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/ 

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/

Is the NFL Dying?

Here is one of the more intriguing headlines of Super Bowl week:  “Is the National Football League dying”?

Probably not, but too many of its former players are dying young, and for reasons that may be preventable.  Many people are concerned about growing evidence of brain injury from the violence of the game. But that’s just part of the story.

Linemen are too heavy. Their excessive weight is a danger to running backs now and to their own health after they hang up the cleats.

Baltimore Ravens safety Bernard Pollard raised the issue when he was quoted as predicting the demise of pro football, in part because of its violence, but mostly because of the way the rule makers are responding to that violence.  “I hope I’m wrong,” he added, “but I just believe one day there’s going to be a death that takes place on the field because of the direction we’re going.” 

President Obama weighed in on football safety, too, but in a less dire way.  “I think that those of us who love the sport, he said in an interview with the New Republic, “are going to have to wrestle with the fact that it will probably change gradually to try to reduce some of the violence.”

Both Pollard and the President were alluding to head trauma – a growing concern for athletes and others exposed to repeated brain injury.

Last month, the New York Times summarized a number of studies related to football and brain injury.  One concluded that 60% of NFL players had a least one concussion during their football playing years, and 26% had 3 or more.  

Another was published in the Journal Brain in December 2012.  Researchers examined the brains of eighty-five deceased individuals who were subjected to repeated minor head trauma during their lives.  They looked for evidence of brain damage called chronic traumatic encephalopathy, or CTE. 

They found that 80 percent of the brains (or 68 of the 85) showed evidence of CTE. 

Thirty-five were from former professional football players, all but one who played in the NFL.  Thirty-four of those showed signs of CTE.  The brains from those who were hit most during the game – linemen and running backs – were most likely to have it.

CTE is clearly a significant health problem for NFL veterans, but it isn’t the only one. 

We learned recently that the brain of former player Junior Seau showed evidence of CTE at the time he took his life in the spring of 2012. 

His death stood out in part because he was the 8^thplayer from the 1994 San Diego Chargers Super Bowl team to die young.  I wrote about this in a column last year.

But among the Chargers who died young, Chris Mims was reported to have weighed 468 pounds (170 pounds over his playing weight) when he died at the age of 38 of heart disease.  Lew Bush, who played at 245 pounds, died of a heart attack when he was 42.  Shaun Lee was reported to be over his 300 pound playing weight and have diabetes when he died at age 44.

So it is not just the hard hits.  Weight-related chronic disease is also a significant health problem for many football players.

And this year’s Super Bowl teams are heavier than ever, putting them at greater risk than ever.

The linemen on Pollard’s Ravens team weigh in at an average of 308 pounds.  Without the tight ends, their average weight is 318.

The San Francisco 49ers linemen average 296 pounds.  Without the tight ends, their average weight grows to 311.

To put this in some context, the 1994 Chargers linemen were thin by comparison, weighing in at 289 pounds.  And the linemen (absent tight ends) from last year’s Super Bowl teams averaged 306 pounds – 12 pounds less than the Ravens this year.

But the CTE and obesity-related disease we see today occurs among players who played at the time of the 1994 Chargers, not the 2012 Ravens and 49ers.

The eleven running backs on the Ravens and 49ers weigh an average of 222 pounds.  And that’s only because 260 pound Ravens fullback Vonta Leach is one of them. 

Without Leach, they average 217 pounds – almost 100 pounds lighter than the linemen who block for, and tackle, them.

So, among rules and equipment changes, why doesn’t the NFL also introduce an upper weight limit for players in the game?

Then maybe we wouldn’t have to read so many obituaries of great athletes who die young. 

Go Ravens!  

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

Pushing for Mental Health Parity

Former U.S. Congressman Patrick Kennedy was in South Florida last week pushing the radical idea that all people, including those with mental illness, are created equal.

What makes this idea radical in 2012 is that we continue to discriminate against the 6% of Americans who have serious mental illnesses.  Patrick Kennedy understands this, and is devoting his life after Congress to fighting on their behalf.

It is a fight that affects him personally, as it does the one-fifth of all children and the one-fourth of all adults with a diagnosable mental illness each year.

Discrimination against people with mental illness takes on many forms – arrests for loitering, incarceration instead of treatment, and perhaps most commonly in the unequal coverage by insurers for mental health conditions.

