Answering the Call

It is worth noting on this “traditional” Memorial Day of May 30^th that over 6,400 service people have lost their lives so far while fighting our two most recent wars.

Unless we put more money into health and mental health care, many thousands more will eventually lose their lives fighting the physical and mental effects of these wars.

This past weekend, we learned that 45% of returning Iraq and Afghanistan War veterans are seeking compensation for service-related injuries. 

The challenge of finding the billions of dollars needed to treat these men and women will test us as a nation. 

It will likely stoke the fires of yet another protracted battle about “public option” health care in America.

This fight is about to take place because of two reasons.

The first is that the percentage of veterans seeking compensation is twice what it was in past wars.  “Invisible” injuries with behavioral manifestations, like PTSD and traumatic brain injury, account for much of the difference.

The second is that the VA system has too little capacity to meet the needs of even the lower percentages of those who have survived past wars and made similar claims for assistance.

This usually means that we begin by denying the existence of injuries we don’t easily see. 

I remember a Memorial Day parade I attended when I was a youngster in Middletown, Connecticut.  Then, as it still does today, Middletown closed its mile-long Main Street to traffic as a collection of high school and middle school bands, children’s sports teams, public safety officers, public officials, and groups escorted war veterans past cheering crowds.

The particular parade I recall featured two of Middletown’s earliest returning Vietnam veterans.  I remember standing on the roof of a two-story building watching them as they rode in a convertible down the parade route.  They were impressive in their dress uniforms, waving to the crowd.  One, as I recall, had lost a leg in battle.  The other, an arm and an eye.

Their injuries were undeniable.

The thing about parades, though, is that once one float passes by, we always turn our heads to see what comes next. 

And with Vietnam veterans, what injuries came next weren’t always so easy to see.  Agent Orange affected thousands, addiction affected tens of thousands, and PTSD affected hundreds of thousands.  As a matter of public policy, we ignored all of these for years as the Vietnam War’s real death toll mounted. 

The ongoing lack of capacity to serve the health and mental health needs of veterans is an even bigger threat to the well-being of veterans today.

A March 2012 Gulf War Veterans’ Illnesses Task Force Report provided some recent, statistical insight into this.  It noted that of the over 500,000 service members who served in Operation Desert Shield, 152,126 filed successful service-connected disability claims.  But only half – 79,415 – received VA healthcare.  The same was true of the almost 600,000 Desert Storm service members.  165,596 filed successful service-connected disability claims, but only 87,612 received VA healthcare.

There are three times as many Iraq and Afghanistan veterans as there were Desert Shield or Desert Storm veterans.  By percentage, twice as many returning Iraq and Afghanistan service veterans are filing claims as did Gulf War-era veterans. 

Based on the current numbers of claims being filed, over 750,000 may ultimately file successful claims, and at least 400,000 already need treatment for mental illnesses.  The VA system has the capacity to provide health and mental health care to only a fraction of them.

These are wars for which most of the rest of us have been called on to make no sacrifice by public officials who dishonor the sacrifices of brave veterans when they cower in fear at the word “taxes.” 

This may seem harsh, but we were asked to pay no new taxes for these wars, in spite of the billions of dollars we spent on them and the thousands of lives we sacrificed.  Does that seem right?

We would say that we meant it when we honored the sacrifices of veterans – especially those who have died fighting our wars – when we flew our flags, visited our cemeteries, and attended our parades this week.

So here’s our choice.  Will we answer the call when asked to sacrifice more tax dollars for health and mental health care for all? 

Or will we turn our backs on our veterans once the parades have passed us by?

Wait a Minute

An accurate but off-the-mark news headline this week proclaimed that health care costs for people insured in the private sector rose twice as fast as inflation in 2010.  But it didn’t mention that health insurance premium prices rose six times as fast.

The Health Care Cost and Utilization Report, 2010 was released by the Health Care Cost Institute (HCCI).  It was based on claims data for 33 million people – one fifth of those with employer-based health insurance.

The bottom line: the consumer price index rose by only 1.6% in 2010, but health care spending was up by 3.3% for the same year.

The report summarized that “prices increased across all categories of service, with outpatient services experiencing the fastest growth.” 

This is bad news for Americans with private health insurance already fed up with low and flat salaries and the high price of health.  The cost of health care now absorbs over one-sixth of our entire gross domestic product, and just seems to grow every year.

