:

“How many more votes will it take for the House of Representatives to repeal Obamacare?  It doesn’t matter, because the House doesn’t count anyway.”

The very first column I wrote after the mid-term election in 2010 was entitled “Six Reasons Why Health Reform Won’t be Repealed.”  In it, I argued that there were at least five substantive reasons why the Affordable Care Act would not be repealed in spite of the Republican House takeover.  These included the popularity of the expanded Medicare benefits, the benefits to early retirees, the benefits to adult children, and the benefits to those with chronic conditions.

I concluded with a political reason.  People who were already upset at the high cost of health insurance would never vote for someone who would vote consciously to make that cost even higher.    

That is as true today as it was then.

So, almost three years later, here are six more reasons why Obamacare will remain the law of the land even after 2016, no matter how many more meaningless repeal votes the House takes between now and then, or how many Senators suggest shutting down the government to prevent its implementation.

First, states with expanded Medicaid programs will never support the repeal of that provision of Obamacare.

That means that neither will most of their members of Congress, no matter how they vote for show.  At present, those states have 205 representatives in the House.  By the end of the year, that number should be closer to 238.  In other words, by next year, states with expanded Medicaid programs will have a majority in the House of Representatives.

Second, the infrastructures to implement Obamacare in all fifty states are now being established – and one of these is an advocacy infrastructure.  Ironically, the advocacy infrastructures may become even more potent in states that have opposed Obamacare.  Because those state governments are giving them no help, they can marshal anti-government on behalf of Obamacare.  For example, the enrollment efforts of Florida CHAIN and its allies already show an impressive level of planning and sophistication.  And they will only get better in the days to come. 

It is difficult to repeal any governmental program.  It is even more difficult when there is an organized effort to protect it.

Third, the existing Medicare program for current and newly-enrolling Medicare beneficiaries is still untouchable for politicians.  

That includes the Obamacare changes that are now an integral part of Medicare – better prescription drug coverage and better wellness benefits.  Imagine being the politician who wants to take away those!

Fourth, unless and until the Congressional Budget Office changes the way it projects budget impacts, you can’t repeal Obamacare without adding to the deficit.  And, for the record, no one in office or running for office favors adding to the deficit.

Fifth, too many people – as many as 25-30 million, by most estimates – are going to benefit directly from the tax credits beginning next year.  If you repeal Obamacare and raise the annual cost of their health insurance by thousands of dollars, they will notice.  Suggesting that they can just become uninsured probably won’t cut it.  And they will probably vote against you in the next election.

And finally, the House lost the issue’s long-run political debate right after the 2012 election, when it replaced “repeal and replace” with simply “repeal.”

“Repeal” may be easier to argue in the short-term, but opponents have to have a plausible alternative to Obamacare to build their constituency.  And they don’t have one.

So whether or not Obamacare becomes more popular in the days to come, to most people it will be much better than nothing.

Even if the House casts forty more votes to repeal it, and even if more senators join the tin-eared chorus threatening to shut down the government over its implementation, Obamacare is here to stay. 

And all the members of Congress already know this.

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/ 

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/ 

The Stories Behind the Headlines: Is This the Best We Can Do?

Health policy has often been in the news headlines this month.  

To cite three examples, CDC released a new report about causes of death.  CMS published data showing wide variations in hospital charges for common procedures.  And, in the context of a newly-reported Oregon Medicaid expansion study, states have been making decisions about Medicaid expansion.

Let's look at the mental health policy stories behind the headlines.

Suicide on the Rise

The CDC reported this month that as of 2009, there were more deaths from suicide in the United States than there were from motor vehicle accidents.

Suicide rates increased by over 28 percent among men and women aged 35-64 from 1999 to 2010.  While men were three times more likely to commit suicide, the rate increased more for women (32 percent) than for men (27 percent).

Suicide rates are highest in the west, but they are increasing in 39 states.

Men are most likely to commit suicide with firearms, women with poison.  The most rapidly growing cause is suffocation.

During the same period, results were down slightly among elders, and up slightly among youth.  CDC speculated that the bad economy could be affecting rates.  It also noted that baby boomers have had elevated suicide rates throughout their lives.

So what are we doing about this?  The recent Medicaid and Medicare debates suggest a whole lot less than we should be.

Oregon Study Links Medicaid Expansion to Reductions in Mental Illness

By now, everyone knows that the Florida legislature decided not to expand Medicaid to over 1 million residents.

Florida isn’t alone – it looks like elected officials in approximately half the states will turn down Medicaid expansion for at least this year, and forfeit billions of dollars that could be used for patient care.