This last form of discrimination was supposed to have ended with the passage of the Mental Health Parity and Addiction Equity Act of 2008.  But the federal “rule” implementing this law has never been finalized.

At a field hearing hosted by Rep. Kennedy on October 9^th, a speaker from the American Psychiatric Association talked about the effect this has had.  In late 2011 Florida Blue (formerly Blue Cross Blue Shield of Florida) terminated its contracts with nearly every behavioral health provider in the state.  Providers had to sign new contracts for significantly less reimbursement.

Before that action, a psychologist was receiving just under $52 for a full counseling session, already far less than the average hourly rates paid to carpenters, plumbers, and electricians. 

After the action, the same psychologist received just $46 per hour.

The Florida insurance commissioner said that he had no jurisdiction over this. 

This isn’t just Florida’s problem.  I point out in testimony being presented today (October 17^th) at a public hearing on behavioral health parity hosted by the Connecticut Office of the Healthcare Advocate that actions like this affect every state.  Because there is no federal rule, a Connecticut insurer covering mental health care given in Florida also pays that pitiful amount – because the Florida insurer sets the reimbursement for others.

Insurance discrimination affects everyone.  But people with serious, chronic mental illnesses face worse today. 

As low income, single adults, they were all supposed to become eligible for Medicaid benefits in 2014 to cover mental health services.  But the U.S. Supreme Court said earlier this year that states could opt out of that Medicaid provision.  As homeless people, they often end up in jails and prisons because there are not enough places of care.  And as returning veterans – or “returning heroes,” as Rep. Kennedy prefers to call them – they often wait months to receive treatment through the VA.

There is still another way we deny people with mental illness fair treatment for their disease – ironically, by hiding behind their “civil rights.”  Local police officers and sheriffs known as mental health officers have become gatekeepers to emergency mental health services, and judges often make decisions about treatment.  A mental health officer once denied my son emergency care at a time of severe crisis because he didn’t think the crisis was severe enough to “deny his civil rights” by bringing him to a hospital for 24 hours.  So he didn’t get care that day. 

But he was jailed six times over the next three years. 

People with chronic mental illness, Kennedy noted at a reception my wife and I hosted at our home, don’t have a big political constituency. 

That’s why states have been able to cut $4.6 billion in mental health funding since 2009.

We can change this nightmarish reality if we want to. 

Here are just two examples of how.

In recent months my son has been involved with a behavioral health court in San Francisco.  Behavioral health courts take into account a person’s mental illness in devising treatment strategies to reduce recidivism.  There’s evidence that they work.

And instead of just playing catch-up long after a disease has ruined lives, we can begin with equal treatment – including parity in insurance coverage – for a set of chronic diseases that take as big a health toll each year as cancers.

Rep. Kennedy is optimistic that the tide will turn soon.  He believes that this time we will not repay war heroes with neglect, and that what we do for them will lift up everyone with mental illness.

I sure hope he’s right.

Because there are elections around the corner, and something has got to change. 

Mental Illness, Aging, and the Failure of Public Policy

In the next twenty years, more than 3 million people over the age of 65 will likely experience serious mental illness.  Are we prepared to treat them?

The answer is no, according to a new Institute of Medicine report. 

The report was released in July, and it contains some striking evidence of the challenges we face as we confront the growing behavioral health care needs of our aging population.  We don’t have nearly enough trained providers.

And when states cut their existing state Medicaid programs or refuse to adopt the ACA Medicaid expansion, these decisions have devastating consequences for the providers we do have – and, of course, their patients. 

Today, between 5.6 and 8 million adults over the age of 65 are believed to have mental illnesses.  These numbers could nearly double over the next twenty years. 

There’s a reason that the range is so big.  We’ve given so little attention to this challenge in the past that we don’t even have an accurate count.

We do know a lot, however.  As the IOM report documents:

• At least 14-20% of the elderly population has a mental illness.
• Up to 1.9 million have a mental illness described as “serious” – a number that could grow to over 3 million by 2030.
• 57% of nursing home residents, or 675,000 people, have one or more mental health conditions.
• Dementia is not the same as mental illness.  However, 57% of adults with dementia, or approximately 2.5 million people, also have symptoms of mental illness.
• Older women are more likely than older men to have every type of behavioral health condition except two – alcohol abuse and drug abuse.  In fact, the prevalence rates of mental illnesses among elderly women are 50% higher than they are among elderly men.

Publicly funded programs – like Medicare and Medicaid – are essential to treating all these people. 

