What We Worry About Least in the Health Policy Debate

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

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

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

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

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

Long Term Care. 

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

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

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

Medicare.

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

Research.

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

Child health.

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

Personal Responsibility and Wellness. 

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

Environmental health. 

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

Eric Cantor.

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

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

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

States Refusing to Set Up Health Exchanges are Helping Their Children - But Not in the Way They Think

The reasons that 25 states chose not to participate in creating a new health exchange aren’t exactly the ones they’ve been claiming – that Obamacare is too complicated, too anti-consumer, or too politically unpopular. 

The truth is that they have never done a very good job of protecting the health and well-being of their people – especially their children – and they were not ready to start now.

Now that all fifty states have decided whether or not they will at least participate in running their own health insurance exchanges as allowed by the Affordable Care Act (you can see the updated information about what each state decided on my state rankings page), a clear picture is emerging of what distinguished the states choosing to participate from those refusing to do so.

On the whole, when compared to one another, the 25 states that have chosen to participate in running their exchanges (17 by themselves, 8 in partnership with the federal government)do a much better job of taking care of their people than do the 25 states that have deferred to the federal government.

So, just as we imagined a few months ago, residents in the states that refused are likely to be much better off with the federal government running their exchanges.

In many cases, the differences between the states choosing to participate and those refusing to participate are significant.

Let me illustrate why by showing you some updated numbers.  But first, let me explain briefly how I get to them. 

If you rank the states from best to worst, and assign the ranking of 1 to the best and the 50 to the worst, then two “averages” result.  The average ranking of all the states will be 25.5.  And if you divide the states into two equal groups of 25, with all the top-ranked states in one group and all the bottom-ranked states in the other, then the average ranking of the top group will be 13, and the average ranking bottom group will be 38. 

So keep in mind that 13 is the best possible average ranking for any group of 25 states to have, and 38 is the worst possible.

Now here are some average health-related rankings of the group of 25 states choosing to participate in establishing their own exchanges:

• Overall health (OHPM 2012 rankings):  21.5
• 2012 Kids Count ranking: 21.2
• Percentage of uninsured: 21.7
• Percentage with employer-based insurance: 22.4
• Ranking in spending on mental health: 24.7

And here are the average rankings of the group of 25 states refusing to participate in establishing their own exchanges:

• Overall health (2012 OHPM rankings): 29.5    
• 2012 Kids Count ranking: 29.8
• Percentage of uninsured: 29.3
• Percentage with employer-based insurance: 28.6
• Ranking in spending on mental health: 26.3

In every instance, states choosing to participate in setting up their own exchanges have a much better track record than states refusing to participate.   In only the mental health spending ranking is it even close. 

Those of us living in one of the 25 states refusing to participate ought to be thankful that our state policymakers punted on the exchange, because it is more likely than not that we’ll be much healthier and better insured in the long run. 

Especially our children.  States choosing to participate rank an average of almost ten places better than the states refusing to participate.  Children may have literally won the health lottery when those states decided that the federal government could do a much better job of assuring access to health care in the future.

The differences among the states are not just political ones, either. 

Solid Republican states like Utah, Idaho, and Kentucky are all creating their own exchanges, and states like Arkansas, West Virginia, and South Dakota are partnering with the feds.  Meanwhile, Maine, Wisconsin, Ohio, and Pennsylvania are all letting the federal government create their exchanges.

And the decisions have turned the traditional north/south, “state’s rights” argument on its head.  States’ rights states, like Texas and Florida, are refusing to participate, while states like Connecticut, Massachusetts, and New York are choosing to do so.

States refusing to participate may have tried explaining their decision by claiming that the federal government created a program that was too complex, too controversial, or too anti-consumer.  But those clearly aren’t the reasons. 

No, the real reason is that they know that the federal government has already proven itself over time to be better equipped to protect our health than they are.

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

Echoes of Scrooge

Except for summertime humidity, the Florida and Connecticut “climates” don’t have a lot in common. 

