Members of Congress Scrutinize Navigators More Than a Run-up to Possible War

In the nervous run-up to a possible military strike in Syria, fifteen members of Congress last week took time from their busy vacations to sign a letter demanding more information from governmental contractors. 

But the targets of their attention were not the defense contractors who received $161 billion for their services.  They were universities, legal aid organizations, and small nonprofits who will share $67 million to help citizens apply for health insurance beginning in October.

The Congressional Gang of 15 included Fred Upton from Michigan, Pete Olson, Joe Barton and Michael Burgess from Texas, Tim Murphy and Joseph Pitts from Pennsylvania, Marsha Blackburn from Tennessee, Phil Gingrey from Georgia, Steve Scalise from Louisiana, Gregg Harper from Mississippi, Corey Gardner from Colorado, Morgan Griffith from Virginia, Bill Johnson from Ohio, Billy Long from Missouri, and Renee Ellmers from North Carolina.

They sprang into action after the grants were awarded in mid-August, demanding a response in writing within two weeks.

Here are some of their demands (thank you to Kaiser Health News for linking to the letter):

• “a written description of the work that will be performed,” including “a description of the number of employees, volunteers, or representatives that will be utilized and the pay and duties for each.”  
• A detailed budget for the program.
• “a written description of the training or education employees, volunteers, or representatives must complete,” plus educational requirements of the organization “beyond that required by any federal or state entity.”
• Supervisory processes and procedures.
• A description of how the organization will use the information obtained, including in follow-up communications with anyone with whom the organization speaks who might want to register to vote.
• Any communications with any health provider or any health insurance carrier to whom any individual might be referred for health care or coverage.
• All materials related to the grant application and award process.

Imagine being a 20 year old navigator in Florida just trying to help someone get insurance.  Do you really want some Congressman from Michigan “ACORNing” you if the person also asks you how to register to vote? 

Florida’s governor and do-nothing insurance commissioner aren’t going to help you.  They’ve already signaled their mistrust of navigators. 

You might think that any member of Congress who devotes so much vacation time to finding out whether sick people are getting help in finding a doctor would pay even more attention to matters that could soon drag our nation into another war.

And you might think that any member of the Congress taking time demanding this level of scrutiny about a program to help people get insured would apply a similar standard to other federal contractors. 

But you would be wrong.

When there’s more at stake, they sit back and wait.

Fred Upton, who has been on the job for twenty-five years and wrote the letter to the community agencies, hasn’t said a word in public about Syria.  He did, however, help a Vietnam veteran get his long-deserved service medals this month.  Pete Olson has no public position on military action, but said Congress should approve any.  Tim Murphy and Steve Scalise are among 140 members who want Congress “consulted” before the U.S. goes to war. And Billy Long went out on a limb when he asked the President to “tell his side of the story.”

If only they were as deferential about demanding the details about a paralegal contacting an insurer on behalf of a man with mental illness or a woman with cancer.

And take a look at the chart.  The value of the navigator contracts is so small compared to defense services contracts that you can’t even see it with the naked eye. 

As for the scrutiny they give to these other contracts that are worth 2499 times the value of the navigator contracts:

• They don’t demand educational credentials.  In the Snowden case, a 29 year old high school dropout was given access to “some of the most highly classified information in our government,” according to Sen. Susan Collins.
• They don’t t-cross and i-dot in advance. “According to the US Government Accountability Office in December 2012, there was a backlog of approximately 25,000 audits of DOD contractors as of the end of FY2011. “This backlog represents hundreds of billions of dollars,” GAO reported, and “has quadrupled over ten years.”
• And they don’t demand details about the numbers of employees, volunteers, or representatives, including their pay and duties.   Over 6500 contractors are working on $2 billion NSA expansion projects, according to a recent article.  As to who those contractors are, that information is simply described as “hush-hush.”

There is reason for outrage here.  You can decide over what.

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

The Ten Worst States for Your Health, 2013

Arkansas supplants Oklahoma in the 2013 OHPM rankingsas the worst state for your health. 