But wait a minute.  There was a piece missing in the HCCI report.  It was related to an insured consumer’s most significant health care expensive – the cost of insurance premiums.

That would have been even more newsworthy.  The price of employer-based family insurance coverage increased by 9%, or almost six times the rate of inflation, for policies renewed in the same time frame.

You won’t find that number headlined in the HCCI report, but you will find it in an equally impressive study released by the Kaiser Family Foundation and Health Research and Educational Trust last August.

How was it possible for HCCI to overlook so significant a cost increase? 

It might have something to do with HCCI’s funding.  HCCIwas formed just last September, “with an aim” according to its website, “of becoming the nation’s leading source of information on health care costs.” An article appearing on May 21, 2012, in Kaiser Health News makes it clear that insurance companies are the sources of both HCCI data and funding.

This bias doesn’t make the data in the report bad.  But it does suggest that the actual aim of HCCI might be better re-stated as “becoming a leading source of information on health insurers’ payments.” 

Especially if HCCI plans to continue to leave out the information about health insurance premiums.

Because when you add that into the mix, here’s another headline. 

At a time when – according to insurance companies themselves – health care costs rose by just over 3%, private insurance companies increased consumer health insurance premiums by three times that amount.

Adding insult to this injury, consumers got hit not once, but twice.  HCCI noted that out-of-pocket health spending increased by 7.1%.  In other words, insurance companies also required consumers to pay twice their fair share of the increase in health care prices.

This begs the question: where did all this money go?

If the purpose of the HCCI report was to deflect our attention away from this, it won’t work. 

The public may not have all the facts at its fingertips, but a March, 2012, survey sponsored by NPR, the Robert Wood Johnson Foundation, and the Harvard School of Public Health was released this week.  It found that 77% of all respondents, and 75% of sick ones, said that insurers “charging too much money” is a major reason for rising health care costs.

Americans don’t buy it when insurers point fingers at providers, any more than they believe major providers who just point fingers at insurers.  In the survey, consumers blamed hospitals and drug manufacturers for the rise in health care costs just as much as they did insurance companies.

So here’s the real bottom line. 

When – in the private sector – health care costs increase twice as fast as CPI, out-of-pocket costs increase four times as fast as CPI, and the cost of insurance increases six times as fast, there’s plenty of blame to be spread around.

The one entity we can’t blame for the increase is the one at which everyone usually points a finger – our government.

This in no way lets the government off the hook.

Instead, the data make a compelling case that elected officials should do more, not less, to contain all health care costs – if for no other reason than to protect the interests of the people who elected them. 

Will they do this, or will they leave us at the mercy of the marketplace?

States and Rebates

If you run a small business in Florida, are self-employed in Texas, or work for a large corporation in New Jersey (see an update below), then your state insurance regulators probably haven't been working for you.

The news that 15.8 million people can expect $1.3 billion in rebates from insurers this year because of the Affordable Care Act (ACA) underscores how weak health insurance regulation has been in states across the country. 

It may come as no surprise that Florida and Texas, two leaders in the fight against ACA, have been exposed as anti-consumer.  But they are not the only states with an anti-consumer bias.

First, the good news: last week, the federal government announced that three-quarters of us will get letters beginning on July 1 telling us that our insurance plans paid out at least 80 to 85 cents in benefits for every premium dollar they collected.

This means that under ACA they met the minimum standard for a reasonable benefit payout (which is still ten or more percentage points worse than the Medicare payout). 

But there’s bad news as well.

According to new data released recently by the Kaiser Family Foundation, 31% of consumers who purchase health insurance in the individual market, 28% who get insurance in the small group market, and 19% who get insurance through the large group market were covered by plans that failed to meet the minimum standard.

Assuming the Supreme Court upholds this most important consumer protection in the Affordable Care Act, all of these people are entitled to rebates.

The amount of the rebates will vary widely.  For example, over 2,700 Alaskans in one small group plan will get over $500 each.  Over 325,000 Floridians in thirteen individual market plans will get an average of $152.  And 46,000 Connecticut residents in three individual market plans will average almost $137 in rebates.    But people insured through the individual market in Maine won’t get anything – because they weren’t overcharged in the first place.

Until the Affordable Care Act passed, this type of insurance regulation was handled by the states. 

