Term Limits Are Bad for Your Health

It costs an average of $6,000 per person per year in federal, state, and local taxes to cover the government’s share of our national health care bill.

The three levels of government pay about 71%, or roughly $1.8 trillion, of our nation’s annual health expenditures.  It is no wonder that most rational people want policymakers to do more to bring these costs under control.

Policy leaders talk all the time about controlling health care expenditures.   This would help.

But if we actually want to reduce costs significantly, we have to invest in prevention and public health.  This is a position I’ve pushed in the past.  All it takes to understand why is to recognize that prevention and public health have been responsible for half of our increased life expectancy during the past century while absorbing less than 5% of our overall health spending.

This is old health policy news.  So why aren’t policymakers doing more in prevention?

The answer may boil down to two words – term limits.  Term limits, it seems, are bad for your health.

State legislators have a direct say in how roughly 40-45% of government health dollars are spent, and an indirect say in much more.  We now have almost twenty years of experience with term limit laws.  States that limit the terms of their state legislators do a worse job protecting the health of their people than states that do not.

Term limit legislation swept through half the nation in the 1990s as citizens sought to rein in the power of lifetime citizen politicians.  California, Colorado, and Oklahoma were the first states to enact them in 1990.  Nebraska, the 21^st, was the most recent in 2000.

There are currently fifteen states with term limits for state legislators.  California and Florida are the most prominent among them.  With just a handful of exceptions, none of them ranks near the top in my States for Your Health ranking, the Healthy State rankings (which focus on public health), or the Kids Count rankings (which focus on children and prevention). 

Only four of these fifteen term-limiting states – Colorado, Nebraska, California, and Maine – make even the top half of the States for Your Health.  Only Colorado, Maine, and Nebraska are in the top 20 in the Healthy Staterankings.  And only California, Maine, and Nebraska are in the top 20 in the Kids Countrankings.

Overall, the average ranking for the fifteen states with term limits is 31^st in all three rankings.  The average ranking for the 35 states without term limits is 23^rd.

Six states – Idaho, Massachusetts, Oregon, Utah, Washington, and Wyoming – enacted term limits and then repealed them.  Their average rank is 13^th in my rankings, 11^th in the Healthy State rankings, and 15^th in the Kids Count rankings.

The reason term limits have such a significant effect on the health of a state’s population may be because term-limited politicians don’t have the time to come up to speed on complex health issues.

Election to office or appointment to a legislative committee does not make one an instant expert on policy.  And term-limited politicians are often political lame ducks the day they get elected, with no incentive to work on issues with a long-term policy payoff.

Public health and prevention initiatives demand patience, with payoffs often measured in decades, not four two-year terms.  For example, reducing smoking prevalence from 42% of the U.S. population in 1965 to 21% in 2006 required a generation of a Surgeon General-led public education campaign, bans on smoking in public places, increased cigarette taxes, and restrictions on sales of tobacco products to minors.  Saving billions in cancer and heart disease costs required this level of ongoing effort.

It also required having in place long-term legislators with whom tobacco lobbyists had to deal.

When the top-ranked state for health, Massachusetts, passed its health reform legislation in 2006 that led to near-universal coverage in the state, two legislators who spearheaded the effort – the Speaker of the House and the President of the Senate – had been in office for 27 years and 13 years, respectively.  And in Connecticut, my second-rated state for health, the current Speaker of the House has been in office for 19 years, and the Senate President has served for 18 years.  Both have considerable achievements in health and environmental health during the past decade – long after term-limiting states would have put them out of office.

In fifteen states, term limits have led us to trust a large portion of $6,000 a year in health spending annually to people without this experience. 

And that has proven to be very bad for our health.

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

The Worst States for Your Health

Some states do a much worse job than others of keeping their residents healthy and providing for high-quality, affordable health care when their residents need it.  People usually live shorter, less healthy lives in these states than they might if they lived elsewhere.

In my last column, I described a new States for Your Health ranking, and examined the states that finished near the top.