Arkansas was joined in the bottom ten by five other southern states and four states from the west.  And here's all you need to know about why states in the bottom ten are bad for your health.  Life expectancy in those states is the same as it is in Paraguay - 76.6 years.  This is four years fewer, or an entire Presidential term less, than life expectancy in Massachusetts and Connecticut - the two states at the top of this year's ranking.

Two states – Texas (39, up two places from last year) and West Virginia (38, up five places from last year) – escaped the bottom ten this year.  Kentucky found its way back after one year in 35^th place, and South Carolina entered the bottom ten after dropping eight places from 40^th last year. 

Here are the bottom ten, with the change from last year in parentheses:

41. Kentucky (-6).   Kentucky entered the bottom ten this year not because it did poorly in most rankings (its 44^th place healthy state ranking was its only bottom ten finish), but because it places in the bottom half in every category except Medicaid access.

42. Alabama (+3).  If Alabama’s 35^th place Kids Count health ranking can help to improve its 45^th place healthy state ranking in the future, then it may be poised to escape the bottom ten in the next couple of years.

43. Oklahoma (+7).  Oklahoma moved up from last place this year on the basis of a top 15 performance in Medicaid access and per capita Medicare community spending.  But 43^rd place finishes in both the Healthy State and Kids Count Health rankings cemented its position in the bottom ten.

44. Louisiana (0).  Louisiana is top ten in Medicare community spending and percentage of people on Medicaid, but bottom ten in the Healthy State rankings, the Kids Count health rankings, access to primary care providers, and the percentage of people with employer-based health insurance.

45. New Mexico (+4).  New Mexico is 5^th in percentage of people on Medicaid, and 50^thin percentage of people with employer-based insurance.  Not exactly an indication of a “worker-friendly” environment.

46. Montana (-5). Montana is last in the Kids Count health rankings, and next-to-last in the percentage of people with private health insurance and Medicare community spending.  These offset its middle-of-the-pack healthy state ranking (29^th).

47. Mississippi (0).  At least Mississippi is consistent, finishing 48^th, 47^th, and 47^th during the last three years.  Although it boasts top ten rankings in Medicaid access and Medicare community spending, it is 45th in employer-based insurance, 48^th in the Kids Count health rankings, and 49^thin the Healthy State rankings.  Mississippi has downside potential.  It hasn’t embraced Obamacare Medicaid expansion.  But both Arkansas and Nevada – the bottom two states in the rankings - have.

48. South Carolina (-8). South Carolina’s dive in the rankings is attributable to the fact that it doesn’t do well in any of the categories. In fact, its highest ranking among the states is only 20^th in Medicare community services spending.

49. Nevada (-1). Nevada’s only top thirty ranking is in Medicare community spending.  It is 47^thin the Kids Count health rankings and number of high-quality hospital programs.  But it is one of four bottom ten states to embrace Medicaid expansion.

50. Arkansas (-4).  What is Arkansas’ recipe for failure? Start with a 48^th place Healthy State ranking.  Add in a 49^thplace finish in access to primary care providers, a 46^th place ranking in the percentage of people with employer-based health insurance, and a 44^th place finish in number of high quality hospital programs. Arkansas ranks in the top ten in just one indicator.  It is 9^th in the percentage of people on Medicaid.  Of course, that’s a pre-ACA percentage, but it may explain why Arkansas – a conservative state – has embraced Obamacare’s Medicaid expansion.

Some interesting notes:

Colorado has the greatest difference in the two prevention rankings – it is 11^th in the healthy state rankings, and just 42^ndin the Kids Count health rankings.

Hawaii (+23.8) and Vermont (+22.5) are the only two states that rank more than twenty places better on the average of their prevention rankings than on the average of their health care rankings.  Rhode Island (+17.9) and New Hampshire (+17.9) tie for third on this measure.

Mississippi (-22.9) and Louisiana (-20.6) are the only two states that rank more than twenty places worse on the average of their prevention rankings than on the average of their health care rankings.  Tennessee (-18.6) is third on this measure. 