The new data give us a picture of which states have been looking out for consumers and which haven’t. 

Here’s a link to a tableI created from the data showing what percentage of individual, small group, and large group customers will get rebates in all fifty states (excepting California) and the District of Columbia.

The two states that have done the best job in protecting the interests of state consumers are Hawaii and Rhode Island.  These are the only two states in which every health insurance plan met the minimum standard last year.

At least one plan in every other state falls short.  But New Mexico, South Dakota, Vermont, New Hampshire, North Dakota, Alabama, Alaska, Maine, and Oregon all protect well over 90% of their health insurance consumers.

However, in Florida alone, two dozen plans don’t meet the minimum standard.  Twenty-one fall short in Texas.

By far the worst state overall is New Jersey, where 62% of people covered in the individual market, 79% of those covered in the small group market, and 67% of those covered the large group market have been overcharged for their health insurance. (See an update below.)

Several other states aspire to New Jersey’s low standard. 

South Carolina and the District of Columbia have even worse consumer protection records than New Jersey in two of three areas.  And in Oklahoma, Arizona, and Texas, more than eight out of every ten consumers were overcharged in at least one of the three areas.

Who specifically is paying the price for this?

In Texas – where over 90% of those insured in the individual market were overcharged for insurance – it is people who are either self-employed or have chronic conditions which disqualify them from group coverage.

In Florida and Missouri, it is small business owners and employees.   In Florida, 73% of those covered in the small group market were overcharged for health insurance, and in Missouri, 72%.

Florida’s numbers are worse than the nation’s across the board – in addition to 73% of those in the small group market, 38% of those covered by individual plans and 37% of those covered by large group plans have been overcharged.

And Connecticut – home to the insurance capital of America – was worse than the nation as a whole in both the individual market and the large group market, where 42% and 28% were overcharged, respectively.

So should ACA consumer protections trump states’ rights?  In this case, I can think of 1.3 billion reasons why they had to.

Click here to see the full list of the states in the Kaiser rankings.

Update:  HHS released its final list of the states in June (available at this link).  The final national rebate numbers were amended downward somewhat - to 12.8 million customers receiving $1.1 billion in rebates.  As was pointed out to me by a New Jersey reader, some of the individual states' information changed dramatically in the final analysis - New Jersey's among them. The final New Jersey numbers were significantly lower than the initial Kaiser Family Foundation numbers.  $7.5 million in rebates will be given there - none in the small group market - placing New Jersey in the upper tier of states. 

Confused and Confusing

President Reagan gave his first speech on the AIDS epidemic almost twenty-five years ago on May 31, 1987.  This was after 36,058 Americans had been diagnosed with AIDS, 20,849 had died, and over a quarter of a million had been infected with HIV.

For years, he had been criticized for ignoring and underfunding the worst public health crisis of the late 20^thcentury.  

So he began his speech with a joke:

“A charity committee approaches the wealthiest man in town for a contribution.  ‘Our book shows that you haven’t contributed any money this year,’ they tell him.  ‘Does your book also show that I have an infirm mother and a disabled brother?’ he replies.  ‘Why no,’ they say, ‘we didn’t know that.’ ‘Well, I don’t give them any money.  Why should I give any to you?’”

The bad joke was an inadvertent punctuation mark on a presidency too fondly remembered by both republicans and democrats today.

On matters of health, Reagan took us backwards.  He was neither in touch with the nation’s growing needs nor successful in addressing them.

His inattention to the AIDS catastrophe in particular and public health in general were just two examples.

He also helped create a new generation of chronically homeless people when he significantly cut federal mental health funding as part of the Omnibus Budget Reconciliation Act of 1981.  During his two terms as President, he also cut funding for safety net community health centers by over 25%.

Suggesting that Reagan would be too liberal by today’s GOP standards – as both some progressives and conservatives have done – is too liberal a stretch where health policy is concerned.

It was the Bushes who were progressives by today’s standards. 

Both delivered on campaign promises to expand the government’s role in health.

“Compassionate conservative” George W. Bush doubled funding to community health centers during his term and added a prescription drug benefit to Medicare.

And George H.W. Bush significantly expanded the federal Medicaid program.

Long before blogging, those of us who wished to express our opinions publicly used the “Letters to the Editor” forum in our local newspapers.  When I was in the Connecticut Legislature in the 1980s, I communicated regularly with my constituents through my local newspaper.

