Mental Health Cuts Will Lead to Increased Health Costs

On December 8, 2010, Jack Dalrymple, a Republican Governor in the safely Republican state of North Dakota, sent a budget to the state Legislative Assembly calling for an $8 million increase in funding for mental health services.

His transmittal message accompanying his FY2011-2013 proposed budget was simple. “We… need to make investments that help take care of people.  We have all been alarmed recently about teen suicide rates, especially on our Native American reservations.  These highlight the need to make more resources available for critical mental health services for our citizens.”

So, in a $3.3 billion general fund budget, he proposed over $6 million for new inpatient services, community crisis stabilization, and drug dependency treatment.  He also proposed $1 million for suicide prevention, another million dollars for mental health services on college and high school campuses, and a rate increase for mental health providers. 

He summed up these requests by saying that “the physical and mental health of our citizens is always a top priority.”

The North Dakota Legislature apparently agrees.  According to a recent report of the National Alliance on Mental Illness, the state has made up for historically low spending on mental health services over the past three years by topping the nation in increasing spending for mental health. 

As overall state mental health spending in the nation declined by $1.6 billion, North Dakota increased spending for mental health by 48.1%.

In the same time frame, South Carolina, Alabama, Alaska, and Illinois all cut mental health spending by over 30%, and Nevada, the District of Columbia, and California all cut it by over 20%.  In fact, most of the rest of the country is clearly out of step with North Dakota.

A Bloomberg News article headline this past week made clear what cuts to mental health mean: “Mental Health Cuts by U.S. States Risk Boosting Health Costs.”  The reason, as one Illinois emergency room physician pointed out, is that sick patients don’t just disappear when they are denied one set of services.  They seek out another, often more costly, alternative.

In the case of people denied mental health care, it is usually the hospital.

According to the Centers for Disease Control and Prevention (CDC), there were 2.4 million primary diagnoses of mental illness in general hospitals in 2006. In the same year, state mental health spending totaled $104 per capita, according to Kaiser Family Foundation State Health Facts data. 

CDC recently released new data for 2009.  In that year, the number of primary mental illness diagnoses decreased to under 1.6 million.  But the State Health facts data reported that state mental health spending had increased by then to $123 per capita.

In other words, during a time frame when state mental health agency funding increased by 18%, mental health diagnoses in general hospitals decreasedby 35%.

These are the facts, and there is an association here, at least for the most recent three-year period for which we have data. When states spend more on mental health as they did in 2009, fewer people with mental illness need hospitals for care.  And when states spend less on mental health, as they did in 2006, hospital use goes up.

Now that they have the facts, what are states proposing this year?

• The Florida Senate has proposed to reduce adult mental health services funding by 34%.  The House saved Florida from such a spending disaster last year; it will have to do so again this year.
• Connecticut’s Governor has proposed a $12 million cut to the Department of Mental Health and Addiction Services from the state’s already-approved FY2013 budget.
• Alabama last week announced plans to close 4 psychiatric hospitals.
• Illinois has proposed cuttingtwo psychiatric hospitals and a host of community health centers throughout Chicago.
• Mississippi is proposing a 5% cut to mental health that could result in the closing of six mental health facilities throughout the state.
• The Pennsylvania Governor’s newly proposed budget will cut Philadelphia by $42 million in mostly mental health and addiction services funding, according to information provided by the Mental Health Association in Pennsylvania.

Do you detect a pattern here?

Proponents argue that these cuts are being made in the name of fiscal responsibility, but they don't have the vision to see the forest beyond the trees.  Every one of them will make people sicker, state costs higher, and an already bad situation worse.

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

The 13,386 Lives Congress Sacrificed Last Week

“I will keep them from harm and injustice.”

“I will prevent disease whenever I can, for prevention is preferable to cure.”

-Classic and modern versions of the Hippocratic Oath, from MedicineNet.Com

Senator Tom Coburn of Oklahoma is a physician.  He’s familiar with the Hippocratic Oath, and has used it to explain his opposition to health care reform.

Last November, Senator Coburn famously termed a $15 billion appropriation for public health and prevention a “slush fund.”  That’s because it was paying for community tobacco control programs, immunization activities, and addiction disorder prevention and treatment services around the country. 