The states that are most balanced in their prevention and health care rankings are Kansas (+0.6), Colorado (+0.5), and Montana (-0.7).

Connecticut (2^nd overall) favors prevention and public health (+8.2, on average), and Florida (34th overall) favors health care (-11.9, on average).

To see the full rankings, click here.

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

The Best States for Your Health, 2013

After a year in second place, Massachusetts is once again the best state for your health in the 2013 Our Health Policy Matters rankings.

In first place in 2011, Massachusetts dropped to second last year behind Connecticut.  It edged out Connecticut this year based on the rankings of all fifty states in a combination of seven national source rankings and/or spending categories.

Here are the top ten states, with the change from last year’s ranking in parentheses.

1. Massachusetts (+1).  Among the seven components of the rankings, Massachusetts was only 4^th in the Healthy State rankings, and 11^th in the Kids Count health rankings.  But it earns its top rank overall because of consistently high placements in five other health care rankings.

2. Connecticut (-1).  Last year’s winner, Connecticut ranks 2^ndoverall in the Kids Count health rankings and in the percentage of residents with employer-based private insurance.  But it is only in the middle of the pack (20^th) in total number of high-quality hospital programs.

3. New York (+3). Never highly ranked in the healthy state rankings (18^th this year), New York has jumped from 19^thto 3^rd in two years on the strength of its hospitals, and good access to care for both younger and older residents.

4. Vermont (+3). Vermont tops the healthy state rankings and is 4^th in the Kids Count health rankings.  With an earlier investment in universal health care for its residents offsetting its lack of high-quality hospital programs, it may go higher in the future.

5. Maine. (+3). Maine tops three individual categories – the Kids Count health rankings, Medicaid access, and primary care access – accounting for its three-place gain this year.

6. Minnesota (-2). Minnesota scores highly in the Healthy State rankings, and also has high-quality hospital programs and a highly-insured population.Wisconsin (+6).  

7. Wisconsin owes its improvement in the ranking to healthy kids (3^rd) and solid performances in most other categories.  But it lags a bit in the Healthy State and primary care access rankings.

8. Utah (0). Utah scores well in the Healthy State rankings (7^th), but less well in the Kids Count health rankings (14^th).  It also has a high percentage of its population covered by employer-based insurance.

9. Washington (+7). Like Wisconsin, Washington made a big move into the top ten this year on the strength of a solid Kids Count health ranking (6^th).

10. Maryland (+2).  Maryland is in the top ten in the Kids Count ranking and in the percentage of its population with employer-based insurance.

In individual categories, Maine had the most first place rankings – the Kids Count health ranking, the primary care access ranking, and a tie for first in Medicaid access. California (19^th overall, up 3 places from last year) placed first in the number of high quality hospital programs and tied for first in the Medicaid access rankings.  Vermont topped the Healthy State rankings and tied for first in Medicaid access.  New Hampshire (11^th overall, after a 4^th place showing last year) placed first in employer-based health insurance. 

And Florida (34^th this year, down one place from last year) was first in community Medicare spending.

These rankings are the last before some significant Obamacare changes go into effect next year. For example, Vermont (ranked 4^th), Maine (5^th), Wisconsin (7^th), and Rhode Island (12^th) have all announced plans to cut their Medicaid rolls to encourage people to enroll in the exchanges, according to an article this week in Kaiser Health News.   Next year’s rankings may be adjusted to take into account insurance exchange enrollments in all the states.

Washington (9^th), Delaware (18^th), and Oklahoma (43^rd) were the biggest gainers this year.  They all gained seven spots in the rankings. New Jersey (13^th) experienced the biggest drop – 10 places. Virginia (23^rd) lost nine places, and Pennsylvania (16^th) and South Carolina (48^th) each lost eight.

Next week: the ten worst states for your health.

To see the full rankings of all fifty states, click here.

How These Rankings Are Developed:

OHPM combines seven rankings of the states to create this Top Ten.