Here’s something I wrote about presidential health policy in October 1988: 

“When health insurance is necessary to pay for health care, how do we ensure that everyone has access to affordable insurance?  Both presidential candidates talk about this.  Governor Dukakis believes that the answer lies in the private sector, in all employers providing health insurance to their employees.  Vice President Bush believes that the answer lies in the public sector, in expanding the state and federal financed Medicaid program.  I know this looks like a classic role reversal, but solutions to health care dilemmas defy ideology.”

You can read the full text of what I wrote here.  If you do, you’ll be either fascinated or fatigued by how little health policy progress we have made in the last 25 years. 

Today, Mitt Romney, another former governor from Massachusetts, has a position on health care more similar to Michael Dukakis than to either Reagan or Bush.

Dukakis wasn’t very persuasive arguing for the private sector solution then, and Romney hasn’t been very persuasive arguing for it now – possibly because both headed a state with a long and solid reputation for making significant public investments in health.

At least President Barack Obama, the most vocal Democratic opponent of the individual mandate in 2008 who is now its leading proponent, recognized the importance of government funding for health when he said this past weekend:

“I refuse to pay for another millionaire’s tax cut by eliminating medical research projects into things like cancer and Alzheimer’s disease.  I refuse to pay for another tax cut by… eliminating health insurance for millions of poor and elderly and disabled Americans on Medicaid.”

But this hasn’t stopped President Obama from initiating or agreeing to multiple raids on public health funding.

Are you confused by all this?  You should be.  Presidents and presidential candidates have long taken confused and confusing positions on health policy with dire consequences for the public’s health.

Need some evidence?  Connecticut had over 250,000 uninsured people when I wrote my letter back in 1988.  Today, it is one of the states with the lowest percentage of uninsured people.  It has 384,000 uninsured.  Mental illness prevalence is up, autism is epidemic, obesity and its related effects have skyrocketed, and HIV still infects over a million Americans.

And our children, we all know by now, could be the first generation to live shorter lives than their parents.

An additional note on three sources:  I took the Reagan speech anecdote from the book And the Band Played On by Randy Shilts (1988 Penguin edition). My constituent letter was published in the Middletown (CT) Press on October 7, 2008. Kaiser Health News provided the Obama quotation on May 7, 2012.  

Iraq and Back: Veterans Experience Tragic Delays in Obtaining Mental Health Care

A newly released report found that hundreds of thousands of veterans experience excessive delays in trying to obtain mental health services from the Veterans Administration (VA).  This is especially sad to consider today, both because May is Mental Health Month and the President has just renewed our troop commitment to Afghanistan.

William Hamilton was a 26 year old Iraq veteran when he died in May 2010.

One of five siblings, he joined the army when he was nineteen.

He experienced his first symptoms of mental illness while serving a tour in Iraq in 2005. He was diagnosed with PTSD and an anxiety disorder. 

He was discharged honorably later that year and sought treatment at a VA Center.

For four years, as his condition worsened, Hamilton bounced from one VA treatment setting to another. 

In 2006, he was diagnosed with major depressive disorder.  Chemical dependency complicated his treatment.  He was hospitalized at the VA on several occasions over the next two years, and had several unsuccessful VA transitional housing placements.

In 2009, he was diagnosed with schizoaffective disorder.  He had two extended stays at the VA hospital and another at a rehabilitation center. 

In 2010, he was also diagnosed with psychosis, and by then it seemed to his parents that the VA didn’t want to see him anymore. 

Three times in 2010, his parents contended, Hamilton was denied admission to a VA medical center. 

The first was early in the year after he was found running in and out of traffic and hospitalized in a community hospital.   The second was after he was hospitalized a month later after being found walking the streets naked.  

In both instances, hospital personnel documented that the VA center reported that there were no beds available those days. 

The third was a few days before he died in May.  Community hospital personnel said that when they spoke by phone with the VA center at 4:20 p.m. they were told that the VA did not accept transfers that late in the day.  So they found a Department of Defense hospital to admit him.  His parents expected him to be transferred to the VA center from there, but instead he was released three days later. 

His parents said that he was unstable.  He died four hours later when he stepped in front of a train.

Did the VA center’s failure to accept and treat William Hamilton contribute to his death that day?