This week, I want to look first at why Florida, ranked first in one of the seven indicators – per capita Medicare spending on non-institution-based services – only finished 30^thoverall.

Florida’s doesn’t invest enough in public health and prevention.  It is 36^th among the states in the 2011 Kids Count rankings, and 37^th in the 2011 Healthy State rankings.  Children in poor environments for their health are more likely to develop both physical and mental illnesses as they age.  Obesity, cancers, heart diseases, and mental illnesses are all expensive, and can cut decades from life expectancy.  

Florida’s care quality rankings are much higher than its prevention rankings.  It is 11^thin the number of times its hospital programs made the U.S. News and World Report national rankings.  These high quality programs are usually found in just a few hospitals in major cities, but this is the case in most states.  It is 16^th in nurse practitioners per 100,000 residents, and 19^th best in keeping Medicaid nursing home and hospital spending under control. 

Florida is, however, is near the bottom (45^thplace) in the percentage of residents with private insurance.  That hurts.

The ten lowest ranked states either score exceptionally low in the prevention or health care rankings, or consistently low across the board: 

50. West Virginia.  The lowest-ranked state isn’t at the bottom in any individual ranking.  It is just near the bottom everywhere – 40^th in the percentage of people with private insurance, 43^rd in the Healthy State rankings, and 44^th in Kids Count.  It broke into the top half in only one ranking, the amount its Medicaid program spends on hospitals and nursing homes.  Even that may not be such a good thing.  While low Medicaid spending on institutions was considered positive in this ranking, it is also an indicator of low spending on health care in general.

49.  Louisiana. Louisiana finished next-to-last in both the Healthy State and Kids Count rankings.  That’s why it’s 49^th here, too.  On the other hand, it was 2^ndin per capita community Medicare spending, and has some quality hospital programs.  It clearly has assets on which to build.

48.  Mississippi.  Mississippi is last in the Kids Count and Healthy State rankings, and next to last in percentage of people with private insurance.  However, it is in the top ten in community-based Medicare spending and in the number of nurse practitioners per 100,000.  Both could contribute to a healthier state in the future.

47.  Oklahoma. Oklahoma is in the bottom ten in nurse practitioners, Kids Count, and Healthy State rankings.  It is also one of 18 states with no highly ranked hospital programs.

45t. Arkansas.  Arkansas’s profile looks similar to some of the others at the bottom.  It has low prevention ratings that bring down its overall ranking, but it is near the top in number of nurse practitioners and limiting Medicaid hospital and nursing home spending. 

45t. Kentucky.  Kentucky isn’t near to the bottom in any single indicator.  It is just consistently weak across the board.

44. New Mexico.  New Mexico is in last place in the percentage of people privately insured.

43. Nevada.  Nevada is in last place in the number of nurse practitioners.

42. Alabama.  Alabama ranks low in prevention and primary care rankings.

41. Montana.  Montana is as high as 25^th in the Healthy State rankings, but it lags in Kids Count and all of the health care rankings.

Two states finished last in individual rankings but did not make the bottom ten.  South Dakota was at the bottom in community-based Medicare spending per capita, but ranked 29^thoverall.  New Jersey spent the most from its Medicaid program on hospital and nursing home care, but still finished 9^th overall.

To see the complete rankings, click here.

If there is a bottom line, it is this.  Despite our discouragement with our public health and health care systems in general, people in nearly every state have at least something for which to be thankful.  And there will be better days ahead for all of us if policy leaders understand that we want them to do more for our health, not less.

Happy Thanksgiving!

The Best States for Your Health

When the Supreme Court reviews the constitutionality of the Affordable Care Act next year, it will do so against the backdrop of both a national sentiment for government to do more in the area of health and significant inequalities in access to health and health care based solely on the states in which people live.  

A new poll released last week by the Robert Wood Johnson Foundation and the Harvard School of Public Health found that 52% of Americans want government to put more resources into health. 

Only 41% gave high grades to our health care system, and only 33% gave our public health system high grades.

We would all like a more effective health and health care system.  But a better national delivery system would make a much bigger difference in some states than in others.