For information on sources, see note below

“Prevention is about focusing on an individual patient,” he commented, apparently forgetting everything he learned about epidemiology at the University of Oklahoma’s College of Medicine and at least some of the words of the Hippocratic Oath.

Public health is the basis of health promotion and disease prevention. 

It focuses on the well-being of entire populations and communities.  It gets only 3% of our total health funding according to CMS data.  It has been responsible for at least half of the increase in life expectancy in America in the last century.

Now it is going to get even less funding, because Senator Coburn’s view has prevailed. 

Last week, his Congressional colleagues – in approving what was described as the last significant piece of legislation like to pass this year – agreed to cut $5 billion from the public health fund.  (Senator Coburn voted against the final bill, but not because it cut public health funding.)

We now know how many lives that $5 billion cut to public health will cost. 

This is because of an article written by Glen Mays and Sharla Smith and published last July in Health Affairs.  In that article, the authors showed that increasing spending on public health reduces infant deaths and deaths from cancers, heart disease, diabetes, and other chronic illnesses. 

They found that a 10% difference in public health funding is associated with a 6.9% difference in infant deaths, a 3.2% difference in heart disease deaths, a 1.4% difference in diabetes-related deaths, and a 1.1% difference in cancer deaths.

The CMS tally of U.S. spending on public health in 2010 was $78 billion.  A $5 billion dollar cut represents 6% of that total.

So that 6% cut this year will be associated with the following:

• 1,077 additional infant deaths;
• 7,831 additional deaths from heart disease;
• 617 additional deaths attributed directly to diabetes;
• 3,861 additional deaths from cancer.

Let’s be clear.  Mays and Smith were careful to point out that we can’t say that lower public health spending causes more deaths – but the association is real.  The amount of disease and death go up as public health spending goes down.

There are two levels of irony in the vote.

The first is that, before this happened, Mays and Smith cited the public health fund as evidence of Congress’s increasing awareness of the value of public health.  So much for awareness.

The second is that Congress decided to use the $5 billion to pay physicians to see Medicare patients who suffer from conditions like heart disease, cancer, and diabetes.

Physicians needed that so-called “doc fix.” Congress caused the problem way back in 1997 when it adopted a Medicare reimbursement formula with a flaw. 

Ever since the flaw became apparent a decade ago, Congress has plugged the reimbursement hole it created one year at a time, kicking the solution another year down the road.  After ten years of kicking, the hole is so large that doctors’ reimbursements would have been cut by 27% without the plug.

Kaiser Health News has an excellent summary of the doc fix dilemma on its web site for those who want to read more about it.  Because Congress won’t fix it for good, doctors are forced to waste their time and money lobbying for a fix every year.

Physicians are undoubtedly relieved that they came out okay again this year, but I seriously doubt that most of them would have wanted the money to be taken from public health.  After all, they’ve all sworn the same Oath as Senator Coburn.

But here’s the important question.  When Congress is able to afford $40 billion in oil and gas tax subsidies over the next ten years for hugely profitable companies, how come, when our health and well-being is concerned, it has to be either/or – and at the expense of thousands of lives?

Note on Source Data for Lives Lost Calculations:  Sources for numbers of deaths attributable to cancer, diabetes, heart disease, and infant mortality were websites of national chronic disease advocacy organizations and U.S. Government (CDC).  Death calculations were made by OHPM using the one-year death total for the most recent year available (usually 2010) and applying a 6% change factor.  The implicit assumptions is that if the 6% cut were to become annualized, so too would the annual number of increased deaths.

If you have any 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.

The Contraception Exception

In arguing last week for the “contraception exception,” did Catholic Bishops – whose compassion for human beings is generally second to no one’s – really mean to open the door to those who would deny people access to other needed prevention services?

To recap, the Obama Administration announced that birth control had to be a part of employer-based health insurance plans.  Contraception is considered preventive health, and the Affordable Care Act mandates this and many other prevention services be offered free of charge.

The Catholic Bishops objected strongly.  They are morally opposed to birth control, and argued that, as an employer, the Church should not be compelled to pay for prevention services it deems immoral.

The Obama Administration then announced a compromise.  No religious institution would be required to pay for contraception services in its health insurance plan, but insurers would still have to cover the services for women who wanted them.