The 2009 AHRQ MEPS data determined that the cost of the mental health services alone for the over-65 population exceeded $17 billion.  Affecting 7.4 million individuals, behavioral illness was the 8^th most costly condition for the over-65 group. 

Medicare paid just over half the bill all by itself and the combined Medicare, Medicaid, and other public share was 70%.  Private insurance, on the other hand, paid under 12%, far less than patients paid out-of-pocket.

These costs don’t occur in isolation from other health care costs.

This is because elders with mental illness are also likely to have chronic physical conditions.

In one representative study cited in the IOM report, this group had an average of 3.8 co-occurring physical conditions:

• 58% had hypertension
• 57% had chronic pain
• 56% had arthritis
• 55% had hearing or vision loss
• 39% had urinary tract or prostate disease
• 28% had heart disease
• 23% had chronic lung disease
• 23% had diabetes
• 21% had gastrointestinal disease
• 11% had cancer  
• 8% had neurological disease

This puts pressure on providers, who must manage multiple chronic conditions at the same time. 

What’s the most cost-effective way to do this?  We already know the answer.

“What works for many older adults who need MH/SU services is a patient centered, team-based, primary care-centered model that is proactive and employs a coordinated team of personnel with specific roles and special training,” the IOM report concludes.

In other words, the same primary and behavioral health care integration initiatives that work for the non-elderly population work for elders, too.

But unless policymakers change the course of their current thinking dramatically, we may not get close to what we need.

• The report identified “a conspicuous lack of national attention” to developing an appropriate workforce – including mental health counselors, primary care providers, care coordinators, and others – to give this care.
• It also described “a fundamental mismatch” between the need for coordinated care and Medicare’s refusal to pay for the services of trained care managers and psychiatric consultations.

We could add a third.  State cutbacks to existing Medicaid programs and states’ refusals to implement the ACA Medicaid expansion compromise our most vulnerable aging adults.  Those with mental illness and other chronic conditions usually have few resources of their own to pay for their care.

The question raised by the way we treat elders with mental illness is an important one.  Do federal and state policymakers mean to throw the neediest of us out into the cold as we age?

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.  For more columns about mental health policy, click on the “Mental Health” tab at the top of the page.

Mitt's Plan

Imagine what a nightmare healthcare scenario might look like.

You are diagnosed with a debilitating chronic disease while young.  At first, you can’t even work because of it, and you are dependent on a family member’s insurance to help pay your medical expenses. 

Eventually, your disease goes into remission, and you find a job with health insurance.  You go off your family member’s plan.  But your employer goes bankrupt, and you’re left with no job and no insurance. 

Then you get another chronic disease.

You try the individual health insurance market, but the only insurance available to you comes from a high risk pool in which everyone else also has at least one chronic disease.  The price is outrageous, but you pay the bill as long as you can.

Eventually, you can’t afford it, and you become uninsured for a few months. 

You apply to your state’s Medicaid program for help.  You are denied because your state has already spent all the Medicaid dollars the federal government has given it for the year. 

You keep searching for work.  When you finally land a new job, you are informed by your employer that it only offers a high-deductible, catastrophic-only insurance plan.  You have to cover your basic health care needs, including annual physicals, prescription drugs, and counseling, out-of-pocket. 

At least, you think, the plan will help with recurrences of your chronic conditions.

But then you learn that as a result of your earlier lapse in coverage, the company’s insurer refuses to cover you because of your pre-existing condition.

You’re out of luck.

You might call this nightmare far-fetched.

Or you could call it Mitt’s Plan.

Mitt Romney now has a plan to repeal the Affordable Care Act if he is elected President. 

These are some of the mandates with which he would replace it:

• High risk pools for the chronically ill.  These high-cost, unsubsidized private insurance plans for the sickest among us have been around for years, but have never enrolled many people because of their prohibitive costs.
• A law to prevent insurance discrimination against people with pre-existing conditions only if they maintain continuous coverage.  If they ever have a lapse in insurance for any reason, insurers could use that lapse to deny insurance to them forever.  Eventually, this could affect nearly everyone, because over one-quarter of the population has a lapse in coverage every year. 
• A return of states to “their proper place of regulating local insurance markets” – but this would be accompanied by a new federal mandate that would gut state regulatory authority.  The federal government would mandate that out-of-state insurers could sell policies in a state that don’t meet the minimum standards set by that state.
• A Medicaid block grant to the states.  This will cap federal Medicaid spending each year.  States will be forced either to pay a larger share of long-term and indigent care costs or to cap both Medicaid payments and enrollment.
• More managed care and fewer “fee-for-service” plans.  Private insurers will be given even more power over patients and doctors to decide who is worthy of care and who isn’t – and no level of government will have the authority to put an end to this rationing of care in the interest of the consumer.