For example, Connecticut has one of the best climates for health and health care, while Florida’s is in the bottom half.  On the other hand, Florida has one of the best business tax climates, while Connecticut’s is near the rear.

Their political climates are also polar opposites.  Florida’s governor is a Republican, and its Legislature is overwhelmingly Republican.  Connecticut’s governor is a Democrat, and its legislature is overwhelmingly Democratic.

And the difference in their policy climates is reflected in the way they handled their 2011 budget crises.  Connecticut raised taxes and cut spending, while Florida just cut spending.  As a result, Connecticut’s budget now balanced.  Florida, meanwhile, extended its crisis by another year.  And its Governor has just proposed cutting $2 billion from health services alone in his proposed new budget.

But for two states with so little in common, their emerging 2012 Medicaid cost containment strategies are remarkably similar echoes of the ghost of Ebenezer Scrooge.

They both want to “decrease the surplus population” of needy people on the program.  Florida is targeting kids; Connecticut young adults.

In Florida, Health News Florida reported last week that nearly 800,000 Florida residents could be forced off of Medicaid because of a new co-pay Florida has asked the Federal Government to approve.  The vast majority would be children. 

While he awaits the decision of the Feds, Florida’s governor is also proposing massive cuts in Medicaid reimbursements to a host of safety net hospitals.  Jackson Memorial Hospital in Miami would be cut by $133.5 million, Memorial Hospital in Ft. Lauderdale would be cut by $58 million, Shands Hospital in Gainesville would be cut by $52 million, Miami Children’s Hospital would lose $35 million, and Tampa General would be slashed over $32 million. 

Shands, Jackson Memorial, and Tampa General all have been ranked among the best hospitals in the country by U.S. News and World Report.   This would greatly limit poor people’s access to them.

Meanwhile, in Connecticut CT News Junkie reported that a “reduction in health care benefits, asset tests, and a potential cap on enrollment” are all under consideration by the Department overseeing its Medicaid program.

The reason is because its caseload is growing too quickly.  In 2010, Connecticut was the first state to shift 45,000 state-only medical assistance program clients – many young adults – to Medicaid under a provision of the Affordable Care Act.  The Federal Government paid 60% of the cost and the state saved millions.   But the number of people signing up for the program has grown to 70,000 in the last eighteen months, erasing the savings.

So Connecticut has sent a letter to the Federal Government asking permission to change the eligibility requirements for the program and the benefits package.

Even though Connecticut acknowledges in the letter that the poor economy is a reason for the unexpected growth in the program, its solution, like Florida’s, is to deny some of its neediest people access to care.

So here’s the question that both Florida and Connecticut must answer.

If they make these cuts, where do they think these people will go, and who do they think is going to pay the bill?

Workhouses, a favorite of Scrooge’s?  Prisons, which are already the largest mental health providers in the country? 

Or perhaps they want them to go to the hospitals from which Connecticut took $32 million in 2011 and Florida wants to take millions more in 2012? 

Of course, in both states there are good, local alternatives to cutting and slashing, and wishing and hoping that poor people will recover from disease and disability on their own. 

Connecticut could offer the same wellness and disease management program to these Medicaid recipients as it offers its 50,000 state employees.  The State projects that it will save over $100 million this way – close to what it hopes to save in Medicaid cuts. 

And Florida could stop slashing public health and prevention – which already took a $56 million hit in 2011 – and instead increasefunding to local public health departments by 10%, giving them the flexibility to spend the new dollars anyway they want.

A Health Affairsarticle this past summer showed that this approach leads to reductions in cancers, heart disease, and infant deaths (here’s a link to a related article and chart I created from the data).   

Wouldn’t these cost-saving options be preferable to a Scrooge-like denial of care to desperate children and destitute young adults? 

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.

Fifty Years Later: Class, Children, Mental Illness, and Cancer

Fifty years ago, we already knew that there were environmental causes of chronic conditions like mental illness.  Had we taken them on as an American nation-building project with the zeal with which we have approached nation-building overseas, we would be a healthier country today. 

