Americans Want Medicare and Medicaid Left Alone

It turns out that our health policy still matters to us, which shouldn’t surprise anybody – except a few politicians next election.

A recent Rasmussen poll found that healthcare remains the second most important issue, behind the economy, to our people.  63% say it is very important to them in determining their vote.

And last week, a new Washington Post-ABC News poll was released.

source: Washington Post-ABC News Poll, 4/14-17/11

On the two major health care spending issues of the day – Medicare and Medicaid – the public had surprisingly strong opinions.  And it seems that some political leaders are incredibly out of touch with those opinions.

Only 21% supported cutting Medicare.  78% were opposed, 65% strongly.

Only 30% supported cutting Medicaid.  69% were opposed, 52% strongly.

This comes after an avalanche of political debate about deficits that blame them on Medicare, Medicaid, and Social Security. 

Many elected officials, led by Representative Paul Ryan, single out entitlement spending as what’s wrong with government spending these days.  They favor deep cuts to health, mental health, and other safety net programs, while favoring tax cuts for corporations and the wealthy.

From the Washington Post-ABC News poll, it doesn’t appear that the people are buying what these politicians are trying to sell.

People who follow the news regularly know that the deficit is as high as it is not because of entitlements, but because of a combination of the Bush tax cuts and Congress’s waging of wars in Iraq and Afghanistan without raising any money to pay for them.

More tax cuts and more wars aren’t going to help.

The poll results show clearly that people do not blame government-run health care programs like Medicare and Medicaid for the deficit.  After all, people recognize that they pay a dedicated Medicare tax on every paycheck they receive, but no war tax.  It’s pretty hard to miss.

So when they were asked how the budget deficit should be closed, 59% of the people said through a combination of tax increases and spending cuts.

Just as there is consensus on not cutting health care, there is a great deal of consensus about where to raise taxes.  72% thought income taxes should be increased on those making more than $250,000 a year.  54% were strongly in support of this; only 17% were strongly opposed.

Interestingly, the Affordable Care Act already contains a provision to add a new Medicare tax on unearned income for those making more than $250,000, but people would like to see regular income tax rates increased on these incomes as well.

Of course, almost 80% of poll respondents had incomes less than $100,000.  It’s always easier to support raising someone else’s taxes instead of one’s own.

However, in this instance, almost half of the people were surprisingly unselfish when it comes to pitching in to help. 

45% said they would support raising taxes on all Americans while making small reductions in Medicare and Social Security benefits to bring down the deficit.  While a slim majority – 53% - opposed this approach, only 40% opposed it strongly.

However, they are very clear that they don’t want Medicare changed dramatically, to a voucher program or privatized.  65% said they want it to remain the way it is today, versus only 34% who want it changed. 

What might be the reason? The Medicare program consistently pays out well over 90% of premium dollars in benefits.  People understand that private insurers cannot match this level of efficiency, and they don’t want to pay more money for fewer benefits, for their parents or for themselves.

Even most of the 34% supporting Medicare privatization change their minds when they factor in the cost increases associated with private insurance.  When asked if they would continue to support privatization if the value of the vouchers didn’t go up as fast as their premiums, 60% said no, leaving only 14% still in favor.

People support their government-run health programs. They want a Medicaid program that will help provide for the long term care needs of elders and people with disabilities, and provide safety net coverage for the poor.

As they’ve become more experienced with private managed care, people have become more skeptical of its benefits.  They don’t want someone making what could be a life or death decision for them or their loved ones based on cost.  And they certainly don’t want this decision made somewhere in a corporate backroom.

When people say “don’t touch my government-run health care,” they’re not trying to hold onto something we can no longer afford.  They’re keeping a firm grip on the one thing standing between many of us and misery.   

To receive an email alert when new Our Health Policy Matters blogs are published, send an email to gionfriddopaul@gmail.com.