This week, Our Health Policy Matters unveils a new ranking of the states that reflects which states invest most effectively in our health and health care. 

It was created by combining four existing rankings and three new ones.  It includes mental health as well as health, the work of other health professionals in addition to doctors, and availability of community care as well as quality institutional care.  It ultimately rates the states based on how good they are at simultaneously:     

• keeping their children and adults healthy; and 
• taking care of their residents when they are sick or have chronic conditions; and 
• providing for both health and health care at a price their residents can afford. 

Taking everything into account, here are the ten best States for Your Health, and why:

1. Massachusetts.  Massachusetts is the only state with five top five finishes among the seven rankings.  It takes good care of its children, invests in wellness and prevention, has many top-rated hospital programs including one of the highest rated mental health facilities in the country, and insures its population well.  Where health and health care are concerned, every state should want to be more like Massachusetts.
2. Connecticut.  Connecticut is near the top in six of the seven rankings.  Its children, working adults, and elders all thrive on a rich set of high-quality prevention and health care services. The only ranking in which it did not excel was one that measured affordability – the high amount its Medicaid program historically spends on hospital and nursing home care. 
3. New Hampshire.  New Hampshire rates as the best state in the nation in three of the individual rankings I combined – the 2011 Kids Count child health and well-being rankings, and two Kaiser Family Foundation State Health Facts rankings – the number of nurse practitioners per 100,000, and the percentage of people who are privately insured.
4. Vermont.   Vermont is number one in the Healthy State rankings and in keeping its Medicaid hospital and nursing home costs under control.  It has figured out that the best way to control Medicaid spending is to keep its population healthy.
5. Utah.  Utah proves that good health is a conservative value.  It takes good care of its children, promotes healthy lifestyles among its residents, and is home to a high percentage of residents with private employer-based insurance – a key measure of affordability.
6. Minnesota.  Strong in the prevention and public health rankings, Minnesota is also home to a top hospital.  It gives its residents access to quality public health and quality health care at the same time.
7. Washington.  Washington cracked the top ten in only one individual ranking, so it may be a surprise that it is ranked so high when they are all combined.  But it does just about everything well compared to other states, and isn’t close to the bottom in any category. 
8. Hawaii.  Hawaii scores high in prevention and keeps Medicaid institutional spending under control.  It doesn’t have any of the top rated hospital programs.  If it did, it would rank even higher.
9. New Jersey.  New Jersey does especially well by its children and its elders, and is in the top ten in three individual categories.  But it is an expensive state for Medicaid recipients to get sick in, and a lot of that money goes to hospitals and nursing homes. 
10. Wisconsin.Like Washington, Wisconsin is consistently in the top half of the individual rankings.  If its residents were able to spend relatively more of their Medicare dollars on community services and less on institutional ones, it would move up.

There are two states that topped individual rankings that didn’t make the top ten.  California, according to US News and World Report the best state in the nation to find high quality hospital programs, tied for 15^th.  Florida, first in per capital Medicare spending on community services, finished 30^th. 

To see the full ranking of all the states, click here.

Next week:  More about why Florida finished where it did, and a closer look at the ten states that finished near the bottom.

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

Note: Here are the rankings I used, the reasons I used each of them, and a link to the 

original data: 

• the 2011 Healthy State Rankings and the 2011 Annie E. Casey Foundation Kids Count state rankings – to measure the effectiveness of public health and overall prevention (including mental illness prevention) activities; 
• the Kaiser Family Foundation (KFF) State Health Facts ranking of the percentage of people with private employer-based insurance – to measure health care access and affordability for workers and families; 
• the KFF State Health Facts ranking of the number of nurse practitioners per 100,000 residents – to measure support for non-physician providers and high quality primary care;
• To measure quality of care and medical professional development, I calculated and ranked the states by the number of times a hospital in a state was included in the 2011 U.S. News and World Report rankings of best hospitals in the country across specialties, including mental health and overall rankings of children’s hospitals (33 states had at least one hospital mention);
• To measure the availability of community-based services for elders, I used the most recently available data from the Centers for Medicare and Medicaid Services reporting per capita state spending in each state on Medicare minus hospital and nursing homespending;
• To measure the effectiveness of state intervention to keep people with disabilities in their homes and out of institutions and as a measure of affordability, I used CMS data to calculate per capita state spending on Medicaid hospital and nursing home care as a negative measure.