Will we do any better in the next half-century?

I’ve recently been reading a book written in 1969 about the 1968 Presidential campaign, called An American Melodrama.  It is a very long book about a very short political campaign by today’s standards.

Bobby Kennedy, for example, didn’t announce for the Presidency until March, and George Wallace – who won several southern states as a third-party candidate – didn’t pick his running mate until October.  Political scientists will find many parallels from that time to today.  One example: former Governor Romney was the early favorite for the Republican nomination.  (He never made it to the starting gate.)

It was a campaign and a time repeatedly rocked by violence, and worries about domestic terrorism consumed policymakers and the public.  About halfway into the book, the authors – without today’s benefit of hindsight – searched for an explanation for the tensions of those days.  They found it partially in a mental health study published in 1961.

It was entitled Mental Health in the Metropolis: The Midtown Manhattan Study (Volume 1).

The authors surveyed a sample of 1,660 adult residents of Midtown Manhattan.  They found that 23.4% of Midtown adults were impaired by mental illness, and 45.2% had at least moderate symptoms of mental illness.

These percentages are almost identical to the percentages of US residents today who have diagnosable mental illness in a given year (around one quarter of the population) and who will have a diagnosable mental illness in their lifetime (around one half of the population).

They believed that the high percentages of mental illnesses must be related in some way to the conditions in which people lived.

So they tested this belief, by identifying and measuring attributes of good mental health:

·         Freedom from disabling inner tension
·         Ease of social interaction
·         Feeling of adequacy in social roles
·         Capacity to accept deprivations and individual differences
·         Identification with ethical and moral values
·         Adaptability to stress
·         Healthy acceptance of self
·         Conservative handling of hostilities and aggressions

They divided the Midtown population into six socioeconomic groups, and found a direct relationship between class and mental health.  Only 17.5% of those in the highest socioeconomic group had symptoms of serious mental illness, versus 32.7% of those in the lowest group.

Arguably, their most important finding wasn’t just about class, however.  It was about child health.  They divided the adult population into the socioeconomic groups based on the socioeconomic status of their parents, not themselves.  In other words, the “class” measure was a measure of the impact of childhood socioeconomic status on adult mental health.

We know today that many of the preventable causes of adult mental illness are rooted in childhood, and socioeconomic status is the culprit in a variety of chronic diseases besides mental illness.

In its recent publication Cancer Facts and Figures 2011, the American Cancer Society devotes a special section to a description of socioeconomic status as a carcinogen.  Low socioeconomic status leads to a doubling of cancers among men and similar large increases in many types of cancer among women.

As public health professionals have been explaining for years, environmental factors linked to socioeconomic status – such as exposure to violence, abuse and neglect, poor diet, unsafe living conditions, lack of health insurance, limited educational opportunities, and increased risk of smoking – are among the causes of some of the most common chronic diseases in America – mental illnesses, cancers, cardiovascular disease, hypertension, and diabetes. 

We haven’t addressed these environmental factors adequately in the last fifty years, and we have no unified governmental vision for doing so now, either.

We’ve been too busy fighting endlessly about the role of our government at home and insufficiently about the role of our government overseas.

We celebrate Independence Day this weekend.  As we do, we should remember that we didn’t fight for our independence on foreign soil and we weren’t magically transported from 1776 to 2011 without anything happening in between.  We can explain why Americans today are less healthy than their counterparts in many other developed nations by taking notice of the conditions in which we live and how we got to this point.

We may know where we want to be in the future.  But if we stumble around in the present with no clear sense of our relatively recent past, we won't get there.

If you have questions about this column, or to receive emails notifying you when future Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

How Did We Let This Happen to Our Children?

The late comedian Jack Benny made himself the butt of a running gag about how cheap he was.  A crook would come up to him and demand “your money or your life!”  After a long pause, Benny would deadpan to the increasingly impatient crook, “I’m thinking about it.”