Two of the rankings among the most highly-regarded public health or prevention-focused rankings – the United Health Foundation/APHA/Partnership for Prevention America’s Health Rankings and the Annie E. Casey Kids Count state health rankings.  The most recent America’s Health (Healthy State) Rankings were published in December 2012, and the most recent Kids Count health rankings were released in June 2013.

Because prevention and public health account for 50 percent of the gains in life expectancy over the last century, these two rankings account for 50 percent of the weight in the OHPM rankings.

The other five components of the ranking account for the other 50 percent, and are related to health care access and quality.  This year, they include the number of nurse practitioners and physician assistants per capita in the state (as a measure of the strength of the state’s primary care system), the percentage of state residents with employer-based private insurance and with access to Medicaid (as a measure of the availability of third-party payments for health services in general for the under 65 population), community-based Medicare spending (as a measure of the availability of elder health services), and, from the 2013 US New and World Report Hospital Rankings, the total number of high quality hospital specialty programs in the state (as a measure of the availability of specialty care for all chronic diseases and conditions).

To see the full rankings of all fifty states, click here.

Source links:

http://www.americashealthrankings.org/mediacenter/mediacenter2.aspx

http://www.statehealthfacts.org/comparetable.jsp?ind=125&cat=3

http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=7248

http://kff.org/medicaid/state-indicator/medicaid-enrollment-as-a-of-pop-fy09/

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsStateHealthAccountsResidence.html

http://health.usnews.com/best-hospitals/area

http://data.bls.gov/oes/search.jsp?data_tool=OES

http://samhsa.gov/data/NSDUH/2k11State/NSDUHsaeTOC2011.htm

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

Six More Reasons Why Obamacare Won't Be Repealed

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

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

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

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

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

That is as true today as it was then.

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

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

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

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

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

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

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

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

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

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

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

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

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

And all the members of Congress already know this.

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

The Ten Best and Ten Worst States for Your Mental Health

Connecticut spends four times more per capita on state mental health services than Texas.  In Florida, 25 percent fewer people report having mental illnesses than in Washington.

Across the nation, there are significant differences in the amounts states spend on mental health services.  Connecticut spends $189 per capita, while Texas spends only $39.

But there are also significant differences in the reported prevalence of mental illnesses.  For example, fewer than 18 percent of Floridians report having a mental illness during the past year, but in Washington almost 24 percent do.

But what happens when you put spending and prevalence together?  Some new rankings emerge that give you a measure of each state’s real commitment to protecting mental health – and treating mental illness – in their population. 

This week, I have ranked all fifty states using both spending and prevalence data.      

I have taken per capita mental health spending from Kaiser Family Foundation’s State Health Facts data, and prevalence data from SAMHSA’s Summary of the National Survey on Drug Use and Health (NSDUH).  Both data sets are from the 2010-2011 time period.

It turns out that some states spend more than ten times as much as others on behalf of people with mental illness.

You can review the full list of the states along with the full set of the data I used here. 

But for now, if the commitment of state government is your measure, here are the ten best and ten worst states for your mental health.

The Best:

1. Maine.  Maine spends almost $1,900 per person with mental illness – 25 percent more than the next closest state.  It is tops in spending per capita, and but also 7^th best in percentage in percentage of people reporting mental illnesses.

2. Alaska.  Alaska is middle-of-the-pack in prevalence, but it is second in spending per capita.  The result?  Alaska spends just under $1,500 per person with mental illness.

3. Pennsylvania.  Pennsylvania is 3^rd overall in spending, but only 16^thbest in prevalence.  That still results in spending of over $1,400 per person with mental illness.

4. New York.  New York is 4^th in spending, and middle-of-the-pack in prevalence.  It spends over $1,200 per person with mental illness.

5. Vermont.  Like New York, Vermont is 23 places higher in spending than in prevalence.

6. New Jersey.  New Jersey is 3^rd best in prevalence, but still spends over $1,100 per person with mental illness.

7. Arizona.  Arizona is only 36^th best in prevalence, but it invests well in mental health services, spending $1,044 per person with mental illness.