Mental Health Budget Cutters on the Wrong Side of Reality

How do we help political leaders understand that the actions they take can have a profound, long-term effect on the mental health of our population?



copyright Mental Health America, 2011

David Shern, CEO of Mental Health America and one of the nation’s leading mental health advocates, has an answer.  Arguing that “the next century of mental health in the U.S. needs to be fundamentally different” from the last one, he makes the case for a new “vision for mental health now within our grasp.”

Speaking at an April 13th seminar sponsored by the Mental Health Association of Palm Beach County, FL, Dr. Shern offered a glimpse into a policy future that could reverse the epidemic of mental illness in America. 

“The United States has the highest rate of mental illness in the world,” he began, as he laid out the present state of mental health in the United States.

·         One in four of us have diagnosable mental illnesses each year.  Half of us will have diagnosable mental illness in our lives.

·         By 2002, serious mental illness cost us $193.2 billion in lost earnings per year, an amount greater than the annual revenue of every Fortune 500 company except one.

·         The mean age of onset of mental illness in America is 14, but treatment for mental illness is typically delayed for up to ten years.

·         Chronic disease, or disability, accounts for 70% of death.  Diabetes accounts for 3% of disability, arthritis 4%, cancers 12%, cardiovascular disease 15%, and mental illness over 20%.

Dr. Shern believes that we have accepted this current state of affairs for far too long.

Serious mental illness robs people of 25 years of life, but as he pointed out, “these are not death sentences.”  With proper diagnosis, care, and rehabilitation, even 50% of people with schizophrenia can largely or fully recover.

Dr. Shern says that there is a lot we can do about mental illness.  He believes that a 21^st century mental health system should focus on both prevention and treatment. 

Mental illness prevention strategies should be modeled on the hugely successful 20^th century public health program. 

He cited compelling evidence from a 2009 IOM report that addressing environmental factors, including child abuse and assault, neighborhood and family violence, and substance-abusing caregivers, can prevent mental illness.  He used as an example a long-term Seattle-based study, which found that at-risk children whose parents received training had a 38% reduction in mental illnesses 15 years later.

To illuminate the point some more, he presented data showing that when immigrants arrive in America, they have the lower rates of mental illness of their former nations.  After several years in this country, they experience mental illness at the higher rate of the rest of our population. 

His treatment strategies are modeled on inclusion and integration. 

In his talk, he advocated for a reversal of the 20^th century practice of segregating mental health care from other health care.  He promoted collaborative care models, in which primary care and mental health professionals practice side by side.  It’s a good investment, which one insurance company found saved $2 for every dollar spent.    

He sees hope in both the Mental Health Parity Act and the Affordable Care Act, which provide for better treatment coverage and more prevention dollars for mental health.  But he observed that it took more than a decade for Congress to pass the Mental Health Parity Act, despite strong public support for it.

He derives inspiration about the future from Dr. Julius Richmond, former Surgeon General, who said that societal change requires three elements – science, the ability to implement, and political will. 

We have the science to identify the best methods for preventing and treating mental illness, he said, and the ability to implement them.

But what of our political will?

Around the country, political leaders are making people with mental illness budget scapegoats.  In a recent blog, I wrote how states are pushing huge cuts to mental health. The same day Dr. Shern gave his talk, the U.S. House voted to repeal the ACA prevention dollars he referenced. 

It is as if they believe people with mental illness are responsible for unbalanced budgets. In the face of overwhelming evidence to the contrary, they act as if nothing they do for, or to, people with mental illness will make a difference.

If they listened to Dr. Shern, they would know that they were on the wrong side of reality.  Mental illness prevention and treatment programs are working and should be expanded. 

If legislators are not careful, a new mental health catastrophe may be just around the corner from the cuts they make. 

This is an important message for every American.  And every American, Dr. Shern concludes, must play a role in creating the political will we need to change our mental health trajectory for the better.

For more information, contact Mental Health America at www.nmha.org, the Mental Health Association of Palm Beach County (www.mhapbc.org) or your local Mental Health America affiliate.  You can also get information about mental health and mental health advocacy through NAMI (www.nami.org) or your NAMI affiliate. 