His parents thought so, and the Office of the Inspector General of the Department of Veterans Affairs agreed to investigate.  It released the report of its findings a little over a month ago.

It determined that the VA center did have beds available on the first two dates in question, and should have admitted him.  However, it could not determine whether he had been denied admission in May, too. 

That’s because when it tried to verify the 4:20 pm phone call, the VA center records showed that “no outgoing calls were recorded from any VAMC extension to anywhere on the subject day.” No one could say why, but the OIG suggested that “it would not be plausible” that no outgoing calls were made during that entire day.

This tragic case is an exclamation point on a bigger story.

According to a new reportissued by the OIG just last week, hundreds of thousands of veterans experience delays in obtaining mental health evaluations and care from the VA.

The VA mandates that all initial mental health evaluations for veterans seeking mental health care from the VA for the first time be completed within fourteen days.

Over 373,000 veterans sought such care in FY2011.  Only 49% had their mental health evaluations completed within 14 days.   An estimated 28,000 evaluations were never completed at all.

The VA also mandates that patients new to a specific mental health clinic be granted appointments within fourteen days of when the veteran wants to be seen.

Out of 262,000 appointments, only 64% met this deadline.  94,000 veterans waited longer.

In Denver CO, the average wait was 19 days.  In Milwaukee WI, it was 28 days.  In Spokane WA, it was 80 days, and in Salisbury NC, it was 86. 

One of the things that jumps out at me about William Hamilton’s tragedy is that as his symptoms of mental illness became more and more serious, his treatment never seemed to catch up with his disease.

And what jumps out at me about the VA data is that where veterans’ mental health is concerned, playing catch-up seems to be the norm.

Comments are welcome on this and other columns.  If you have questions about this column or would like to receive an email notifying you when new OHPM columns are published, please email gionfriddopaul@gmail.com.

To Be Healthy, Live Among the Wealthy?

If you want to be healthy, then be wealthy. Or at least live in a wealthy county.

That’s the obvious message you get from combining the recently released County Health Rankingswith poverty and income data from the 2010 U.S. Census.

Source: US Census and County Health Rankings, 2012

But if you look closer, you see something else.  It’s not just that poorer people are less healthy than their wealthier counterparts. 

People are less healthy where too few resources are invested in public health.

Earlier this month, the 2012 County Health Rankings were released by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation.  In the release, Dr. Risa Lavizzo-Mourey, President and CEO of RWJF, said that “where we live, work, learn, and play has a big role in determining how healthy we are and how long we live.”

She’s right.

The poorest counties – as measured by the percentage of people living below the poverty level – are usually home to the least healthy people.  And the wealthiest counties – as measured by income – are home to the healthiest.

That much isn’t news.  We’ve known for a long time about the relationship of poverty to poor health. 

But we usually think about that relationship in terms of individuals – the poorer the individual, the worse his or her health status is likely to be.

The county-level data suggest that we look at the relationship in another way – as a community problem.

Then we discover something more.

The poorest counties often have both the least healthy residents and some of the poorest public health infrastructures in their state. 

Consider these examples from three different states.

• The three poorest counties in America – Ziebach (the only county in America where over 50% of the population lives in poverty), Todd, and Shannon – are in South Dakota.  Of the 59 South Dakota counties in the County Health Rankings, they are at the bottom, placing 53^rd, 58^th, and 59^th, respectively.
• Owsley County, Kentucky, is also one of the nation’s poorest counties.  It is the poorest county in Kentucky, and it ranks last in the state’s county Health rankings.
• South Carolina’s Allandale County is one of the poorest counties in America.  It, too, ranks last in its state county health rankings. 

What do they share besides poverty and poor health?

The North Dakota communities are worst off.  They have very limited governmental infrastructure and services.  All are Native American reservations.  Two don’t even have a County Seat. 

Owsley County shares its health department with six other rural southeastern Kentucky counties.  The regional health department covers a geographical area larger than some states, and its central office is located over an hour away from Booneville, the Owsley County Seat.

Allandale County also lacks its own dedicated public health infrastructure, sharing public health services with several other South Carolina counties.

Is it poverty or poor public health infrastructure that matters most? 

That’s hard to say, but poorer public health infrastructures are common in relatively poorer counties in wealthier states – even when those counties are well-off compared to the nation as a whole.