The resulting nightmare isn’t far-fetched.  Candace Brown is already living most of it every day. 

Candace Brown is a nurse.  She was diagnosed with Crohn’s Disease when she was 30.  She wasn’t able to work for three years, but was covered on her father’s insurance.  Her disease finally went into remission, and she found a job with health insurance.  However, she lost both the job and her insurance when the company went out of business.

Then she was diagnosed with depression, and struggled to find insurance afterwards because of her two pre-existing conditions.  She finally found a plan that would accept her, but it now costs $1,200 a month. 

She describes herself as “financially drained.”

I imagine she sometimes feels physically drained as well.

At least she hasn’t yet had to deal with being uninsured, but even that hasn’t come without stress.  She’s afraid to let her coverage lapse to qualify for the Pre-existing Condition Insurance Program (PCIP) - which Romney also would repeal.

The only nightmares Candace has avoided so far – because they won’t be legal unless Mitt’s Plan becomes law – is a non-entitlement Medicaid long term care program someday and being dumped by her current insurer.

But Candace is a realist, and that’s why she is counting the days until ACA takes full effect.  

Note: Candace Brown's story was published and made available by Florida CHAIN at the link provided in the column.  More information about the work of Florida CHAIN can be found using the link.  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.

The Curse of the Super Bowl Chargers

Are the 1994 AFC Champion San Diego Chargers a cursed team, or just a reflection of a growing trend toward chronic disease and early death in America?

Led by running back Natrone Means and linebacker Junior Seau, the 1994 Chargers won the AFC West with a record of 11 wins and 5 losses, and beat the Miami Dolphins and Pittsburgh Steelers to reach the Super Bowl.  The 53 players on the active roster averaged 26 years of age.

According to 1995 life expectancy tables, a 26 year old male could expect to live to the age 75.

But when 42 year old Lew Bush – a linebacker on that Super Bowl team – died on December 9, 2011, he was the 7^th member of the team to die more than 30 years prematurely.

Source:  ESPN Official 2011 Roster Information

There is talk that these 1994 Chargers are cursed.  The first player to die, linebacker David Griggs, was 28 when his car slid off an expressway ramp in Ft. Lauderdale and crashed into a pole in June, 1995.   The second, running back Rodney Culver, died in a plane crash in 1996.  He was 26.

Young people most often die of injuries.  So those two deaths, while untimely and tragic, didn’t make anyone think “curse.”

The third one did. In 1998, linebacker Doug Miller, also just 28, died when he was struck twice by lightning while on a camping vacation.

For the next decade, “curse” talk faded as the surviving 50 players went about their lives and careers.

Then, in 2008, two more Chargers died.  Center Curtis Whitley was 39 when he died of a reported drug overdose, and defensive lineman Chris Mims was 38 when he died of heart failure.  Mims – a relatively svelt 288 pounds for a six foot, five inch lineman in 1994 – was reported to weigh 456 pounds when he died.

Defensive lineman Shaun Lee was the sixth to die, on March 1^stof last year.  He was 44 when he lost a battle with pneumonia.  He was reported to weigh over 300 pounds and suffer from diabetes at the time of his death.

And when Lew Bush died of a heart attack in December, these seven men together had lost 280 years from their expected life spans when they played in their Super Bowl – the equivalent of nearly four full lifetimes. 

Are the untimely deaths of these young men a curse or a reflection of what causes premature death in America?

According to the NFL Players Association, the average life expectancy for an NFL football player is under 60 years.  Traumatic football injuries, such as concussions, are blamed for this.  They are a factor, but the common conditions of life in America today – including obesity, chronic disease, and non-football injuries – have been the “curse” of the Chargers.

Even if all 46 remaining members of the team now live to their normal life expectancy, the team as a whole will still have lost 5.3 years of life per player to premature death. 

NFL football players don’t have a life expectancy that is approximately 20 years less than the norm just because they played football. 