Because prevention and health care each account for approximately 50% of the gains in life expectancy over the last century, I gave the two prevention-oriented rankings – the Healthy State and Kids Count rankings  – a combined weight equal to that of the other five.  

Veterans Dazed, Not Dazzled, By Mental Health Care

Nearly 2.1 million veterans received mental health care from the Veterans Administration between 2006 and 2010.  According to a Government Accountability Office report released in October, 1.2 million veterans received mental health treatment in 2010 alone.

Almost 30% of the 7.2 million veterans who received treatment from the VA received mental health treatment.  So did 38% of Iraq and Afghanistan (“OEF/OIF”) veterans.  Many more probably needed it. 

The GAO report shows how pervasive mental illness is among veterans, and how co-occurring mental illnesses overwhelm both veterans and their service delivery system.

Younger veterans and reservists are especially affected.

We now have over 22 million living American veterans, but only 4 million served during World War II or the Korean War.  Seven million served during the Vietnam War, and almost 6 million are OEF/OIF veterans. 

OEF/OIF veterans accounted for 12% of all those receiving VA mental health services in 2010, a three-fold increase in just five years.  The GAO said this was expected “because of the nature of OEF/OIF veterans’ military service – veterans of this era typically had intense and frequent deployments.” 

Another October 2011 report entitled Losing the Battle: The Challenge of Military Suicide quantifies the tragic effect of this.  We lost 33 active and reserve duty Army personnel to suicide in July 2011 alone, and veterans – less than 10% of our population – account for 20% of all suicides in America.

There are three reasons why we lose so many veterans to suicide.  They are

• Traumatic brain injury, resulting in disability;
• Chronic pain from bodily injury; and
• Post Traumatic Stress Disorder (PTSD).

PTSD is far and away the most significant of these reasons.  I wrote about this in an earlier column.  As both the GAO report and the chart accompanying this column show, nearly half of the veterans receiving VA mental health care in 2010 had PTSD.  Most had at least one other mental health diagnosis, too.

It is a national failure that we don’t do a better job of identifying suicide risk factors and intervening earlier.

VA screening protocols may be part of the reason.  The authors of Losing the Battle report that returning veterans have historically been discouraged from admitting to mental health problems as they fill out their post-deployment screening forms.  As a result, the GAO reports the VA now “requires veterans treated in primary care settings to be screened for mental health conditions such as PTSD, depression, substance abuse disorders, as well as a history of military sexual trauma.”

And it turns out that veterans are more dazed than dazzled by the mental health care they are offered.

They avoid it, the VA told the GAO, because of stigma, lack of understanding about available services, logistical challenges accessing health services, and concerns about the quality of VA care.

• Mental illnesses are stigmatizing largely because many people still believe that they are “behavioral” weaknesses, not serious and life-threatening diseases that can shorten life expectancy by 25 years.
• Many also believe that services are only for people who are severely mentally ill.  They avoid seeking care for fear they will be labeled “whiners” and “psychosomatics.”
• Veterans, reservists, and non-veterans have logistical challenges in accessing services.  The VA does not have a full complement of mental health providers.  At least those they have get paid.  Major insurance companies are cutting reimbursements to community mental health providers, so patients who find providers outside of the VA often can no longer afford the out-of-pocket cost.
• It is impossible to have a quality mental health care system unless non-mental health professionals don’t just screen for – but are trained in managing – mental illnesses.

A 2009 SAMSHA reportfound similar reasons given by the 5.1 million civilians who also reported unmet mental health needs.