For information about this blog, or to subscribe to the Our Health Policy Matters weekly email, contact gionfriddopaul@gmail.com.     

What's at Stake for Health in the Budget Debates

The President, the Congress, and State Legislatures are struggling mightily through their budget debates as if the health of the nation is at stake.  It is. But not in the way they think.

Whether wealthy people will pay more or less taxes, young people will get fewer social security benefits, and the governments will get smaller are important considerations.

But they are only important to people who are healthy enough to care about them.

What about those who aren’t? 

source: County Health Rankings, 2011

If someone were to tell you right now that you had a medical condition that was going to take 25 years from your life, would cutting spending and giving corporations tax breaks be your top legislative priority?  Would you vote for anyone who made those a bigger priority than your health?

Here are some of the people whose life expectancy today is 25 years less than the norm:

• A person born with Down Syndrome.
• A person born with Cystic Fibrosis.
• A young person diagnosed in his/her late teens with a serious mental illness.
• A person who played professional football in his 20s. 
• A woman in her thirties with Stage 4 breast cancer.
• A man in his forties diagnosed with Lou Gehrig’s disease.
• A 50-year-old man or woman with advanced congestive heart failure.

I don’t imagine these people see the budget debates the way politicians do.  Many rely on public programs and government spending for their health.  Whether they are for or against health reforms, there is a reason they are so passionate.  It’s not the money.  It’s literally life or death for them.  The sicker they become, the more they choose life.

Most of the politicians voting to privatize Medicare and cut Medicaid, or to cut $600 million from community health centers as members of Congress agreed to do last week, don’t rely on these programs to help them live well.  Terms like “medically needy” mean nothing to them.  For people who are medically needy, on the other hand, the stakes are much higher. 

Significant percentages of Americans are living with serious chronic conditions that cost a huge percent of their monthly income and most of their savings.  These Americans witness government leaders who don’t realize that when they say share the “pain” of cuts, it’s a cruel joke on people feeling real pain. 

Health spending cuts come at a real price.

This year’s county health rankings were released a couple of weeks ago.  Palm Beach County, my home for the last six years, is ranked 11^th among 67 in the State of Florida – pretty impressive.  Only 12% of us are in poor health and, based on a calculation that adds up the overall harm this does to our life expectancy, we lose only 7.5 years of life to premature death for every 100 people.

Other south Florida counties also do well.  Broward County, which ranks 10^th in the state, loses only a little over 7 years of life for every 100 residents, and Miami-Dade, ranked 8^th, does even better, losing only 6.5 years.

By contrast, northern Florida counties have some of the lowest scores in the state.  24% in Baker County are in poor health, and they lose 11.5 years of life for every 100 residents.  Union County residents fare worst of all, ranking 67^th.  They collectively lose over 21 years of life to premature death for every 100 residents.

I was feeling pretty good about my county’s ranking until I compared it to the two counties in which I lived before I moved to Florida. 

Middlesex County, CT, ranks 2^nd of Connecticut’s eight counties, and its residents lose only 4.8 years of life to premature death for every 100 people.  Despite its harsh winter climate, only 10% are in poor health.

 Travis County, TX, ranks 6^th out of 223 Texas Counties.  Even though 14% of Travis County residents are in poor health, its people lose only 5.6 years of life to premature death for every 100 people.

Why should the health of Palm Beach County’s residents be demonstrably worse than that of Middlesex County and Travis County residents?  We’ve got our fair share of fine hospitals, clinicians, and public health services.  Historically, we’re not poorer than either of these two other counties – in fact, 10 years ago per capita income was about the same for all three. 

We also have lower taxes and less government.  Connecticut has a state income tax, and property taxes there and in Travis County are much higher than they are in Palm Beach County. 

But lower taxes and less government wouldn’t account for our poorer health status.

Or would they?

Florida's $11 Billion Medicaid Gamble

Want to get an email notice when new Our Health Policy Matters columns are posted?  Send an email to gionfriddopaul@gmail.com and I'll add you to the list.