On Friday, it appeared that Catholic leaders would accept the compromise. 

Cardinal-designate Timothy M. Dolan, who heads the U.S. Conference of Bishops, called the Administration’s announcement “a first step in the right direction” of “preserving the principle of religious freedom.”

But by Saturday the U.S. Conference had issued a strong statement declaring that “the only complete solution to this religious liberty problem” was “to rescind the mandate of these objectionable services.”

Some commentators have taken a cynical view about the Bishops’ statement, arguing that they’re out of touch with the 99% of U.S. women who have used birth control. 

In the past, governments have preserved access to ethically controversial services, including contraception, abortion, and capital punishment, while assuring that no one with an objection had to pay or participate.

As Kaiser Health News pointed out in a February 8^th blog, over half the states required coverage of contraception services before the passage of the Affordable Care Act, and twenty of those had some form of exemption for religious institution employers.

The Bishops’ Saturday statement breaks new ground in demanding that a prevention “mandate” be rescinded. 

It has the potential to change the way we make public policy regarding both prevention and health care services in ways the Bishops themselves would not support.

Historically, we have protected most religious objections to health care treatment.  But we haven’t allowed a religious organization to run roughshod over nonbelievers.  Jehovah’s Witnesses, for example, can refuse blood transfusions, but they can’t deny them to a non-believer. 

But it is a prevention service to which the Bishops seek to deny access, not a health care treatment service. 

The Bishops argue that this is just about their rights under the first Amendment to the Constitution, which reads in part “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof.”  

However, we also have a Ninth Amendment which reads:  “The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.”   In other words, the Church’s First Amendment rights don’t come at the expense of someone else’s Ninth Amendment rights.

So then everyone must be given the opportunity to maintain their health by accessing whatever prevention services they need, consistent with their own religious and secular beliefs – unless we do not have a Constitutional right to health.

That last part is the door the Bishops – who also support universal health care – have now cracked open.

By creating a Constitutional objection to some prevention services under the Affordable Care Act, they are inviting others with less life-affirming goals to make theology-based Constitutional objections to other prevention services, too.

There are policy leaders in this country who don’t believe that people have a “right” to health.  They see health care as a commodity, subject to the whims of the free market.  They don’t support insurance mandates – for contraception, prenatal care, child health, or anything else.  You can already see them piously wrapping themselves in the Bishops’ cloaks. 

It is a slippery slope for Bishops – who on Saturday also reiterated their support for “access to life-affirming healthcare for all” – to cast their lot with these “unchristian” people. 

If the Bishops are true to their beliefs, they will speak out in the coming days as forcefully to these policy leaders as they did to the President – about why they supported health care for all in the first place.

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.

Is Medicare for All on the Horizon?

We’re now just a little more than a month away from the day the Supreme Court will hear the arguments that determine the fate of the Affordable Care Act.  

The fight will be narrow – about the constitutionality of the individual mandate and Medicaid expansions.  

The consequences for health care financing, however, will be widespread.

And, ironically, both states rights conservatives and pro-national health insurance progressives may end up rooting against their own positions.

To understand why, consider the four ACA Supreme Court issues that will be argued. 

The first is the constitutionality of the individual mandate under the Commerce Clause of the Constitution. 

To be constitutional under the Commerce Clause, a law has to regulate economic activity that “has a substantial effect” on interstate commerce. 

While it may seem that all the activity under ACA will have a substantial effect on interstate commerce, Judge Vinson in Florida disagreed.  In considering the individual mandate, he found that the failure to purchase insurance by an individual is economic “inactivity,” not “activity.” For Judge Vinson, there’s no distinction between economic inactivity and non-economic activity. (I’m not so sure.)

Two times – in 1995 and again in 2000 – the Supreme Court held that non-economic activity wasn’t covered under the Commerce Clause.  So if the Supreme Court agrees with Judge Vinson, then the individual mandate won’t be constitutional under the Commerce Clause, and the Court will have to consider the second issue.

Is the individual mandate constitutional under the taxing authority of Congress?

If the Commerce Clause doesn’t make the mandate constitutional, then the Anti-Injunction Act might.  It prevents anyone from challenging the right of Congress to collect taxes. 