We can begin to fix this if we do four things:

1. Commit a fraction of the resources we committed to the wars to fight the mental illnesses they have caused – in the VA and in the community, wherever veterans, reservists, and non-veterans receive services.
2. Increase training of primary and specialty care providers so they recognize, diagnose, manage, and refer patients with mental illnesses.
3. Make periodic mental health screening a part of wellness exams for everyone, starting with young children.
4. Insist that insurers honor the mental health parity mandate.

We remember the sacrifices of our veterans when we fly our flag.  We honor those sacrifices when we take care of the men and women who made them.

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The Growing Obesity Challenge

Obesity is a disease, just like cancer, heart disease, mental illness, and addiction.  That’s the message of experts at a recent Future of Medicine summit on the subject.

And there are missing pieces in the way states with some of the largest concentrations of obese residents, like Florida, Connecticut, Texas, California, New York, and New Jersey, approach the epidemic.

As recently as 25 years ago, obesity was uncommon in America.  Most states didn’t even collect data on it, and not a single state reported obesity in more than 15% of its population.  Connecticut and Florida both reported rates under 10%.

The CDC map at that link shows what has happened since.  Every state in the country quickly grew bigger. 

By 2010, in 12 states, including Connecticut, between 20% and 25% of the population was obese.  In 24 states, including Florida, between 25% and 30% of the population was obese.  In the remaining 12 states, including Texas, over 30% of the population was obese.

Why has this happened at a time when people arguably have become more health conscious than ever before?   

The reasons that are emerging from research are changing the way experts think about obesity.  If policy makers listen to the experts, then this will change the way they attack the problem, too.

According to the research, obesity is not the result of an exercise of free will to overeat, any more than drug dependence is the result of a desire to overmedicate.  Dr. Paul Kenny of the Scripps Research Institute, a member of the expert panel convened by the Palm Beach County, FL Medical Society, argued that low-quality, high calorie food is proving in laboratory studies to be nearly as addicting as cocaine.

He and others say that we must use a disease model to attack obesity.  We must prevent it whenever we can, and treat it aggressively when it is present.

Unfortunately, identifying a single cause of obesity is elusive.  Dr. Kenny suggested that no single obesity gene will be found.  Dr.Ronald Romear, a practicing pediatrician, said that “in eighteen years, I haven’t seen the thyroid as a cause” for any of the obesity in the children he treats.

Investing in prevention, therefore, is imperative, and this has become the first line of attack against obesity in the public policy arena.

The American Academy of Pediatrics and public health professionals both favor the 5-2-1-0 campaign.  Children and adults are urged:

*  to eat five servings of fruits and vegetables a day,

*  to limit television, computer, and video game play to no more than two hours a day,

*  to exercise at least one hour a day, and

*  to drink zero beverages sweetened with sugar. 

Focusing on individual behavior is important.  As I wrote in an earlier column, there are also broader, community prevention strategies for states to consider.  They could regulate the amount of sugars added to foods and drinks.  They could make an hour of physical education a mandatory part of the school day, and they could offer safe outdoor play areas in all neighborhoods.   

Aggressive treatment is also part of the arsenal against obesity when it has progressed to critical stages.

Bariatric surgeries, such as lap band and gastric bypass, are becoming more common.  Dr. Andrew Larson, a bariatric surgeon on the panel, noted that 45 state Medicaid programs pay for bariatric surgeries.

But, in the disease treatment model, what are largely being ignored by states are the treatment options between prevention and end-stage obesity surgery – primary care integration and behavioral health intervention.

Some argue that primary care providers must play a bigger role in treating obesity in its early stages.  However, primary care providers need tools and resources – including adequate reimbursement for their time – to identify and treat those at risk, and they don’t currently have them as a matter of policy.  

And with addiction at the heart of obesity, states should recognize the importance of mental health services like counseling.  They should make Medicaid coverage for counseling part of the anti-obesity campaign.   

According to a recent George Washington University publication entitled Coverage of Obesity Treatment, neither Florida nor Connecticut (nor most of the high-concentration states) does.

Some of us undoubtedly shake our heads, wondering why government should address what we see as personal choice and weakness. 

But if the experts are correct, then obesity today is no more the result of human weakness than cancer or heart disease, and it is in the public interest that we do more about it.