Treating the public policy arena like a casino is never a good idea.

Florida is placing an $11 billion bet on Medicaid this year.  If the state loses, we’ll all be emptying our pockets for lower services.

The bet involves moving all Medicaid recipients to managed care.  As reported in an article by Jim Saunders in Health News Florida last week, passage of this legislation this year is as close to a sure thing as there is in government.

Florida hopes to save $1 billion the first year, and $2 billion by 2013 – nearly 10% of the total State Medicaid budget.

There are three problems with this calculation.

The first is that the projected savings from moving to managed care might be too high.  In a 2009 report prepared for America’s Health Insurance Plans, the Lewin Group found that savings in 24 different state Medicaid plans ranged from half of one percent to 20% after a switch to managed care.  Savings tended to be low at first, and most were still in the single digits after several years.

The second is that the savings will be offset by lost federal revenues, because the federal government will reimburse at least 55% of Florida’s Medicaid costs the next two years.  The actual savings to taxpayers is under $1 billion in FY2013, less than half of what the Governor and legislators are claiming.

The third problem is that to achieve these savings, Florida has to include elders and people with disabilities – who together account for 70% of Medicaid expenditures – in managed care.

To many people, “managed care” means the same thing as “care delayed or denied.” If $700 million of Florida’s Medicaid savings come from denying care to nursing home residents, cutting back on treatment services to people with mental illness, and delaying care for people with mental retardation, legislators fighting Medicaid growth won’t exactly be hailed as conquering heroes.

Together, these factors leave at most $300 million in savings associated with the non-long term care Medicaid program.

But the savings may not be even that high.

The reality is that Florida had a much slower growth rate in its Medicaid program from 2004 through 2009 than did the nation as a whole. The cumulative savings in Florida over this period was 10% compared to Medicaid spending in the nation as a whole.  Florida may have already squeezed the savings from Medicaid without resorting to managed care. 

Also, there is a new cost associated with turning the program over to the private managed care companies.  Unlike the state, these companies have to make money, which has to be added into the cost calculation.

Finally, reports authored by Jack Hoadley and Joan Alker of the Georgetown Health Policy Institute and released yesterday by the Jessie Ball DuPont Fund suggest that Florida’s own Medicaid managed care pilot program has disrupted care for Medicaid recipients while saving little or no money. 

In the face of all this evidence, saving even $300 million in Medicaid non-long term care is a long shot. 

So on what is Florida wagering $11 billion? 

Senator Joe Negron, the Senate legislation’s sponsor, says that Florida will drop out of the Medicaid program if the Federal Government refuses to go along with Florida’s managed care plan.

That’s an $11 billion gamble – the annual Federal reimbursement that Senator Negron says Florida will give up if the federal government doesn’t let it switch to managed care.      

Obtaining federal approval for unpopular Medicaid changes which could disproportionately and adversely affect elders is no sure thing.     

If Florida drops out of Medicaid, 3 million Medicaid recipients will become uninsured.  This will bring the total number of uninsured people in Florida to close to 7 million – more than 35% of the population.

Hospitals, nursing homes, independent physicians, community health centers, mental health centers, and other providers do not have the capacity to absorb care for 7 million uninsured people. 

Instead, Florida would have to create and fund a new plan to pay for the care of all 7 million people.  To do this, it would have 9 billion state Medicaid dollars with which to work. 

$9 billion – or $1,300 per person – may seem like a lot of money to provide care for these 7 million people.  But they aren’t young and healthy – remember, 70% of the Medicaid dollars go to long term care – and one nursing home bed alone can cost fifty times this amount.

$9 billion could disappear in a matter of weeks.

Florida can’t afford the gamble.  If saving $300 million in the Medicaid non long-term care program is the state’s goal, it should either find out in advance if the federal government is willing to approve or find another way to do it.   

After all, Florida’s not playing with house money, but ours.      