Like many other young people in our society, their lives are being claimed before their time by the cardiovascular diseases, behavioral illnesses, and other chronic conditions that result from poor diets, stress, and unhealthy habits.

This problem is real, and isn’t going to go away on its own.

The average weight of the 44 linemen, excluding tight ends, on the 2011-2012 AFC Champion New England Patriots and the 2011-2012 NFC Champion New York Giants is 306 pounds.  They are a year older than the 1994 Chargers were.  But they also weigh an average of 17 pounds more than the twenty Chargers who played the same positions in 1994.

To what do they have to look forward as they age?  If you believe the NFL Players Association, they will be walking advertisements for premature death.

They are not the only ones. 

According to AHRQ data, 60% of all Americans have at least one chronic condition, 38% have two or more, and 16% have at least three.  In this one way, we are all just like the Chargers.

Like most Americans, I enjoy watching the Super Bowl and celebrating this unique American holiday.  But we should embrace not just the game, but the light it can shed on the real curse that affects us all.  That is the curse of both men and women dying young for reasons we could have, and should have, prevented.

Update:  When Junior Seau died on May 2, 2012, he became the eighth member of the 1994 Chargers to die before the age of 45.  His death was an apparent suicide. There is widespread speculation as to whether the suicide was brain trauma related.  Suicide is also commonly linked to mental illness - another significant cause of premature death in America, known to reduce life expectancy by over 25 years.

If you have questions or suggestions about this column, or would like to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

Cain Not Able

Herman Cain’s ascendant Presidential campaign brings into focus the limited health policy thinking that has dominated the campaign so far. 

Here are our current major health policy challenges:

• Reversing the trend toward lower investments in the public health and prevention activities that have accounted for half of our increased longevity in the last century;
•  Assuring fair coverage of the chronic conditions, including mental illness, cardiovascular disease, and cancers, that affect 60% of our population;
• Giving even the uninsured 16% of our population access to high quality, comprehensive, integrated primary, specialty, and hospital care; and
• Figuring out how best to pay for all this.

Despite the urgency of these challenges, the current health policy debate can be condensed into a four word sound bite – “Repeal Obamacare Individual Mandate.”

Here are the specifics of what the candidates have been talking about the past couple of weeks.

Mitt Romney and Newt Gingrich are fighting over whether Romney got the idea for the “individual mandate” from Gingrich or the Heritage Foundation.  (Both, it seems, from their exchange in the last debate.)

Ron Paul wants to abolish our health care system in its entirety and replace it in part with free care “as a charitable benefit provided by doctors” for all poor people.

Rick Perry’s first national health policy headline came when he advocated eliminating the Medicaid program that pays for long-term nursing and home care for elders and people with disabilities.  His last came this past weekend when he questioned Hawaii’s vital statistics record-keeping – at least where Barack Obama’s birth certificate is concerned.

And Herman Cain, the self-proclaimed a “problem solver,” solved his business’s financial problems in part by helping to pay for health insurance for only 17% of his employees.

As Cain’s sketchy health care plan shows, his plans for what he would do for the other 83% are few and far between.   

First, he wants to sell insurance across state lines.  The Affordable Care Act already will permit this, but there’s a catch.  The only policies that could be sold across state lines must meet minimum coverage standards. 

He opposes this.  So when he favors selling insurance across state lines, he doesn’t care if it actually covers anything for which you might need insurance, such as cancer, heart disease, mental illness, comprehensive primary care, drugs, or even most hospital stays. 

Second, even though it would violate his 9% flat tax proposal, he wants to allow individuals who buy insurance to be able to deduct it from their income tax.    

Why?  So that businesses could eliminate group health insurance from their employee benefits package – as Cain himself did – and let employees pay for the more expensive individual plans on their own.

Third, he wants to expand the use of health savings accounts, into which individuals and families would have to deposit their own money to cover the thousands of dollars of deductibles in the stripped down insurance policies that would flood the market if his “across state lines” plan passed.

They might get a tax deduction for this – if he violated his 9% flat tax policy again – but that’s just another way of shifting even more of the cost of health care to individuals and the federal government. 

Citizen Cain refers to these proposals as “patient-centered” reforms.  But patient-centeredness involves most everything that is absent from “Cainsian” health economics. 

It is about promoting health and well-being and improving access to affordable, quality care, not making insurance companies more profitable.