Cain Not Able

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

Here are our current major health policy challenges:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Will you buy it?  Apparently not.

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

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

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

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

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

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

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

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

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

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

Why so few?

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

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

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

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

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

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

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

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

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

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

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

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

Supreme Court Ruling Against Individual Mandate Could Result in Care Denial to Poor

Opponents of the Affordable Care Act (ACA) are now looking to the Supreme Court to overturn the 2010 law before time runs out on them.

After ACA became law eighteen months ago, they were optimistic that they could beat back several of its key provisions.  These included the minimum medical loss ratios, the expansion of Medicaid, the health insurance exchanges, and the individual mandate.

A brief review of the current status of each shows why the individual mandate is the last one standing.  But as the arguments for and against it have crystallized in the Courts, they show how the Supreme Court could open a Pandora’s Box best left closed.

 Minimum loss ratios

ACA mandates that all private insurance plans will have to pay at least 80 to 85 cents in benefits for every premium dollar collected, or rebate the difference to policy holders beginning in 2012.  Opponents argued that many existing plans would be forced out of the market because of high administrative costs.

However, the federal government has approved several short-term waivers from the requirement, deflating opposition.  Also the Center for Medicare and Medicaid Services has told Florida that it must meet the 85% minimum loss ratio in its public Medicaid program, too.  Once private insurance rebates start to flow to consumers in 2012, the remaining opposition will likely melt away.

Medicaid Expansion

Beginning in 2014, everyone below 133% of poverty will be eligible for Medicaid.  The 26-state lawsuit against the ACA – the one most likely to be taken up by the Supreme Court this term – argued that the Medicaid expansion imposed an unconstitutional financial burden on the states.

But the Courts have already ruled against the states on this one, and so the Medicaid expansions will go forward in two years unless Congress changes the law.

Health Insurance Exchanges

Beginning in 2014 states will have to have exchanges through which consumers will purchase health insurance.  Only plans offering the minimum benefits mandated by ACA can be offered on the exchanges.  Some state regulators argued that they did not have the authority to enforce the “minimum benefit provisions” mandated by ACA.  Florida decided to establish its own exchange that will not meet the ACA requirements.

However, a dozen other states are already moving forward with their approved exchanges, undercutting “lack of state authority” argument and putting Florida out on a limb.   

The Individual Mandate

Beginning in 2014, a system of subsidies and penalties will go into effect to encourage people to purchase health insurance.  Those making up to 400% of poverty will receive subsidies for health insurance, but all those above 133% of poverty who refuse to purchase insurance will have to pay a federal income tax penalty.

The crux of the legal argument against the individual mandate is that it is unconstitutional for the Federal government to impose a tax penalty on an individual for refusing to purchase a consumer product.  However, opponents have conceded that it would be Constitutional to impose such a mandate at the time of service.

Judge Stanley Marcus, one of the judges who heard the appeal that may now go before the Supreme Court, made this clear in his dissent.

He wrote that “the plaintiffs and, indeed, the majority have conceded, as they must, that Congress has the commerce power to impose precisely the same mandate compelling the same class of uninsured individuals to obtain the same kind of insurance, or otherwise pay a penalty, as a necessary condition to receiving health care services, at the time the uninsured seek these services.”

So what the Supreme Court is being asked to decide is not “if” the individual mandate is constitutional, but “when.”

Some legal experts don’t think that there is much of a distinction in this. 

But if the Supreme Court feels differently, and ultimately decides that it is Constitutional to impose the tax at the time of service, but not in advance, then this may well open up a Pandora’s Box that we would all rather stay tightly closed and locked.

Even a narrow ruling against the “pre-tax” could have a far-reaching unintended consequence for indigent, uninsured people.  These people include many of the over 50 million uninsured people today and the 22 million who will still be uninsured after ACA implementation.  A Supreme Court ruling that holds that people could be forced to pay at the time of service could also be construed as permitting providers to deny care to those who cannot afford it.