Making People with Mental Illness Pay the Price

Isn’t it worth a few dollars to preserve essential mental health services?  It would appear that many state legislators would say no.

According to the National Alliance on Mental Illness, states have cut a total of $1.6 billion for mental health services over the past three years.

That was just the teaser. 

This year, states around the country are making people with mental illness pay the price for tax cuts and deficits.

NAMI state-by-state data show that the State of Florida spends no more for mental health services than it did in 2009.  But Health News Florida reports that the Florida Senate has proposed millions of dollars of cuts to mental health. 

Next week, its Appropriations Committee will vote whether to cut $137 million from adult mental health services, 57% of the total outpatient budget.  Anyone who thinks these services aren’t essential should think again.

On a single day this spring, in addition to offering its full array of group counseling, AA, NA, and individual support services, the only full-time peer drop-in center operated by MHA of Palm Beach County dealt with the death from natural causes of a middle-aged client (people with mental illness die 25 years earlier than normal), a former client’s suicide, a hospital patient discharged to the center for follow-up services, and a person with a traumatic brain injury who had no other place to go.

“Days like this are now common,” commented MHAPBC CEO Pam Gionfriddo, “and will become even more so if policymakers keep cutting.”

 Over 5,300 people in central Texas alone will lose services, according to the Austin American Statesman, if a proposed 20% cut in outpatient mental health services goes through.  The CEO of Austin’s major service provider said this would add to the suffering of families, and Lynn Lasky Clark, President of Mental Health America of Texas added that those affected would be “devastated.”

Texas already spends 3% less on mental health services than it did in 2009. 

Nevada spends 17% less on mental health services than it did in 2009.

But, according to the Las Vegas Sun, the Governor’s proposed budget includes millions of dollars of additional service cuts, including cuts to triage centers in Las Vegas and Reno and to outpatient counseling services.

Sen. Sheila Leslie termed the cuts “a mental health catastrophe.”

Tennessee already spends 10% less on mental health services than it did in 2009.

Now, Tennessee is proposing to cut $31 million more from mental health services, affecting all areas of the state.

The northeast is not immune.  New Hampshire has cut mental health funding by 8% in the last two years.  This year, the state is considering eliminating all services for two-thirds of the 20,000 people for whom it has responsibility. 

Ditto the northwest.  Oregon actually added 23% to its state mental health budget the past two years.  However, Disability Rights Oregon reports that the state is now proposing cutting mental health services by 30%, costing 45,000 Oregonians access to care.

Let’s call this exactly what it is – public officials across the country pummeling people who are the least able to defend themselves.

The bad economy is a phony excuse. 

Even in the Great Depression, state policy makers increased mental health services to meet increased needs.  The census of patients served in mental hospitals – the only care option available at the time – grew from 272,252 on January 1, 1929 in 1929 to 321,824 on January 1, 1934, and the number of first admissions – a signal that new needs were being met – rose from 60,500 on January 1, 1929 to 69,368 on January 1, 1933.

Do policymakers really think times are tougher today than they were then?

Most legislators pray to God for enlightenment and compassion at the opening of each session.  Here is an excerpt from a Florida Senate prayer this year, offered on March 16^th by Monsignor Thomas Skindeleski of Delray Beach:

“Open our minds to better understand the needs of those who have chosen us to serve them. Teach us how to craft laws that will better the lives of millions of people who are counting on our efforts to serve them well.  Let justice and peace be foremost in our minds as we endeavor to legislate in ways that will benefit the lives of our people. Direct our efforts to preserve the life and liberty of the most vulnerable members of our society.”

It’s a powerful prayer.  I hope our leaders listened. 

Don’t smirk.  When was the last time we told our own elected officials that we willing to pay taxes to provide services to people with mental illness?  Today – before it’s too late – is the day to call, email, or forward this column to a policy leader.

We must add our voices to those of the mental health advocates speaking up for some of the most vulnerable members of our society.

Would you like to be notified about new Our Health Policy Matters blogs via email?  Just send an email to gionfriddopaul@gmail.com and I'll add you to my list.