Many expansion opponents latched onto a study published this month in the New England Journal of Medicine to support the case against expansion.  The study analyzed the results of an Oregon Medicaid expansion program over a two-year period.  It concluded that the Oregon expansion had no effect “on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions.”

Expansion proponents looked for a silver lining, arguing that the study also showed that Oregon’s expansion improved access to care and increased the use of preventive services.

But both seemed to overlook the study’s most definitive conclusion – diagnoses of depression went down by 30 percent among those covered by the Medicaid expansion. 

Mental Health America notes that depression has been estimated to cost $77 billion annually.  So how many billions could we save by cutting depression rates by 30 percent?

And why isn’t this garnering all the headlines?

New CMS Data Show Wide Variations in Payments for Psychosis Care

This past week, the Centers for Medicare and Medicaid Services (CMS) released data on charges for hospitals throughout the country.  The release attracted plenty of attention, because there were wide variations in what different hospitals charged for the “same level of care.”

CMS wants high-charging hospitals to lower their charges.

Those charges, however, may not be the most important numbers in the data.  The real headline is in what Medicare actually pays for the “same level care” throughout the country.

If you suffer from psychosis, you’re better off being hospitalized in Maryland – where Medicare pays an average of $11,277 per discharge, twice as much as it does in a half dozen other states – than in any other place in the country.

The variation in payments in states – even within geographic regions – was astonishing.   I put a table with the numbers for all the states on my State Rankingspage, but here are just a few examples.    Alabama hospitals were paid only $5,256 per discharge, while those in Florida were paid $7,006 and those in Georgia $6,605.  Connecticut hospitals were paid $8,239 (note: the overall number of discharges was very small for Connecticut), while those in Massachusetts were paid $7,494.  North Carolina hospitals were paid $6,188; those in Virginia were paid $5,851 and those in the District of Columbia were paid $9,444.  California and Oregon hospitals were paid $8,916 and $8,816, respectively, but Washington hospitals were paid only $6,504.

You can see information for all the states here.

When we look at the three reports together, they certainly beg at least this question.  Is this really the best we can do?

Paul Gionfriddo will be speaking at the breakfast meeting of the Middlesex (CT) County Coalition on Housing and Homelessness on Friday, May 17, at 8 a.m.  It is open to the public; RSVP to ann@anendinten.org. 

To reach 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/ 

A Political Leader Rejects the Safety Net That Saved His Family

Will Weatherford is a political name to remember, no matter where you live.

Weatherford is the Speaker of the Florida House of Representatives, a rising political star and a CPAC convention speaker this week, who “is widely regarded as a polished politician with excellent instincts,” according to the Tampa Bay Times.

I’m not so sure about those instincts.

In his opening speech of the new legislative session, Weatherford came out strongly in opposition to Medicaid expansion, saying it “crosses the line of the proper role of government.” He called Medicaid a “broken system.”  

But Weatherford wasn’t content to leave it at that.  He invoked a moving, personal narrative to introduce his opposition to the Medicaid expansion.

He told the tragic story of his young brother, who developed and died of cancer as an infant.  I can’t imagine what it was like for 15-year old Weatherford, his seven other siblings, or his parents to go through such a heart-wrenching experience.

And on top of it, Weatherford’s father was self-employed and couldn’t afford to insure his family.  I can relate.  I was also self-employed in the mid-1990s, and it cost me over $600 per month even then to insure my family. 

So when the six-figure hospital bills came, they could have wiped the Weatherfords out.

But they didn’t, because of a safety net that was in place.  “It was the safety net that picked my father up,” Weatherford said.  “It was the safety net that picked my family up.”

What Weatherford did not say was that the safety net was Medicaid. 

Afterwards, Weatherford denied that Medicaid paid the bills.  But after his father confirmed that it did, Weatherford was forced to back-track and acknowledge the role of Medicaid in his own family’s life.

This all happened in the mid-1990s. 

And, ironically, it seems that Weatherford’s family may have benefited from a Medicaid expansionthat took place just a few years earlier.  That mandatory Medicaid expansion occurred in 1989, and covered children up to the age of 6 up to 133% of poverty.  It meant that Weatherford’s brother became eligible for Medicaid via its “medically needy” program once the family’s income dropped below approximately $44,000.

That Medicaid expansion had its legislative detractors, too.  I was in a state legislature then.  I remember speeches in which legislators argued against both the expansion and the “medically needy” program because they didn’t think middle class families like the Weatherfords should be taking advantage of the program.  And U.S. Senators Mitch McConnell and Jesse Helms both recorded votes in opposition to the OBRA 1989 law that helped the Weatherfords. 