Opponents hope that a Supreme Court ruling against “pre-taxing” will result in a political unraveling of the law. It could well happen, but not in the way they intended.

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

Florida's Shame is Connecticut's Gain

The next time Florida’s Governor tells you that the only way to create private sector jobs is to cut public sector health spending, don’t believe him. 

According to news reports, the Governor’s Office is already warning state health agencies to expect more budget cuts in 2012.  He wants the dollars to implement his 7-7-7 plan to create 700,000 jobs in 7 years.

source: US DOL data, 2011

How’s the plan working out for Florida so far? Dismally, by two different measures.  The first is the 2011 state unemployment claims data.  The second is the story of why Florida just lost another 7,500 jobs in health research.

The 2011 unemployment data show that Florida’s Governor has been more effective at killing jobs than creating them.  The week before Governor Scott took office, 14,139 Floridians lost their jobs and filed new unemployment claims.  In 36 of the 37 weeks since then, the number has been higher than that.  Another 15,713 Floridians filed new unemployment claims during the most recent September week for which data are available. 

To add insult to injury, there was a press conference a thousand miles away in Connecticut last week that explained why Florida’s job creation performance has been so dismal this year. 

 Jackson Laboratory, a Maine-based company, announced that it will build a new, $1.1 billion research lab on University of Connecticut Health Center property in Farmington, Connecticut.  The lab will produce over 661 new research jobs, support 842 construction jobs,  and create an estimated 6,200 spinoff and indirect jobs.

Jackson carries out cutting edge research in the genetics of Alzheimer’s disease, cancer, and diabetes prevention.  Landing the company was a huge victory for Connecticut.  A source close to Connecticut’s Governor reportedly proclaimed that it “will make Connecticut a world leader in the science of genomics.” 

This was all supposed to happen in Florida, as a part of that highly-touted 7-7-7 plan.   But in June, Jackson announced that it had “withdrawn” its request for $100 million from Florida to locate in Sarasota.  In its June release, its Executive Vice President was gracious, but clear, about why it went elsewhere.   “We respect that the state had to make difficult priority decisions in order to balance the budget this year,” he said.  But the lack of dollars “and the uncertainty of future funding made such a venture too speculative to undertake responsibly.”

In a story last week, the Hartford Courant, Connecticut’s newspaper of record, offered up a slightly different, and blunter, quotation from a company official.  It reported that a “Jackson source said ‘politicians in Florida took a dramatic, hard turn to the right, and funding dried up.’"  

One local Florida health leader recently said that “we used to just show ‘em a palm tree” to get people to relocate to Florida from the north.  Apparently, Florida can no longer sell itself to actual job creators on good looks alone.

As a result, the University of Connecticut – instead of the University of South Florida – will reap the benefits of a billion dollars of private investment in one of the most rapidly growing areas of health care.  In return for a $192 million loan and $99 million in support of research, Connecticut, instead of Florida, will get over 7,500 new jobs.

CT News Junkie, an online publication, rubbed it in with a headline article on September 30^thentitled “Florida’s Loss is Connecticut’s Gain.”  In the accompanying photo, Jackson Laboratory CEO Edison Liu is shown holding up a UCONN tee shirt as UConn’s President speaks, flanked by the Speaker of the Connecticut House and the Chairman of her Board of Trustees.

This was supposed to be Florida’s photo op.  But opportunity knocked, and no one answered. 

Florida has only its “hard turn to the right” to blame for the clouds over its horizon.  That’s why over 7,500 jobs will begin to fly north this winter.

Florida should be a leader in health research and treatment, especially research and treatment in diseases affecting an aging population.  But Florida can’t lead when its elected officials are running backwards. 

Florida’s Governor and Legislature have been slashing from health and mental health programs – including public health, Medicaid, and – as it turns out – even economic development spending.  And now the Governor, who should be ashamed by what happened with Jackson, wants to slash some more.   

The next time you visit Farmington, Connecticut, take a good look at where over 7,500 would-be Floridians will be buying their homes, paying their taxes, and spending their money for years to come.  You won’t see a single palm tree.

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