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. 

The Nuclear Nightmare in Japan

The catastrophic nightmare in Japan could happen anywhere.  It is a reminder of the fragile relationship between our environment and our health.

As the tsunami waves swept over the land, they swept away any pretense that we are more powerful than our environment.  The mere shifting by several feet of two constantly moving plates of the earth resulted in the death of thousands, the destruction of a region, and catastrophic worldwide effects.

Experts have noted that as many as 24% of premature deaths can be attributed to environmental factors.  These result from our inadequate understanding of our environment, and/or our inability to manage its forces.

While the underdeveloped world is more susceptible, the Japanese tsunami reminds us that the overdeveloped world is not immune.   

The images are more powerful than their descriptions.  In the wake of such destruction, we can see -- as we do in the aftermath of hurricanes -- the breeding grounds for disease.  We know that many of the survivors of the initial devastation will still become its victims. 

There are clear psychological effects as well.  In a matter of minutes, the lives of the shocked and stunned people of northeast Japan were changed forever.  Up to 15% of children who survived the tsunami, twice the norm for adults, will likely be diagnosed with PTSD.

Still greater effects are hidden in what we can’t see.

The partial meltdowns of multiple nuclear reactors are resulting in the release of deadly radiation into the atmosphere that will compromise human health for decades. 

Our leaders have forgotten how dangerous nuclear power can be.  Even some who consider themselves environmentalists naively believe that we “harnessed” the atom and made nuclear energy “green.”

Nothing could be farther from the truth.

In the 1950s and 1960s, nuclear energy was promoted as “safe, clean, and cheap” by the brand-new nuclear industry.  It was said that it was safer than walking across the street and would be too cheap to meter.  School children toured nuclear power plants to learn about the “peaceful atom.” 

Our government knew better.  In 1957, it passed the Price-Anderson Act, limiting the liability of nuclear plant owners in the event of a nuclear accident.  This is still the law of the land.  Without it, not a single nuclear power plant would have been commercially viable in this country. 

Each reactor owner must carry only $375 million of insurance to pay for damages from an accident; up to $12.6 billion more is in a secondary insurance pool.  If you lost your home to nuclear contamination, your homeowners insurance would pay nothing.

To put this in perspective, the total cost resulting from the Japanese quake and tsunami is already estimated to be up to $60 billion, and Hurricane Katrina did even more damage than this.  The Chernobyl accident cost Ukraine alone an estimated $201 billion.  The total compensation for a nuclear accident in this country could be as little as five cents on the dollar.

Once their liability was limited, nuclear companies were free to put their plants anywhere – near population centers and even along earthquake fault lines.

After many “minor” incidents in the United States and around the world during the 1960s and 1970s, the Three Mile Island accident in 1979 proved once and for all that the safety systems in nuclear power plants did not work as advertised.    

Then came Chernobyl in 1986.  This was the defining civilian nuclear disaster of the 20^th century.  Twenty-five years later, experts are still tallying its effects.  The World Health Organization conservatively estimates the number of deaths at nearly 10,000, plus thousands more excess cancers, and other health and mental health effects. 

A YouTube video shows how radiation would spread into the atmosphere if a Chernobyl-like accident were to happen in the United States.  It is a frightening reminder of the risks we are taking.

There is a lot we don’t yet know as the fuel rods melt down and the crisis unfolds in Japan.  One thing is certain.  It will be years before we understand the full global effect on human life from this event. 

We can all put those years to good use if we finally take to heart the lessons from this unspeakable tragedy.  We cannot overcome the limitations of our planet.  We do not control the forces of nature.  We can choose, however, not to stand in harm’s way. 

There are 104 operating nuclear reactors in the United States today.  Just as in Japan, some are built near earthquake fault lines and most are close to cities. 

Any one of them could be a time bomb.  It’s time we lived a little greener, and not supply so much fuel for the next environmental health disaster.