Maybe Weatherford is unaware of that history. 

But whether or not Weatherford is aware of history doesn’t change it.  Medicaid was only available for his baby brother because of federal expansions of the program that took place years before. 

And it became available to other children because of subsequent expansions. 

But it will only be available to their parents and older siblings if he supports this expansion.

Like Will Weatherford’s family, my family has benefitted from the Medicaid program.  During her final illness, my mother received Medicaid benefits through a special program in Connecticut so that she could remain in her own home and not have to enter a nursing home.  I have no doubt that this program extended her life.  I know that it improved its quality.

And my son, who has suffered from a life-threatening chronic disease for over twenty years now – one that cost him his education, his ability to work, and even his ability to live independently – has also used Medicaid as his safety net.

So here’s what bothers me most about Weatherford’s position.

It isn’t that we disagree about the safety net.  In fact, we are both openly grateful for what the federal safety net program called Medicaid did for our own families.

It is that his instincts failed him when he took for granted the political courage that it took to expand Medicaid in 1989 to help his family.  And they failed him again when he cavalierly dismissed the expansion today as if helping other families in need were all just a waste.  

He has a duty to see the bigger picture.   

He can start by embracing the program that embraced his brother.

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

Let's Treat Mental Illness Before It's Too Late

Why is mental illness the only chronic disease we don't begin to treat until Stage 4?

I posed that question in a presentation for over 400 attendees at last week’s winter meeting of the North Carolina Hospital Association.  For an audience that witnesses first-hand the crowding of patients with mental illnesses into general hospital beds and emergency rooms, the question resonated.

Stage 4 of a chronic disease is associated with the imminent threat of death – a widely metastasized cancer, for example, or kidney disease so advanced that only dialysis or a transplant keeps the person alive.

The odds of recovery are long.

It is the same with mental illness.  Either the patient's life or someone else's needs to be at stake before we guarantee access to treatment.  That's Stage 4.

Diagnosing and treating a disease at Stage 1, 2, or 3, always improves the odds of survival and recovery.

Why not apply that standard to mental illness, too?  In Stage 1, people show early signs of the disease – sleeplessness, anxiety, and fatigue, for example.  These are signs that can be readily identified using common mental health screening tools, and symptoms that can be managed through the use of medications, counseling, or even healthy living.

In Stage 2, the disease is more advanced and the symptoms more pronounced.  Depression may affect performance at school or work for example, or “command voices” (sometimes known as auditory hallucinations) may become louder and more pronounced.  This is a stage at which – if we act aggressively and provide the proper supports – we can help patients maintain an independent life, even though they may require an occasional hospitalization. 

People in Stage 3 are in need of ongoing treatment and support, which is often expensive – like chemotherapy in the case of cancer.  But with mental illness, people in Stage 3 are far more likely to be in jails than in treatment beds, and among the homeless population instead of the general population. 

While 6 percent of the general population has serious mental illness, that description applies to an estimated 15 percent of male prisoners, 31 percent of female prisoners, and one-quarter of all people who are homeless.

Intervening effectively during Stage 1, 2, or 3 can save lives and change the trajectories of those lives for literally millions of people.

But that isn’t what we usually do.  According to the National Institute of Mental Health, just over half of adults with serious mental illness receive any treatment at all.

That finally may be about to change. 

Last week, Florida’s Governor Rick Scott and the Federal Department of Health and Human Services came to a compromise.  HHS is going to permit Florida to transition nearly all Medicaid patients into private managed care plans, including for those needing long term care.  In return, the Governor dropped his opposition to Medicaid expansion.  If the Legislature agrees, Medicaid will be available for many more adults with chronic diseases – especially for people with mental illnesses.

And this will make a huge difference.  

If Florida implements Medicaid expansion, other states - like North Carolina - that are still on the fence are more likely to follow suit.  And its managed care program may also offer cost-saving lessons to states that have already braced expansion.  

Policymakers will have a new source of revenue to intervene more effectively to treat mental illness at every stage.

This means more screening and early intervention at Stage 1, more integration of behavioral health, education, and primary care services at Stage 2, and more emphasis on treatment as opposed to incarceration or neglect at Stage 3.

The best part is that states can pick and choose from a long menu those strategies that suit them the best. 

And this means that patients in general hospitals throughout the country – where mood disorders are the 5^th most common diagnosis – will finally get some relief.    

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