• Windham County, though relatively wealthy by national standards, is Connecticut’s poorest county.  It also ranks 7^th of Connecticut’s eight counties in health. 
• And Washington County, Maine, is Maine’s poorest and least-healthy county. 

What about their public health infrastructures?  Unlike many Connecticut cities, none of Windham County’s fifteen towns has its own public health department.  Public health services are delivered through three regional health districts shared by several communities. And in all of Washington County, there are just two district offices of the Maine Health and Human Services Department.

So it appears that poor health may go hand in hand with poverty because economically disadvantaged communities often don’t take care of their public health infrastructure – not just because poorer individuals often don’t take care of their health.

Florida is home to one of the exceptions that may prove the rule.  DeSoto County is Florida’s poorest county.  But DeSoto ranks in the top half – 28^th – of Florida’s 67 counties in health.

Why?  It may be because of DeSoto County’s strong public health infrastructure.  Its residents have better-than-average access to diabetes screening and better-than-average low birth weight numbers.  Behind these achievements are a diabetes screening program housed in a county-run primary care clinic and a county-run women’s health clinic.

Living well isn’t always about how much wealth an individual has to spend for a healthy life.  It’s often about how much a community is willing and able to spend for healthy lives.

Jim Hurley's Forgotten AIDS Message

Thirty years ago, AIDS was a total mystery to us.

Six years into what CDC already termed an epidemic, 358 AIDS cases in twenty states had been confirmed and 136 people had died.  No one knew why.

Several people I knew were probably already infected with HIV.  I learned this only as they died over the next few years.  One was a popular Connecticut Congressman, Stew McKinney, who was a moving force behind federal funding for services for homeless people.  Another was a lawyer named Jim Hurley.

I first met Jim when we were high school debaters. 

His school debated against my school at several local and regional debate tournaments.  I remembered him as bright, easy-going, and friendly.

We reintroduced ourselves during our first year in college, when we crossed paths in his dormitory one day.  He hadn’t changed much.  He was personable, still friendly, and happy to exchange a few stories about Catholic high schools and debating.

I transferred to Wesleyan and lost track of him after that.  I became active in Connecticut politics and government after college, and Jim went to law school.  With his skill set, he must have been a very good lawyer.

Our paths crossed just one more time, but not in person. 

The next time I saw him, it was years later on a videotape that was played in 1987 at an AIDS conference at Central Connecticut State University.  On tape, he still looked pretty much the same as I remembered him.  But he was 34 years old and dying of AIDS.    

One of the points Jim made on that videotape stayed with me.  He said that it didn’t really matter how he got AIDS.  What mattered was what we would do to prevent others from getting it in the future.

By that simple standard, there are now well over a million reasons why we haven’t done enough.

There was a time when the Centers for Disease Control and Prevention tracked and reported on AIDS cases every single week.  Now we have to wait years to find data about how many people have HIV and die from AIDS.

In 2009 – the year for which most recent data are available – there were 48,100 new HIV infections in the United States, and 17,774 people died as a result of AIDS.

Last year, CDC also reported that in 2009:

• New HIV infection was as common in men as salmonella poisoning and as common in women as pertussis.
• Among all people between 15 and 24, new HIV infection was twice as common as Valley Fever – a disease well-known and frequently diagnosed in the southwest.
• Among men between 40 and 64 – the population most likely to have been directly affected by AIDS over the years – new HIV infection was more common than Lyme Disease – a disease well-known and frequently diagnosed in the northeast.

AIDS-related deaths declined dramatically when drug cocktails were introduced during the 1990s, and so we began to forget about how serious it is.  People are living longer with HIV infection than they ever did before, but HIV still shaves up to 30 years from life expectancy, and still accounts for more deaths in the under 45 population than diabetes and stroke.

The AIDS epidemic isn’t nearly as under control as we might think.

And it is worse in some places than others.  Connecticut, for example, has more new HIV infections than any other state in New England. 

But for the most part, the HIV/AIDS epidemic has moved south.

Florida leads the nation in new HIV infections, with over 5,400 in 2009 alone – nearly as many as New York City and the entire State of California, two other “ports of entry,” combined. 

HIV death rates are also highest in Florida, Louisiana and Maryland.  New York, New Jersey, Delaware, Tennessee, Mississippi, Georgia, and South Carolina are all in the next tier. 