We can pretend that what’s happening in Japan is just someone else’s nightmare, or we can wake up and start doing something about it. 

A Long Term Care Win for Everyone

Why is it so important that Florida has won a $35.7 million health reform act grant to participate in the federal “Money Follows the Person” program?

A recent news story provides the answer.   It tells the story of a 20-something Florida resident who is a quadriplegic living in a nursing home.  He doesn’t want to live there.  But he doesn’t have a choice.  It’s the only option for which the Florida Medicaid program will pay. 

We hope he’ll be alive for many years.  A back-of-the-envelope calculation suggests that the cost of his care could approach $4 million by the time he is 65.

A December, 2009, AARP Long Term Care Brief showed that Florida spent 86% of its Medicaid long term care dollar on institution-based services.  It spent about half the national average on home and community-based services (HCBS).

The “Money Follows the Person” program offers a low cost remedy. 

Enacted in 2007, the program has already provided over $1.4 billion to 30 states.  It has helped over 30,000 people transition from nursing home care to lower-cost community-based care.    

The result is improved well-being, greater independence, and more productivity at lower cost.  Not just young people benefit; many older Americans with chronic conditions also prefer living at home.

Wildly popular, the program was re-authorized by the Affordable Care Act.  It was extended for several years and expanded to allow more states to participate.  By accepting the new federal grant, Florida will be one of them. 

In spite of the bluster that Florida would refuse to implement any of “Obamacare,” AHCA and the Governor saw the wisdom of pursuing this piece aggressively. 

Florida may have come late to this party, but better late than never. 

The cost of long term care is one of the biggest drivers of the increase in health care costs in our country.  A majority of our population has one or more chronic conditions.  These conditions are often diagnosed and monitored using expensive medical tests.  They are managed with costly pharmaceuticals.  People with them often need physical and occupational therapy and other supports.  Treatment costs may rise in the future, because genetic therapies are on the horizon.

In a recent issue brief on Medicaid and long term care, the Deloitte Center for Health Solutions noted that Medicaid expenditures are projected to increase by 7.5% per year, largely due to the increase in the numbers of elders and others with chronic conditions on the program.  Examining Florida and nine other states, Deloitte estimated that the percentage of state resources devoted to long term care could double over the next twenty years. 

Controlling long term care costs should be a priority for everyone.  However, this isn’t always the case.  The report noted with concern that states are cutting back on lower-cost community-based services covered by Medicaid, instead of increasing them.

That’s what makes the “Money Follows the Person” program so important.  It helps expand community-based services, at a time they are sorely needed.

Florida’s action also serves as a reminder that the Affordable Care Act isn’t one big government health care program.  It is a collection of smaller, independent initiatives that affect many different components of our health care delivery system.

Another provision of the Act – the creation of the CLASS Long Term Care Insurance program, effective in October, 2012 – is also aimed at changing the way we finance long term care in the future.  It will make more private long term care insurance available for home and community-based care.  My wife and I purchased long term care insurance policies several years ago, when we were in our early 50s and healthy.  Unfortunately, many others wait until it’s too late. 

The HHS National Clearinghouse for Long Term Care Information notes that over 70% of us will need long term care services at some point in our lives.   HHS Secretary Sebelius has pointed out that one in six people who reach the age of 65 will spend over $100,000 in their lifetime on long term care.  The total cost could be upwards of $5 trillion.  The government can’t pay all this.  Private long term care insurance will be needed.    

However, as the planning for the CLASS program is unfolding, people who develop serious chronic conditions before applying for long term care insurance may be out of luck.  To keep insurance costs affordable, HHS is considering limiting the program to higher wage-earning, healthier people at the start. 

That means Medicaid will remain the main long term care payer for the foreseeable future. 

The more it can do to help 20-somethings stay in the community and be productive, the better off we all will be.  This is a health care reform with which no elected official should disagree.

The War on Health

Policymakers across the country have declared war on health.  You may have missed the headline, but this is a war with many casualties.

Its objective is to topple health care as we know it.  When health care falls, our health will be the victim.