It’s funny to think about someone who would hold onto his own money so tightly that he would put his own life at risk.  It’s not funny to think about people who would do the same and put their children’s lives at risk.

At the beginning of the 21^st century, we could feel good about the progress we were making to improve the health of our children.  While child poverty rates were doggedly high, other key indicators, including infant mortality rates, low birthweight rates, immunization rates, and violence rates, were all improving.  We had reason to believe that even the “compassionate, conservative” approach to policymaking would continue to get results.

It didn’t happen.  Some data from the Annie E. Casey Foundation’s KidsCount program tracking children from birth to adulthood show just how poorly we've been doing these last few years:

• After dropping from 38,351 in 1990 to 28,035 in 2000, the number of infant deaths increased to 29,138 in 2007;
• The number of low birthweight babies increased from 289,418 in 1990 to 354,333 in 2007, and the percentage increased from 7% to 8.2% of all births during the same time period;
• 75.7% of children age 2 are properly immunized, up from 72.5% in 2003 but down from 77.4% in 2005; 
• 52% of children age 6-17 do not engage in exercise at least five days a week, and 32% of 10-17 year olds are overweight;
• 14,140,000 children in 2007 had special health care needs, up from 9,360,356 in 2001;
• There were 10,198 teen deaths from accident, homicide, and suicide in 2007, age 15-19, a number that has remained steady over the decade.

When some political leaders hold up a mirror to these facts, they see them backwards.  They see decline and call it exceptionalism; they see investment in our children and call it waste.

In the early part of the past decade, we cut our taxes and got involved in two wars.  We paid less attention to the health of our children than we should have.  We put too little money into their well-being, and the trend line is still going in the wrong direction.  

Where children are concerned, American exceptionalism has become American “except-ionalism.”  We’re taking care of everyone “except” our children.

Governors have asked the federal government to let them cut children’s health programs this year, when they should be expanding them.  Twenty-six of them even went to court over the Medicaid expansion mandate, arguing that they were being “coerced” into providing needed services for families and children (see below).

There was a time when we invested in programs for our children because we understood that letting any children go hungry, be homeless, or become sick and not be able to get care was unacceptable in the greatest nation in the world.

We created mandatory immunization programs to protect them from deadly diseases.  I've still got the polio immunization card my mother was given by the public health department when I received my vaccine.  No one argued that we didn't have the resources to pay for this.

We didn't always need a crisis to take care of our children.  We built playgrounds and sports fields to give them plenty of opportunities to exercise.  We protected them from weapons and violence to keep them safe.  We invented Medicaid and Children’s Health Insurance Programs in part to make sure they had health care when they needed it. 

Today, we have elected officials saying we can’t afford all these things.  It’s not really because the money’s not there.  It is.  It’s because they think we’re too cheap to part with it.  They have us playing Jack Benny's old role, except no one's laughing.    

The decline in the health status of our children is where the political fantasy that we can cut and do no harm is introduced to reality.  Children get sick, and some even die, when we stop investing in their health.

Some brave political leader needs to step up and ask: What's more important, your money or your children's lives?  Will we really need to think about it for long?

A note about the Florida court ruling on health reform:  A short version of what the judge decided on Monday was that the individual mandate is unconstitutional, but that the Medicaid expansions are not.

The Supreme Court will have the final word on the individual mandate, probably in 2012 or 2013, but before it takes effect in 2014.  The judge's ruling in that area will have no effect for now.  States that don't want to implement the provisions that are already part of the law probably will not be let off the hook.

Though it wasn’t part of the headline, the judge also found that states are not being “coerced” into participating in the Medicaid program and providing the expanded coverage mandated under the law.  This finding means that the 26 states battling against the law have been defeated on one of the two main fronts on which they joined the battle. 

The Medicaid expansions will cover over 15 million Americans by 2016, and will be paid for almost entirely by the federal government.  How the states respond will be a test of their support for children, elders, and low income families.