The half million Americans who have died and the 1.2 million who are living with HIV are also evidence that Jim’s Hurley’s message was poorly heeded. 

Nearly all of them got it after he made his videotape and was featured by Newsweek Magazine in its August 1987 “Faces of AIDs” issue.

We can do better than this.  Even since the most recent HIV data were published, over 100,000 more American men, women, and children have been infected.

April is STD awareness month.  In memory of our lost friends and to save lives in the future, we must do more to eradicate this relentless and deadly disease.

April is STD Awareness Month.  To increase awareness about AIDS, please consider sharing this column with friends and colleagues.  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.

Mitt's Plan

Imagine what a nightmare healthcare scenario might look like.

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

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

Then you get another chronic disease.

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

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

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

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

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

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

You’re out of luck.

You might call this nightmare far-fetched.

Or you could call it Mitt’s Plan.

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

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

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

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

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

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

She describes herself as “financially drained.”

I imagine she sometimes feels physically drained as well.

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

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

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

Note: Candace Brown's story was published and made available by Florida CHAIN at the link provided in the column.  More information about the work of Florida CHAIN can be found using the link.  If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Anna Brown's Death

Anna Brown was 29 years old when she died suddenly last September.

She left two small children. 

Sometimes, the tragic and untimely death of a young mother commands our attention.  Anna’s death in Missouri drew a little national interest just last week. 

She died alone on a concrete jail cell floor.  It happened just a few minutes after she was arrested for trespassing.  She refused to leave a hospital emergency room while she was in agonizing pain.   

Anna Brown was homeless, had mental illness, and was on Medicaid.  Hospital officials thought she was a drug-seeker.  They were wrong. 

According to news reports, a morning fog blanketed St. Louis on September 20, 2011 – the day Anna died.  She spent much of her final day going from emergency room to emergency room begging for care.  She started at St. Louis University Hospital complaining of pain in her leg.  She was evaluated and released with a prescription for painkilling medication. 

Unsatisfied with her care, she went next door to Cardinal Glennon Children’s Medical Center.  There clinicians found tenderness in her leg, but explained that they could not treat her because she was not a child. 

Her pain was so bad that she could not walk.  So she was transported by ambulance to a third hospital, St. Mary’s, where she was diagnosed with a sprained ankle. 

But Anna Brown was afraid something more serious was wrong with her.  So when St. Mary’s said she could go, Anna Brown refused.

That’s when St. Mary’s had her arrested for trespassing.  

A police officer later reported that “they thought that she was a drug seeker.”  The police wheeled her out of the hospital in handcuffs.

When she arrived at the jail, she was having trouble breathing.  Officers placed her on the floor of her cell and left her alone.  She died within fifteen minutes of undiagnosed blood clots in her leg that traveled to her lungs.

What a tragedy.

It was compounded by others in Anna Brown’s life.   

She had lost her house a couple of years earlier to a tornado.  She lost her job shortly thereafter.  When she could no longer afford to pay her heating bills, her service was discontinued and she took to building fires in her apartment to keep her children warm.

Child protective services found out, and the state removed her children from her care.

Her mother took in the children, and reported that the family court gave her a choice – she could care for Anna’s children or Anna, but not both.  She was forced to choose her grandchildren over her daughter.

So Anna became homeless.  At the time of her death, she was using city shelters and frequenting a drop-in center for people with mental illness.  Contrary to the assumptions of the clinicians who examined her on her last day of life, she was not using drugs.

Too much of Anna’s story isn’t uncommon. 

We have all read reports about patients with mental illness “flooding” hospital emergency rooms because of state cutbacks to mental health services.

These usually suggest that patients choose emergency rooms for non-emergency health reasons because they have no place else to go. 

In defending its actions just last week – a full six months after Anna Brown’s death – St. Mary’s Hospital sounded this theme.  It issued a statementthat read in part “the sad reality is that emergency departments across the country are often a place of last resort for many people in our society who suffer from complex social problems that become medical issues when they are not addressed.”

That statement may be true.  But Anna Brown wasn’t suffering from “complex social problems” when she showed up at St. Mary’s. 

She was suffering from neglect of her medical condition.  That neglect didn’t begin at St. Mary’s; it just ended there.

And we are mistaken if we think this doesn’t happen every day in every state in the nation.