Battles are raging in many states to cut the legs out from under health care financing.

The Arizona Senate Appropriations Committee recently voted to eliminate the Medicaid program.  This would make 1.3 million people uninsured and cost the state $7.5 billion in federal funding. 

A Florida Senate leader has threatened to eliminate Medicaid unless the federal government agrees to massive changes.  This would cost Florida over $10 billion, and make 3 million people uninsured.

Wisconsin’s Governor has proposed dropping over 60,000 people from Medicaid because they are too rich.  “Too rich” means a two-person household income of less than $29,100.     

Medicaid isn’t the only target. 

Pennsylvania just cancelled its state-funded health insurance plan for low income residents.  As a result, 42,000 people lost their insurance.  A half million more on the waiting list have to fend for themselves.

New Jersey’s Governor proposed a 15% reduction in state health appropriations this year, six times greater than the overall reduction in his budget in his recent speech to the Legislature.

Florida’s Governor proposed eliminating state-run health department clinics, even when they generate revenue.  In Palm Beach County alone, this would cost 60,000 people their regular source of care.    

This war began quietly while the eyes of the public were focused on federal health reform.  The Center on Budget and Policy Priorities has detailed a number of battles we have already lost:

• New Jersey lowered income limits and reduced eligibility for the state’s Children’s Health Insurance Program.  50,000 more people are uninsured as a result.  
• Mississippi reduced its mental health budget by 22% in the last two years. 
• Illinois and Ohio cut community mental health services for children and reduced or eliminated community mental health services for adults who are not on Medicaid.

Elected officials declared this war on health by suggesting that health care was the weapon of mass destruction of our state economies.  It wasn’t.  The real weapons were the war in Iraq and Afghanistan at a total cost of over $1 trillion (and counting), for which the federal government did not have the courage to pay, and the greed of a financial industry which fattened our burst housing bubble. 

Health care is not a foe of the state, and people who need it should not be treated as enemy combatants.

However, people with mental illness are this war’s prisoners, often jailed instead of given the care they need.  This is not an exaggeration. The three largest mental health institutions in the country are Riker’s Island, the Cook County Jail, and the Los Angeles County Jail.  The largest mental health institution in Texas is the Harris County Jail.  It has 2,400 “patients” on any given day. 

In 2011, Texas is considering cutting $1.1 billion from state mental health services.  

According to the US Bureau of Justice Statistics, in 2005, more than half of over 2 million prison and jail inmates had mental health problems.    Over 1.25 million Americans are being “treated” for mental illness in our prisons and jails.

Elderly women and children are this war’s hostages. 

The Medicaid program funds 68% of the 1.8 million nursing home beds in the U.S.  Almost a million people live their lives in these beds.

650,000 of them are women, the vast majority over 75 years old and widowed.  In his recent speech, New Jersey Governor Christie articulated a fearful future for them.  Others share his vision “to move our aged, blind, and disabled [Medicaid] recipients into modern managed care.” 

These sick, elderly women suffer the indignity of being blamed for the state budget crisis they had nothing to do with creating.  If the Governor’s vision becomes reality, they won’t just have to cope with incredible health challenges.  They will be put at the mercy of the discredited “modern managed care” denial system.

Mostly under the radar, 31 states have already implemented cuts in children’s health programs.  As representatives of the Iowa Child and Family Policy Center and Voices for America’s Children note in their recent publication, The Healthy Child Story Book, for the first time in our history children may live shorter and less healthy lives than their parents.

Meanwhile, legislative bodies in Ohio, Louisiana, and Arizona have found the time to pass laws banning animal-human hybrids.  This is no joke.  The Louisiana bill’s sponsor, State Senator Danny Martiny, said the Louisiana Conference of Catholic Bishops asked him to introduce it.    

Louisiana ranks 49^th among the states in health, ahead of only Mississippi.  While imaginary beings occupy the attention of political and religious leaders, this war will produce millions of all-too-real casualties.