But even though ACA forces people who don’t buy insurance to pay higher income taxes, Congress specifically referred to these as “regulatory penalties.”  So is a tax by another name still a tax?  If it is – as the Fourth Circuit Court ruled – then the individual mandate is probably constitutional. 

But let’s say it isn’t.

Then the third issue becomes important – whether the individual mandate can be “severed” from the rest of the law. 

Some laws state explicitly that if one section of the law falls, the rest still stand.  But ACA doesn’t.  So it’s up to the Court to decide what happens to ACA as a whole if it finds the individual mandate unconstitutional.

So far judges who have ruled the mandate unconstitutional have disagreed about its severability.

One judge (Hudson) said it was severable, citing a 2010 Supreme Court ruling. When portions of a law are unconstitutional, all that should be thrown out were “problematic portions while leaving the remainder intact.” 

Another judge (Connor) also found it severable, but not from the entire law.  He said that the sections of the law that prevent insurance companies from denying coverage based on pre-existing conditions and prevent higher rates based on health condition, geography, or gender are intertwined with it.  So he found these unconstitutional, too.

A third judge (Vinson) ruled that the individual mandate wasn’t severable, but essential to ACA’s overarching goal.  He therefore decided that the whole law was unconstitutional.

The individual mandate was originally developed as an alternative to single-payer, government-funded, universal health care coverage.  But the fourth issue – whether ACA’s Medicaid expansion is constitutional – may now glue the two together.

The 26 states opposing the Medicaid expansion aren’t arguing against it per se, but against the federal government “coercing” them into implementing it.  In other words, government health care is fine, but not if states have to pay. 

This year, these and other states are proposing disturbing cuts to safety net health services.  Florida is considering a proposal to turn most state health services over to counties .  The Governor of Maine wants to remove 65,000 adults from the Medicaid program.  Louisiana just announced a new round of cuts to local mental health providers.  And Connecticut has begun denying some Medicaid coverage to kids with disabilities.

It’s as if they collectively believe that any problem can be solved by taking money away from it.

Here’s what they’re ignoring.  When you oppose requiring either individuals or states to pay for health care, you’re left with only one viable future option – federally-financed Medicare-for-all.

On the other hand, when you defend ACA as it is, you’re arguing that a two-tiered system of government-subsidized private health insurance for those who can afford it and public insurance for the poor and elderly is the solution to our health care financing crisis.

So when the Supreme Court decides, who wins?

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.

California Screaming

I first heard about James McGillivray, Lloyd “Jim” Middaugh, and Paulus “Dutch” Smit about a month ago, though not by name.

A tiny news crawler reported that three men were victims of a serial killer in southern California.

James McGillivray’s body was found near a Placentia, CA, shopping mall on December 21^st.  53 year-old McGillivray hung out almost every day at the mall.  Regulars there called him humble, unobtrusive, and a “nice guy.”  A 17 year-old commented “I don’t know why someone would kill him.”  McGillivray was sleeping when he was attacked and stabbed to death.

Jim Middaugh’s body was found along a riverbed trail in Anaheim on December 28^th.  He was also stabbed to death as he slept.  After his death, his mother – to whom Middaugh was exceptionally close – described her six foot, four inch son as a “gentle giant.”

Dutch Smit was 57 years old when his body was found outside a Yorba Linda public library on December 30^th.  He left three children and 10 grandchildren.  He was described by his daughter as “an honest and sincere soul.”  He enjoyed the library, often sitting and reading quietly for hours on end. 

McGillivray, Middaugh, and Smit had one thing in common.  

They were targeted for death because they were homeless.

The police considered McGillivray a “loiterer,” but his homelessness may have been tied to his drinking.  According to the National Coalition for the Homeless (NCH), a 2008 survey identified substance use as the leading cause of homelessness among single adults.

Smit, who called himself a wanderer, not a transient, was a hoarder who left his home when it became too unsafe to live in.  Hoarding is a symptom of mental illness.  Mental illness is the third leading cause of homelessness among single adults.

Middaugh lost his transitional living apartment for sex offenders after he had lunch with a friend at a Chinese restaurant that was too close to a public park where children might be playing.  He had been convicted for “lewd and lascivious acts on a minor under the age of 14.”  But the crime for which the 42 year old was still being punished had occurred more than twenty years in the past.