8. Connecticut.  Connecticut is one of eight states that spend at least $1,000 per person with mental illness.  It pays off for a state that is tied with Georgia for 9^th best in prevalence.

9. North Carolina.  North Carolina’s high ranking is driven by a 4^th best ranking in prevalence, and top twelve spending per capita.

10. Hawaii.  Balance is the key to Hawaii’s ranking – 15^th in prevalence and 10^thin spending.

And the worst:

41. South Carolina. South Carolina ranks 23^rdbest in prevalence, but is 43^rd in spending.

42. Louisiana.  Louisiana is 35^th in prevalence, but it is not enough to nudge up its overall ranking.

43. Utah. Utah is 49^th in reported prevalence of mental illness – a surprise for a state that regularly ranks near the top in other health categories.  It spends only $263 per person with mental illness.

44. Kentucky.  Kentucky is middle-of-the-pack in prevalence, but spends only $259 per person with mental illness.

45. Georgia.  Georgia is tied with Connecticut for 9^th best in prevalence, but it by spends only one-quarter as much per person with mental illness.

46. Oklahoma.  Oklahoma earns its ranking by placing 40^th in prevalence and 45^th in spending.

47. Florida.  Florida ranks second in prevalence, but only 48^th position in spending per capita.  As a result, it spends just $222 per person with mental illness.

48. Texas.  Texas – which has the lowest prevalence of mental illness – still spends only $221 for each person with mental illness.

49. Arkansas.  Arkansas is one of only two states spending less than $200 per person with mental illness.  It is among the worst in both spending and prevalence.

50. Idaho.  Idaho is far and away the worst state for your mental health.  It is worst in reported prevalence and worst in reported spending.  How bad is Idaho?  At $143 per person, it spends less than one-tenth as much per person with mental illness as do Maine, Alaska, and Pennsylvania.

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

For the 37 Percent, Stigma Trumps Acceptance

In November, 2012, a fourteen-year-old Utah boy named David Q. Phan committed suicide by shooting himself on a pedestrian bridge near his junior high school.  It was reported that he had been the victim of bullying.

In June, 2013, the New York Times published a story about three students who committed suicide at East Hampton High School during the past three years.  All three students were Hispanic.

Sam Harris, who is half-Native American and half-African American, has writtena first-person account of his own experience with mental illness that has been published on SAMHSA’s “Promote Acceptance” web site.  In his account, he reports that he lived for years with symptoms of mental illness without seeking help in part because he believed that he would be stigmatized by “going to the white man” for help.

And in a case which has attracted recent national attention in the aftermath of the Zimmerman verdict, 32-year-old Marissa Alexander – an African American and a past victim of domestic abuse – received a 20 year sentence in Florida after she fired a bullet in the direction of her estranged husband during a domestic altercation.

These diverse individuals all have had something in common. 

They all have lived in America.  They all have been among the 37 percent of Americans who are considered minorities.  And they all are or were among the 6 percent of Americans who have had a mental illness – such as PTSD, depression, or psychosis – which is considered to be serious. 

They –and others like them – are the reason that July was designated National Minority Mental Health Awareness Month.

Because while all forms of serious mental illness touch all races and ethnicities, all ages, and all socioeconomic groups, they do not touch them equally. 

For example: 

• Suicide is the second leading cause of death for Native Americans between the ages of 10 and 34.
• Hispanics living below the poverty level are three times more likely to report experiencing psychological distress than are Hispanics living above 200 percent of the poverty level.
• Up to 70 percent of Southeast Asian refugees receiving mental health care have been reported to have PTSD, and Asian American women have the highest suicide rate of women over the age of 65.
• African Americans are 20 percent more likely to report having serious psychological distress than are white Americans.

These are some of the realities Americans deal with every day, and they have been a special focus of the Department of Health and Human Services’ Office of Minority Health.

Serious mental illness is a threat to both life and liberty.