Medicaid emergency room co-pays, cuts to mental health and substance abuse treatment, inadequate funding to combat homelessness, and anti-loitering laws are all just symptoms of this neglect.

Anna Brown died from blood clots, but she also died because too many people looked past her suffering and saw a caricature of a homeless, mentally ill patient, and jumped to a conclusion about what they think such a patient represents.

Anna Brown may have visited far too many emergency rooms on the day she died, but the fault wasn’t hers.  And she and her loved ones paid the price.   

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.

How We Really Hope the Supreme Court Will Rule on the Affordable Care Act

The Affordable Care Act has finally had its days in court this week.

And commentators who were certain on Monday that the Supreme Court would uphold the individual mandate were just as certain on Tuesday that it would not.  Perhaps they have some special insight into the thinking of the Justices. I don’t.  I’ll just wait for the decision. 

In the meantime, I’m wondering not how each of us thinks the Court will rule, but how we hope it will rule.

The answer isn’t so simple, because we divide into – and often move among – three competing minority camps about health reform in general:

• The Affordable Care Act represents the best compromise for insuring more people while preserving most of our current public/private payer system.
• Expanding reform to a single payer system like those favored by other developed nations would be better. 
• Replacing ACA with a private market-based system is at least worth a try.

If we’re as uncertain as polls cited by the Kaiser Family Foundation suggest, I suppose we all could just close our eyes, vote for Mitt Romney, and assume from his record and rhetoric that we’ll get all three.

But the Court will decide first, so let’s consider the rooting interests of several interested and sometimes overlapping groups.    

If you favor a single payer, “Medicare-for-all” program:

You want the Court to find the individual mandate unconstitutional, but severable from the rest of the bill. 

Why?  The individual mandate was originally the alternative to “single payer,” so you would like to get the individual mandate out of the way.  Then single payer becomes an option again, but only if the rest of the law, including the Medicaid expansion and the consumer protections, remain in effect.  This is because our private insurance market will become too expensive if people use those consumer protections to wait to buy insurance until they are sick.

If you want to reduce the size and scope of the state Medicaid programs:

You want the Court to rule the Medicaid expansion unconstitutional, but the individual mandate constitutional. 

Why?  This combination will most constrain Medicaid growth because lower income people will have to purchase health insurance in the private market.  They’ll qualify for a subsidy, but not for Medicaid.

If you want more universal coverage, but don’t care whether it’s private or public:

You want the Court to uphold the entire law.

Why?  Although philosophically impure, the combination of Medicaid expansions, Medicare cost containment strategies, Medicare tax increases for the wealthy, and subsidized private insurance for the middle class will lead to more coverage, and fewer uninsured.

If you or a child of yours has a chronic condition, such as diabetes, mental illness, or cancer:

You may not care whether the individual mandate is constitutional or not, but if it isn’t, you want it to be severable from the pre-existing condition coverage and community rating portions of the law.

Why?  If the PCIP experience is any indication, you may not want to be forced to buy insurance.  But when you do try to buy it, you don’t want to be denied affordable coverage because of your pre-existing condition.

If you are an early retiree on your former employer’s health insurance:

You want any provisions found to be (1) unconstitutional and (2) not severable from the pre-existing condition and community rating portions of the law to be severable from the rest of the law.

Why?  This could gut much of the law, but not the provisions that subsidize your coverage.  You won’t have to worry that you could either lose your health insurance or be forced to pay a lot more for it.

If you are a Medicare recipient:

You want any provisions found to be unconstitutional to be severable from Medicare expansions.

Why? If they aren’t, you’ll need an immediate bipartisan agreement in Congress to keep your donut hole prescription drug coverage and your free annual check-up in place.

If you want insurance that will cover long term care needs:

You’re already out of luck. 

Why? That provision was axed from the law before it was ever implemented – and you don’t hear anyone talking about restoring it.

And, if you’re okay with denying or capping coverage for pre-existing conditions, allowing insurers to make as much profit on insurance as they can, having gaps in prescription drug coverage for elders, and paying for the sick and uninsured through increased premiums on people who have insurance:

You want the Court to find the whole law unconstitutional.

Why?  That’s where we were when all this began.

Note: Click here for simple explanations about some of the Supreme Court issues that are discussed in this week's column.

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.