80% of crimes of violence against homeless people are committed by people under the age of 30. 

The suspect in the executions of McGillivray, Middaugh, and Smit is 23 years old.  Itzcoatl Ocampo, of Yorba Linda, CA, is a former Marine who served in Iraq.  As a Marine, Ocampo was reported to have earned at least four medals and commendations.

Ocampo was caught with blood on his hands on January 13^th, while executing a fourth homeless man, John Berry, a 64 year-old Vietnam Veteran.  Ocampo targeted the others simply because they were homeless, but apparently attacked Berry as retaliation after Berry spoke out in the media about the murders.  During the assault, a Good Samaritan intervened and chased Ocampo down. 

Police and prosecutors seem certain that Ocampo does not suffer from PTSD or other mental illness, but his attorney is not so sure.

There is no doubt that the Good Samaritan, 32 year old Donald Hopkins, now does.  He is receiving counseling after witnessing the violence because the scene keeps playing over and over again in his head.

This story – and the relative lack of national news attention it has received – bothers me a lot. 

Perhaps it is because of the way we treat homeless adults.  Of 235 cities surveyed by NCH, 33% prohibit “camping,” 30% prohibit “sitting or lying,” and 47% prohibit “loitering,” all of which are often selectively enforced against homeless people.  Of the ten "meanest cities" toward people who are homeless, three are in California, but my home state of Florida is home to four – St. Petersburg, Orlando, Bradenton, and Gainesville. 

Or maybe it is because we ostracize even children with behavioral health conditions, setting many of them on their path toward isolation and homelessness as adults.  The school district in my old Connecticut home town of Middletown made news last week for forcing such children into cell-like “scream rooms.” The federal government is now investigating.

Or maybe it is because my son also happens to live in California, and is homeless, has mental illness, and self-medicates.  He has been beaten up, cited for “sitting or lying” on a sidewalk, and been in jail, but he also loves reading in libraries, has an honest and sincere soul, and has been described as a gentle giant.

But I think what screams out most to me is that these executions call attention to our deeply flawed views about homelessness, behavioral health diseases, and the victims of violence in America.  

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

The Curse of the Super Bowl Chargers

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

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

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

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

Source:  ESPN Official 2011 Roster Information

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

They are not the only ones. 

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

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

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

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

The Medicaid Elephant in the Supreme Court Room

States’ Medicaid elephants are being dragged into the courts this year.  States had better be careful, or they just might get trampled under the weight of people they’ve failed to enroll.

Last week, CT News Junkie reported the story of a class action lawsuit filed on behalf of almost 7,000 potential Medicaid recipients in Connecticut as of November 2011 whose applications were not processed within the 45 days mandated by federal law.  

And Health News Florida, among others, reported that Florida’s Attorney General Pam Bondi filed a brief with the Supreme Court on behalf of twenty-six states (Connecticut is not one of them) alleging that Congress exceeds its authority when it “coerces states into accepting onerous conditions” of participation in the Medicaid program –even when it pays 90-100% of the costs of those provisions. 

The two battles raise similar questions about how states avoid Medicaid costs today.

The Supreme Court brief is supposed to be an argument against the Affordable Care Act-mandated Medicaid expansion to cover everyone up to 133% of poverty beginning in 2014.

Bondi builds her argument around a simple point.  States depend so heavily on Medicaid money from the federal government that they can’t afford to drop out of the program.

And the ACA-mandated expansion, she argues, will cost Florida almost $1 billion.

But then there’s a stunning revelation in her brief.

Most of the costs she cites have nothing to do with ACA.  They represent the cost of enrolling currently eligible people in the Medicaid program, not those who will become eligible as a result of the Affordable Care Act. 

On page 17 of the brief, she writes that “Florida anticipates spending approximately $351 million on its share of the cost for newly eligible program participants who are presently uninsured and $574 million on the currently eligible but unenrolled.”

In other words, 62% of the costs she’s claiming will result from ACA are actually costs the state should be paying today, but avoids by failing to enroll Medicaid-eligible residents.

The Connecticut class action suit attacks essentially the same issue – failure to enroll currently eligible people.

In paragraph 25 of the complaint, the plaintiffs allege that Connecticut “has set up a system to circumvent the federal timeliness requirements by making it appear that the applicant has failed to provide required documentation.” 