According to the Office of Minority Health, Black students are 30 percent more likely than white students to attempt suicide during high school. Hispanic students are 60 percent more likely than white students to attempt suicide. Asian American students are 70 percent more likely.  And Native Americans are an astounding 140 percent more likely to attempt suicide.

And SAMHSA has noted that over 26 percent of people who are chronically homeless have serious mental illnesses.  SAMHSA also notes that our sheltered population is disproportionately minority (only 42 percent of those sheltered are white) – and in some of our largest cities people of color comprise nearly the entire chronically homeless population.

Our jails and prisons have also become our de facto mental health facilities in recent times.  And, according to 2012 data from the Center for American Progress, 60 percent of our prisoners are people of color.  Male prisoners are 2.5 times more likely to have serious mental illness than are people in the general population.  Female prisoners are five times more likely!

We can learn a great deal by understanding the realities of mental illnesses among minorities in America.

We can learn, as a matter of fact, that mental illness often seeks its victims from among those who least able to defend themselves.

We can observe, as a matter of perspective, that the stigma associated with mental illness is harder to overcome when it is coupled with de facto discrimination.

And we can remind ourselves, as a matter of public policy, that the experiences of white males in our society are clearly not representative of the experiences of everyone in our society.

This all hits especially close to home for me.  My son is among the 37 percent, the 6 percent, those who have had suicidal ideation, those who have been imprisoned, and those who have been homeless. 

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

Obamacare's Silver Surprise

There was some surprisingly good news this month about the cost of insurance under Obamacare.  It will be cheaper than expected.  But it remains to be seen – will cheaper insurance satisfy Obamacare doubters on either the left or the right?

I doubt it, but first let’s take a look at the details.

A few months ago, the Wall Street Journal warned of health insurance sticker shock when the Obamacare insurance exchanges open for business in another ten weeks. 

There could be an up-to-50 percent increase in health insurance premiums, the Journal warned.

But a report this month from the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) brought a surprise. 

Based on data from the first eleven states reporting actual premium numbers, ASPE now says that insurance costs for Obamacare “silver” plans for individuals will be 18 percent lower than originally projected by CBO.

Premiums for the least expensive plans were averaging around $321 per month – before income-based tax credits were subtracted from those costs.

And in five states plus the District of Columbia reporting small group plan numbers, insurance premiums for the all-important “second lowest cost” silver level plans will range from 6 percent to 36 percent less than they would have been if Obamacare were not the law of the land.

What makes a plan a “silver” plan?

Despite what you might assume from the headlines, plan categories are not based on insurance premiums.  They are based on the percentage of the total cost of health care that the plan will pay for everyone in the plan, versus what the plan’s policyholders will pay out-of-pocket.

There are four categories of plans – bronze, silver, gold, and platinum.  All plans will provide coverage for the same group of essential benefits.  But bronze plans will cover 60 percent of the cost of these benefits, silver plans will cover 70 percent, gold plans will cover 80 percent, and platinum plans will cover 90 percent.  Policyholders will pay the rest.

This does not mean that if you have a silver plan, at the end of the year you will have paid 30 percent of your total health care costs and your insurer will have paid 70 percent. 

Those are just the averages, and everyone’s individual experience will vary from the average at least somewhat.

There are two reasons that the cost of the silver plans will get so much attention.

The first is that, along with gold plans, they will be the most widely-available plans.  The second is that the tax subsidies built into Obamacare are based on the projected cost of the second-lowest-cost silver plan.

But not all silver plans will be alike.

One silver plan, for example, may charge a higher premium than another silver plan.  But that plan might cover 75 percent of hospital costs, while the other pays only 70 percent.

Other silver plans might be less expensive than some bronze plans – particularly if they provide less “first dollar” coverage for care – or more expensive than some bold plans.

But while the premium costs of the silver plans may dominate the news and public policy analysis in the coming months, I don’t think that how good you feel about Obamacare is ultimately going to be based on the cost of a silver plan. 

Here’s why.

Deductibles, co-pays, and uncovered health expenses also factor into how satisfied we are with our insurance.