At least Cain offers a plan on his web site, unlike family-first candidate Rick Santorum.  And in a nod to Michele Bachmann, Cain did acknowledge in a recent debate – without mentioning her – that he lifted much of his health plan from legislation co-sponsored by Bachmann (HR3400) in 2009.

Herman Cain talks a good game about the “sacred patient-doctor relationship,” but his slapped-together health plan is little more than a slap in the face to people with serious health and wellness needs.  There’s nothing in it about wellness, prevention, or chronic disease management.  There’s nothing about access and quality. 

It’s all about stringing together a few of the worst proposals for individuals, families, and taxpaying citizens, and dressing them up as an alternative to the Affordable Care Act. 

Even raising Cain to new poll heights won’t make him able to sell this.   

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

Does The PCIP Enrollment Problem Signal the End of Private Insurance?

There are 4 million or more Americans who can’t get regular insurance because of a pre-existing condition.  You might be one of them.  Now there’s a policy that costs less than $300 per month and covers all of your medical needs, including your pre-existing condition. 

Will you buy it?  Apparently not.

And that may signal the beginning of the end of private insurance in America.

I first wrote about the diminished role of private insurance in a column last month entitled America’s Health Insurance Myth.  Privately-financed private health insurance today pays only 17% of America’s health care bill.

Two recent developments suggest that this share will become even smaller in the future.

The first was last week’s death of the CLASS Act.  As a result, long term care will continue to be an out-of-pocket and government expense only for nearly everyone.

The second was the report of first-year enrollment numbers for the new Pre-existing Condition Insurance Plan (PCIP).  PCIP was created as part of the Affordable Care Act.  It offers low-cost health insurance for adults who have – or have had – conditions like mental illness, cancer, diabetes, and heart disease.  (Children are now covered on their parents’ policies.)

PCIP is comprehensive.  It covers hospitals, doctors, and drugs. 

There is no means test to qualify.  Provided that you have been uninsured for at least six months, all you need to apply is a note from a physician attesting to your chronic condition.

PCIP is inexpensive.  In Florida, the monthly PCIP premium for a forty-year old is only $211 for the standard option.  There are deductibles and co-pays, but annual out-of-pocket costs are capped at $5,950.  This may seem like a lot, but it is less than 20% of the 2009 average charge of $30,655 for a single hospital stay.

The federal government operates Florida’s plan and those of 22 other states.  Connecticut, on the other hand, is one of 27 states that choose to run their own programs.  In Connecticut, PCIP insurance costs $381 per month, but out-of-pocket costs are capped at $4,250 per year.  So its overall costs are similar to Florida’s.

Of an estimated 4 million people eligible for PCIP and 375,000 expected to sign up in the first year, only 30,395 bought policies.  Just 1,454 people enrolled in Florida, and only 62 enrolled in Connecticut.

Why so few?

The answer is obvious in states like Massachusetts, which has only one PCIP enrollee, and Vermont, which has none.  They have near universal coverage, so they don’t need PCIP.

What about states without universal coverage?  Pennsylvania had the highest first-year enrollment.  It had 3,762 people insured through PCIP.  If every state were like Pennsylvania, then PCIP would have around 100,000 enrollees today, still far below the expected number.

There are three explanations for why people aren’t enrolling in PCIP that speak to how little faith we have in insurance.

The first is that they believe that when there’s a crisis, hospitals and doctors will treat them whether or not they are insured.  Health care providers rarely turn their backs on people in need.

But someone still has to pay the bill.  And it usually gets paid through hidden charges in everyone else’s insurance premiums. 

The second is that people don’t think they can afford even $211 per month for health insurance, or up to $5,950 in medical bills in a year. 

But when the costs of common chronic diseases routinely run into six figures, the alternative can be bankrupting.

The third is that we don’t trust insurance.  Insurance companies take our money, fight with us about covering our bills, and make huge profits. 

But PCIP isn’t like that.  Unlike other insurance, it is designed to pay out far more money than it takes in.  PCIPs paid out four times in benefits what they charged in premiums during the first few months of the program, and Congress set aside $5 billion – of which only a fraction was spent – for this.

Here’s the bottom line.  If $211 a month is too much to pay for insurance we are sure we will use, then health insurance is dying in America.  Many of us say we will rely on our own resources, but also expect a government safety net to be there when our resources fall short.

If we roll the dice and don’t buy PCIP when we can, then we may lose more than we think.  There are political leaders who are already celebrating the demise of the CLASS Act.  Many also would happily repeal both PCIP and the Affordable Care Act, and replace them with… well, nothing.