Throughout the nation, these practices result in the avoidance of billions of dollars of costs at the expense of elders, low income children, and people with chronic diseases and conditions – and the health and mental health providers who serve them.

Bondi’s brief suggests that new Medicaid enrollments could cost Indiana about $2 billion over ten years, Arizona and Louisiana over $7 billion, and Texas close to $25 billion.  But these numbers all appear to include the currently eligible populations.

States understandably and justifiably want to contain their Medicaid costs.  But they cross the line when they do it by turning away literally millions of people who already belong on the program.

Bondi works hard to make the currently eligible group relevant to the Affordable Care Act by stretching a silken thread of the individual mandate around them. 

She writes that “the considerable cost for the [currently eligible group] reflects the fact that, unlike for the newly eligible, Congress has not increased federal funding for those newly enrolled (but previously eligible) by virtue of the ACA’s individual mandate.  As a result, the States will continue to pay for up to half of the costs generated by the latter group’s now mandatory enrollment.”

But she stretches the thread to the breaking point.  The individual mandate doesn’t apply to the group of people currently eligible for Medicaid.  Their Medicaid enrollment is “mandatory” by virtue of existing state and federal laws that pre-date ACA.

So what happens when the Supreme Court makes its ruling this spring?

If the Court finds the Medicaid expansion constitutional, then the states will have to implement it in 2014 – and also enroll those currently eligible without further delay. 

But even if it doesn’t, the currently eligible group isn’t going away – and we now know what they will cost.  Florida will still owe at least $574 million and Connecticut will still have to enroll up to 7,000 more eligible people.

That’s the best case scenario.  The worst is that such a ruling could induce the federal government to reduce its role in the Medicaid program to avoid the “coercion” argument in the future.  Then states might have to provide coverage and care to the poor and elderly all by themselves.  

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.

What the New Mitt RomneyCare Would Mean for Health Care Costs

“States and private markets, not the federal government, hold the key to improving our health care system.”

Those are the words of Presidential candidate Mitt Romney, as he articulates his health reform vision on his campaign web site.

U.S. health care costs are around $2.5 trillion. This money buys a lot of care, and pays a lot of salaries.  One out of every six workers in America relies on the health care industry for a paycheck. 

Romney thinks that’s too big a cost for care.

“At its core of this debate,” he writes (jarringly inarticulately for an official campaign web site), “is the question of what creates better patient outcomes and more efficiency: free enterprise and consumer-driven markets, or government management and regulation?”

I realize that he wants us to answer “free enterprise and consumer-driven markets.” But in this case, that doesn’t happen to be true.

The reasons why we have even a semblance of an affordable health care system in America are government management and government regulation.  Relying on free enterprise and consumer-driven markets in their place would lead to an unmitigated (sorry about the pun) health care financing disaster.

It is the salaries of professional athletes that may best illustrate why.

In a free enterprise system akin to what Mitt Romney proposes, the salaries of the most highly skilled health care professionals might be similar to the salaries of the most highly skilled professional athletes.   In fact, they once were.  In 1950, family physicians earned an average annual salary of $12,480.  That was before Medicare, Medicaid, and a whole lot of governmental regulation. 

In 1950, the average salary of a major league baseball player was comparable - $13,300.  That was before television advertising. 

Let’s look at what has happened to health care salariessince then. 

Today, the average salary for a registered nurse is just over $67,000.  Pediatricians make almost $166,000.  Psychiatrists make $168,000, and anesthesiologists make $336,000 a year to ensure that we undergo surgery without pain and without losing our lives to a drug overdose. 

Governmental management and regulation have a great deal to do with those salaries, because the Medicare system drives the prices providers can charge to patients and private insurers.

Are they too high?  When valued public sector employees such as police officers are making $55,000 and firefighters only $47,000, it may seem so.

And in the private service sector a house painter who makes $37,000, a janitor who makes $24,000, and a child care worker making $21,000 may wonder if health care professionals would really be ten times more valuable in a free enterprise system than they are.

The answer is yes, they probably would be.  We demand highly-skilled, highly trained professionals to tend to our health.  We can’t perform surgery on ourselves, but if we had no alternative most of us would do our own painting, clean up our own messes, and give up school and work to raise our own children.