If you believe that being expected to absorb, on average, 30 percent of your health care cost burden when you already have insurance is too big a price to pay, then you will not be happy with a silver plan.  You will either hope you or your employer can afford to pay extra for a gold or platinum plan if one is available, or you will complain as much as you do today about your lousy coverage.

And you will dream again of government-sponsored health care for all.

Conversely, if you think that Obamacare goes too far in requiring insurers to cover at least 60 percent of the health care costs of the people they insure, then you may decline to participate in the system at all and pay the small fine.

And you will join Eric Cantor in the march to health policy irrelevancy by asking the U.S House to repeal Obamacare for a 40^th time.

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

Race Does Matter

On August 7, 2012, Allen Daniel Hicks, Sr., died of a stroke.  The Hillsborough County FL resident was 51 years old.  At the time of his death, he was coaching Little Leaguers.

It is a tragedy to lose someone so young to a stroke, but it is not uncommon.  And race matters with strokes.

According to the Office of Minority Health at the Department of Health and Human Services, African Americans are 60 percent more likely to have a stroke than their white counterparts.  And African American men like Mr. Hicks are also 60 percent more likely to die from a stroke than are white men.

But Allen Hicks’s death was especially tragic because the circumstances surrounding it eerily echo those surrounding the death of a young black woman named Anna Brown a year earlier and 1000 miles away.

Both died from blood clots.  Mr. Hicks’ was in his brain; Ms. Brown’s was in her lungs.  Both died young and left children behind.  Both suffered from pain and paralysis before they died.  And both deaths could have been prevented with prompt treatment.

But here’s what really ties these two tragedies tightly together.  Both Allen Hicks and Anna Brown were taken to jail when they were taken ill, and both lay there without treatment while they suffered.

I wrote about Anna Brown’s horrifying death last year.  You can read the full column here, so I won’t rehash those details again.

But Allen Hicks’ story is also worth telling, because, along with Anna Brown’s, it raises too many questions for us to ignore.

A headline in Health News Florida directs you to the Tampa Bay Times for the details.  According to the Times, when Allen Hicks suffered the stroke in May 2012 that led to his death he was driving along a highway.  Despite experiencing sudden partial paralysis that caused him to swerve and hit a guard rail, he managed to avoid other vehicles and stop his car on the side of the road.  While he waited, witnesses called 911.

The newspaper account noted the extent of his stroke at that time, when it reported that Hicks was “speaking incoherently and unable to move his left arm” when the officers arrived.  And what was their response when faced with such classic symptoms of a stroke?  In a scene absurdly reminiscent of the movie Meet the Fockers, “Hicks was arrested on a charge of obstructing a law enforcement officer when he did not respond to commands to exit his car.”

Then it got worse.  His left side paralyzed, Hicks was brought to a jail, where he was apparently given no medical screening.  He was placed face down on the floor of a cell.  “From time to time his right limbs twitched,” the newspaper reported, as he apparently tried to crawl to help using the non-paralyzed side of his body.

He waited three hours for a medical evaluation.  The conclusion?  His stroke went unnoticed, but it was recommended that he receive a psychiatric evaluation.

Two hours later, he was transferred to another jail (this is how we often treat psychosis in America – jails are our de facto psychiatric holding facilities), but did not even receive his unnecessary psychiatric evaluation until noon the next day.  He was found to be “delusional with a poor memory.”

As the old saying goes, if all you have is a hammer, everything looks like a nail.

By then, he was past the time period during which “clot buster” drugs can save the brains of stroke victims, and so his brain was probably already permanently damaged.  But his jailers did not notice this.  He was not transported to Tampa General Hospital until twelve hours later, almost 36 hours after he suffered his stroke.

He held on for three months before he died.

The Hillsborough County Sheriff’s Office gave the following statement to the Tampa Bay Times:  "It is clear that mistakes were made by Hillsborough County Sheriff's Office employees and contracted medical staff employed by Armor Correctional Health Services."

The two parties reportedly paid a million dollar settlement to the family.  I doubt that this will make their pain go away.