For more information about federal and state PCIP, visit https://www.pcip.gov/.  If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, contact 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.

Health Reform's First Birthday

Babies crawl before they walk.



c. Microsoft Office Image

The Affordable Care Act (ACA) marks its first birthday this week.  It may not be off to a running start, but it isn’t exactly sitting still either.
 

The most debated provisions, like the individual mandate and the Medicaid expansions, are still three years in the future.

In the first year, ACA’s biggest developmental milestones have affected older Americans, people with mental and physical disabilities, and consumers in general.  Which of these populations is making the most progress?

Medicare recipients and early retirees have taken the most steps forward.   

As of January 1^st, all Medicare Part B recipients are entitled to a free annual physical, with free cancer, cardiovascular, and skeletal screenings, and free flu shots.  150,000 beneficiaries had taken advantage of this through February 23^rd.  This number will grow, to many millions before the end of the year.

Also, over 3.4 million Part D recipients who fall into the donut hole will receive an average savings of over $500 on brand name drugs this year.  Many already received $250 rebate checks last year, and the value of this benefit will increase annually as the donut hole closes over the next several years.

Early retirees are also keeping up.  The law allows employers to keep retirees between the ages of 55 and 65 on their plans, and to get reimbursed for some of the costs. 

As of December 31^st, 5,452 plan sponsors had been approved to participate in the Early Retiree Reinsurance Program (ERRP).  Two states – New York and California – had over 500 participants.  Eight others – Pennsylvania, Illinois, Michigan, Minnesota, Indiana, Massachusetts, Florida, and Texas – had over 200.

An estimated 4.5 million early retirees, spouses, and dependents were included. 

Also, the Federal Government had reimbursed $535 million in costs as of December 31.

There were huge differences in the amount of reimbursements paid, with just a few states claiming most of the money.  Georgia had been reimbursed for almost $52 million, with $35 million in direct reimbursements to the state plan alone.  All participating plans combined in its next door neighbor, my home state Florida, had collected a mere $305,000. 

Plans themselves are responsible for claiming reimbursement for high-cost retirees.  It's hard to imagine that Georgia has so many more than Florida.

People with mental and physical disabilities are struggling to move forward. 

Children with pre-existing conditions won coverage on their parents’ plans as of September, but the ban on denying adults with pre-existing conditions access to regular insurance doesn’t take effect until 2014. ACA established Pre-Existing Condition Insurance Plans (PCIP) all 50 states in the summer of 2010 to provide temporary insurance for these people.  

The Administration hoped that up to 250,000 people would find health insurance through these plans, but only 12,437 had enrolled in PCIP plans as of February 1.  Pennsylvania led the way with over 2,000 enrollees, followed by Texas, Illinois, Ohio, California, North Carolina, and Florida. 

Although the price of the plans (usually between $300 and $500 per month) is significantly lower than traditional individual plans for people with disabilities, it is still proving too high for many underemployed adults.

Consumers in general are taking one backward step for every two forward ones. 

The implementation of consumer protections was the biggest news of the first year.  As of September, as plans are renewed, parents can cover their children up to the age of 26, and insurance can’t be denied to children because of pre-existing conditions.  It also can’t be cancelled when children or adults get sick, and annual and lifetime insurance limits are on their way out.

However, not every consumer protection applies to grandfathered plans.

Also, to assure that low-cost, low-benefit plans would not go out of business abruptly, the Administration has granted hundreds of one-year waivers from the annual limit provisions.  As of late January, 733 waivers were granted for plans covering 2.1 million Americans.

Since then, the number of approved waivers for all reasons has increased to over a thousand, affecting 2.6 million Americans.  In early March, Maine received the first waiver from the most important consumer protection in the ACA, the one mandating that 80% of all premium dollars in individual insurance plans be paid out in benefits.

This year, Maine’s individual plans will only have to pay out 65% in benefits, meaning that they could theoretically make up to a 50% profit on every premium payment.  Several other anti-consumer states are asking for similar waivers to protect insurers.

While loss-ratio waivers demonstrably harm consumers, the Administration has announced that it is moving forward with another consumer protection.  It published a notice in early March to require any insurer proposing to increase rates by more than 10% to provide a breakdown to customers of the reasons for the increase.

Baby steps.  That’s what we’ve learned to expect from the first year of life, and that’s what we’re getting.