So in a free enterprise system, how highly might we value health care professionals?

There are only 4,600 neurosurgeons in the entire country.  It just so happens that there are also just over 4,600 elite professional athletes playing in the National Football League, Major League Baseball, the National Basketball Association, and the National Hockey League combined. 

Neurosurgeons are at least as highly trained and as elite a group of professionals as major league athletes.  Neurosurgeons make, on average, around $220,000 a year, though in some areas of the country the number is higher and the best can earn upwards of three-quarters of a million dollars annually.

However, major league professional athletes, who sixty years ago earned what doctors earned, now make, on average, $2.7 million dollars each, more than ten times what neurosurgeons make.  That’s the effect of free enterprise.

If we turned our health care system into more of a free enterprise system, would a professional athlete still be worth ten times as much to us as a highly-skilled surgeon and forty times as much as a nurse? 

Probably not.  The salaries of health care professionals would undoubtedly go up.

Mitt Romney’s new health care vision for America is far different from the one he envisioned as Governor of Massachusetts.  In a consumer-driven, less-regulated market, the high demand for health care would increase, not decrease, health care costs.  There isn’t really any question about this. 

In fact, the only question is why is Mitt Romney pretending otherwise?

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.

A Dime's Worth of Difference in 2012

With the Iowa caucuses finally behind us, the Presidential campaign of 2012 now begins in earnest, and will dominate our news and lives for the next year.  I predict we will hear words like "Obamacare," “Romneycare,” “government takeover,” and “individual mandate” (usually in sentences following the word “repeal”) until we can’t stand it anymore.

If this is to be our fate in the New Year, then perhaps we can take some comfort in knowing that the debate probably won’t make a dime’s worth of difference about where most of us get our health care over the next few years or how we pay for it.

This is because the 2010 Affordable Care Act and the individual mandate were not really health reform.  They were efforts to preserve health insurance as we know it, by getting more people who can afford it to purchase private insurance, and more who cannot onto the Medicaid public insurance program.

So maybe we should take a minute between caucuses, primaries, and the general election to imagine what real health reform in America would look like in 2012.

It isn’t hard.  We just have to keep in mind a few facts.

First, governments already pay approximately $1.8 trillion of our roughly $2.5 trillion annual national health care bill.  Individuals pay another $300 billion out-of-pocket.  These numbers aren’t going down, whether the Affordable Care Act is upheld or repealed by the Supreme Court in June.

Second, there is plenty of money in our health system to delivery high quality health care to everyone who needs it.  We just need to target it to prevention as well as treatment.

Third, for the relatively small amount of money they put into the system, insurance companies have been given an outsized role in determining when, where, and how our health care is delivered.

Fourth, we woefully underfund our most important health services.  Public health and prevention activities have accounted for half of the gains in life expectancy during the last century, but receive far less than 5% of health care funding. 

And fifth, we criminalize instead of preventing and treating much of mental illness, and have made jails our nation’s largest mental health institutions.

With those facts in mind, we should acknowledge what real health reform isn’t.

It is not Romney’s or Obama’s “individual mandate” to buy private health insurance people don’t want and won’t trust.

It is also not Ron Paul’s notion of leaving people to fend for themselves in some non-existent “health care marketplace.”  No civilized nation does this and we are not going to be the first.

Here’s what a true American health reform – one that would result in healthier citizens, better access to care when it is needed, lower long term costs of care, and better quality – would look like.

1.       We would rebuild our health care delivery system around the federalized funding that already dominates health financing.  Medicare would be our basic national health insurance program, and be available to everyone.

2.       Medicaid would become a federal program like Medicare, and cover only long term care needs including chronic mental illnesses.  There would be no means-tested eligibility. States would not have to pay for it or administer it, so they could lower their state taxes accordingly.

3.       Private insurers, which are already such a small part of the overall health financing market, would play a role to which they are more suited.  They could offer supplemental insurance products covering first-dollar deductibles, co-pays, and additional, discretionary consumer services (like private hospital rooms and gourmet meals) at whatever prices they could get, for whatever profit they could make. 

4.       The Medicaid program could still require that people spend down a considerable portion of their own resources before it covered the remainder of long term care costs.  But we should allow everyone to set up tax-deferred long term care savings accounts to use for themselves, members of their families, or anyone else they designate.