Nor will it resolve all the troubling questions this story raises.

How could first responders and jailers fail to recognize obvious symptoms of stroke?

When did incoherent speech and paralysis become synonymous with mental illness?

And – at a time when so many wonder if there is a different standard for whites and blacks – why were Anna Brown and Allen Hicks brought to jail in the first place?

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

What We Worry About Least in the Health Policy Debate

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

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

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

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

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

Long Term Care. 

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

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

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

Medicare.

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

Research.

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

Child health.

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

Personal Responsibility and Wellness. 

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

Environmental health. 

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

Eric Cantor.

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

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

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

100 Days and Counting; 10 Things You Need to Know About Obamacare

In fewer than 100 days, the Obamacare insurance exchanges will be open for business.  Fifteen states will be running their own exchanges.  Thirty-five will be relying on the federal exchange.

Vangent, which is running the federal call center, is preparing for 200,000 calls per day between now and the first of October.

The federal government has also re-tooled its site, www.healthcare.gov, to provide up-to-date information about the exchanges.

These are parts of a massive consumer education campaign, which is badly needed.  Because as of two months ago – three years after its enactment and a year after the Supreme Court affirmed almost all of it – according to a Kaiser Family Foundation poll, 42 percent of Americans did not even know that Obamacare was the law of the land.

Obamacare is and will remain the law of the land.  And here ten things you need to know today as you prepare for it to take full effect.

One, if you are part of a family of four and your household income is between approximately $24,000 and $92,000 per year, and you have to buy your own health insurance, you will be eligible for a tax subsidy beginning on January 1.  Small employers already are, but most are not taking advantage of the credit. If you are insured through your employer, very little will change for you. 

Two, a family of four with a household income of $50,000 will receive a subsidy so large for an average insurance plan that the net cost of the premium for family coverage will be only $280 per month.  And if that is too much, there will be a less expensive choice.  A lower cost “bronze” plan will cost only $140 per month.  You can calculate your own costs by using the Kaiser Family Foundation calculator.

Three, if you are under the age of 26, then as of January 1, 2014 you will have the option of remaining on your parents’ insurance – even if your own employer offers you coverage.  But if you stay on your parents’ plan and can only pick up your employer’s during an open enrollment period, you may need to enroll in the year before you turn 26 or risk a lapse in coverage and a possible tax penalty.

Four, if you earn less than 138% of poverty and your state has expanded Medicaid, then you will have Medicaid coverage.  But if you live in one of the 20+ non-expanding states and have an income that is at or just above the poverty level, then you will be eligible for a “bronze” plan at no cost to you.  (I have an updated list of where states stand on expansion on my State Rankings page.)

Five, under Obamacare you will still get your health insurance from companies you recognize – not from the government.  Blue Cross Blue Shield will be participating in exchanges throughout the country.  United and Aetna will each be participating in a dozen or more states.  Smaller local companies will also be offering plans.

Six, pre-existing conditions will no longer disqualify adults for insurance.  The transitional health insurance program for adults with pre-existing conditions, called PCIP, has ended.

Seven, mental health benefits will finally be on a par with physical health benefits.  This isn’t just because of Obamacare.  The administration has promised that the Mental Health Parity Act of 2008 will finally take full effect before the end of the year.

Eight, soon everyone will know what an “accountable care organization” is, and chances are that at least one of your providers will be participating in one.  Although it is hard to summarize what this means in one sentence, the bottom line is that you’ll see more emphasis on preventive services, and your providers will get paid more for keeping you healthier.

Nine, the number of uninsured people will begin a march downward from over 50 million to between 25 and 30 million, and then remain at that level.

Ten, widespread opposition to Obamacare will die down over the next two years.  Part of the reason is that years of Obamacare-bashing have set the success bar pretty low.

And by 2016, the opposition may be effectively gone.  Most people will be used to paying lower net amounts for health insurance, most states will be reaping the benefits of the expanded Medicaid program, and young people coming of voting age will have never known a time when Obamacare was not a part of the national landscape.

We will be ready to move on.

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