5.       We would double the percentage of health dollars in public health and prevention over the next ten years.

How could we finance such as system of care?  The reality is that this system probably wouldn’t cost us any more than the current one does, and would probably cost less.

Of course, we won’t get this reform, but we can dream.  And I’d much prefer such a real policy debate about health reform in 2012 to the one we’re scheduled to receive – Mitt Romney attacking the individual mandate he invented and Barack Obama defending the individual mandate he opposed. 

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

The Top Health Policy Stories of 2011, Part Two

Last week, I shared four of the top policy stories of the year that told us something about how health policy has been trending over the past decade or more.  This week, I’m offering four more to close out the year that tell us a little about where health policy is going in the future.

4.  Connecticut Employees Choose Health.  Back in the early days of managed care, when HMOs were not yet a four-letter word and they emphasized wellness as much as health care cost containment, they proved to be popular with members.  In August, the State of Connecticut revived the concept, giving its employees the choice of a lower cost health insurance plan that emphasized wellness or their traditional comprehensive plan.  It expected 50% to choose the new wellness plan.  But the state got a big surprise.  When the dust settled in October, 97% had opted for the wellness plan.  This will cost the state much more in the first year, but will also produce more than the $100 million in health care cost savings the state originally projected for the future.

The implication for future policy – people want do more for their health, and will if they see a direct financial benefit.

3. The Florida Legislature Puts the NRA In Charge of Medicine.  During its 2011 legislative session, the Florida legislature attracted some national attention when it decided to include the National Rifle Association (NRA) in the doctor/patient relationship.  The NRA asked the legislature to prohibit pediatricians from even asking parents if there were firearms in the house so they could counsel them about firearm safety – despite well-known evidence that children are more likely to die from unintentional injury than any other cause.  The bill passed, and the pediatricians were eventually forced to go to court to stall its enforcement.  With big lobbying organizations being allowed to sit in the doctor’s office with us, is it any wonder that people wonder whose side government is on?  

The implication for future policy – Patient privacy protections will erode if “smaller government” cedes more power to private entities.

2.  The Attack on Public Health.  After the loss of almost 30,000 public health jobs nationwide between 2008 and 2010, the Association of State and Territorial Health Officials (ASTHO) headlined an April press releasewith the words “Cuts to Essential Public Health Services Jeopardize Americans’ Health.”  The proof came in an article published in Health Affairs in August, which showed that a 10% change in public health funding changed infant death rates, as well as death rates from cancer, diabetes, and heart disease. 

The implication for future – we and our children will be less healthy tomorrow because of the cuts our policy leaders have made today.

1. The Implementation of the Affordable Care Act.  The implementation of the Affordable Care Act (ACA) was once again the health story of the year.  The public is still divided.  A plurality supports it, but the combined numbers of those opposing it either because they believe it did too little or too much comprise the majority.  Meanwhile, the law has begun to affect significant numbers of Americans.  For example, in September, CMS announced that 1.3 million Medicare recipients had received drug discounts averaging over $500 per person, and another 1.3 million had gotten a free wellness visit as a result of ACA.  And this month, the National Center for Health Statistics reported that 2.5 million young adults had insurance because of ACA provisions enabling them to stay on parents’ policies.    The election campaign and the expected May or June Supreme Court ruling on its constitutionality guarantee that this will be the story of 2012, too.

The implication for the future – government’s role in determining our health care future is going to grow, not diminish.  Policymakers will continue to struggle with our expanding $2.5 trillion health care economy and the public will continue to try to figure out whose side they’re on.

In early December, Our Health Policy Matters was averaging over 2,500 readers per month, and had recorded its 20,000^th reader – not too bad for the first year of a once-a-week column focused entirely on health and mental health policy.  I appreciate you all, especially those of you who printed and shared columns with your friends, used them with your students, and offered them to readers of your own electronic journals and web sites.

I’m always interested in your ideas about how to improve the column, and how to get it in front of more people.  Please let me know (gionfriddopaul@gmail.com) if you have any suggestions for me. 

And thank you all for engaging in the health policy debate, and my best wishes for a happy, healthy, and prosperous 2012!