Affordable Care is Simply Not Affordable

HealthCareGovSiteNew Orleans    The more studies that are done, the more time that passes, the more it seems impossible to get around the core issue embedded in the compromises of the Affordable Care Act: it’s just not affordable for lower income families.

The government’s projections for the current signup period are frankly modest at about nine million signups, rather than the twenty million projected several years ago for this period. Given the number of states that continue to boycott the expansion of Medicaid, which is where a lot of the gap for the uninsured continues, the budget offices are finding the predicted costs of Obamacare are about 20% lower than originally expected.

Furthermore, the mandate is not pushing enough people into insurance who don’t have it, particularly among lower waged workers. Studies are finding that at about $40,000 the maximum participation is achieved. Lower income families are simply paying the penalty, because it’s cheaper than the insurance bite.

Reports from employers are very depressing, though not surprising. Having represented big health care employers with sorry health plans for decades and seen the abysmal participation figures, we were hardly shocked, but still reading figures for huge food service companies with tens of thousands of employees and their reports of only 500 workers out of 25,000 actually signing up for employer insurance is ridiculous. The workers are blocked from access to ACA marketplace subsidies and cost sharing because they have opted out of corporate insurance, but they have opted out because the costs are too high and the benefits are too crummy with essentially catastrophic coverage and deductibles as high as $6000. Who can afford any of that on $10 or $15 per hour?

Increasingly, it seems clear we have a little bit of something for health insurance, but it’s only a bit better than nothing, and under the private company and corporate-centered regime, it’s too pricey and too paltry. We need real national health insurance, but that means a more significant governmental investment, and that is a bridge way past the level of political consensus.

It is also way past the level of public support, which fuels the continued opposition to Obamacare. When even the primary beneficiaries of the program among low-and-moderate income families are still priced out of the market, who is left to show the program the love it needs and deserves?

Half-stepping clearly has only gotten us halfway to where we need to be. We shouldn’t be surprised, but that doesn’t make it any easier to live with the disappointment or the continued perilous state of national health protection in the United States for low-and-moderate income families.

Using Telemedicine to Lower Cost and Expand Healthcare

01_philips_eICU_fullNew Orleans   Recently I had my annual physical. I’ve used the same doctor for a dozen years. She chatted and asked me about other family members that I’ve sent her way. She asked me a series of basic, rote questions, checked my pulse, pulled out the stethoscope to take a listen, and then sent me on back for blood and urine samples. All of these were simple procedures that frankly could have been done anywhere and with basic training by a whole range of people, and certainly by nurses or nurses’ aides. The clinic was part of the giant nonprofit Ochsner in Louisiana. They no longer have an x-ray machine there or the capacity for EKG’s so that’s another trip to a larger location, if I’m willing to take it. A doctor or other health professional could as easily review the tests and pronounce me “good to go” or “come back in.” I’m not whining, but once I step back and think about the process my own experience starts to outline part of the problem of the “volume” provision model for healthcare versus the “value” model touted for the future. It also brings to mind the crisis in rural health care facilities that cannot sustain the volume and are challenged to provide the value. Are there some other fixes for this problem?

One might entail a significant expansion of telemedicine. Extensive US-based pilots have established at the least that using telemedicine can link specialists in larger hospitals and cities with patients in rural areas. With equipment and training there are widely reported cases establishing success in matching health needs in other countries, like Latin America, with doctors and specialists in the USA. The Georgia-based Global Partnership for Telehealth touts on its website not only an extensive telemedicine network in that state but a project begun in Africa in 2014 that they claim is the first on the continent. Telemedicine embraces the full range of technical tools from smartphones to computers, and in some developed country experiments, even robots.

In the current clinic-hospital model in the USA where costs continue to be out of control and access continues to be frustratingly difficult, breaking the bricks-and-sticks model of healthcare and embracing access, tools, and outreach could be revolutionary. A telemedicine primer offer this insight:

Globally, the tipping point will be the care model realignment under healthcare reform, where payment is value-driven, not volume-driven. Care providers (hospitals, physicians, and ancillary caregivers — all part of the overall care team) are paid for results, and whether the venue is the office or a virtual visit at home will no longer matter. Quality is measured and payments made for meeting targets. Finally, there are incentives for preventive care — for keeping citizens healthy so there is a decrease in the number of physician’s office visits and hospital admissions.

“The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring and other such enabling technologies.”
(Federal Register, Vol. 76, No. 67, p. 19531, 4/7/11)

They are talking about the call and promise of the Affordable Care Act as the herald to reform and a different model of healthcare. The more you think about it, the more you wonder “Why not?” and “When?” I also start to wonder if the real opposition to Obamacare in the United States by some is their persistent toadying to all of the vested interests of industrial medicine and healthcare delivery systems that have been the standard for decades and need to have voices to protect their old models rather than embracing the change people deserve for universal quality care? The more we deal with the intransigence of hospitals providing even their required financial assistance plans, the clearer we have become about their unified resistance to change.


Please enjoy a new arrangement of Natalie Merchant’s Carnival. 

The Problem of Obamacare Dropouts: Cost, Confusion, and Language

indexNew Orleans   We’re knocking on the door of another Affordable Care Act enrollment period beginning November 1st. There are ten million eligible people who have not yet received coverage of whom 40% or 4 million are lower income. Reports indicate that there are improvements in the website, but there is no indication that there is improvement in the outreach.

Having labored in the vineyards of the enrollment process, it is hard not to take note of the fact that as difficult as it is to enroll families in the program initially, it is also difficult to keep them enrolled. In 2015 after an announcement that 11.7 million had selected plan in the 2015 enrollment year, latest information from the end of June is that 9.9 million continue to be enrolled for a dropout rate of 15% and almost 2 million people. That hurts! Experts are saying the obvious culprits are costs, especially in all of the states that have not extended coverage and expanded Medicaid services, and confusion, which is part and parcel of the continuing fragmentation of the insurance marketplace and the myriad array of choices that confront families inexperienced with the already opaque health insurance industry.

One element of the confusion that may not be on everyone’s radar may be language and the foot dragging, half-hearted compliance with Title VI of the Civil Rights Act and its requirement that there be no discrimination in this area. Recently we participated in a conference call organized by the Seattle-based Alliance for a Just Society, and listening to the work from various groups around the United States, it is hard not to believe that inability to access the website and documents based on language has to be counted as part of the problem, and one that should be easy to correct. Of course seeming easy and being easy are different things, since many of us no doubt can remember that in the initial enrollment year the government was chronically unable to even make the enrollment website accessible in Spanish, much less other languages that are less ubiquitous in modern America.

The Civil Rights Act requires accommodation, either through accessible printed and on-line materials or by providing – and paying for – translation services. A fair number of languages are seen as the major dozen or so in the United States, but where there is sufficient density in a geographical area, ranging to more than 1000 individuals, the requirements stiffen. The proposed semi-official languages are based on a national grid not local issues, so local community organizations are having to step up to advocate and ensure that underserved populations facing language barriers get needed translation services to navigate the complexities of the health insurance mandate. There was talk of a new rule making process so that will have to be kept on the radar as well.

It is unlikely in the current climate of contention that the huge issues of costs and program expansion are going to get a quick fix, but lowering language barriers would seem to be a straight forward objective easily within our reach. What the heck, it’s already the law!

North Carolina is Showing the Way in Fighting for Rural Hospitals

Republican mayor of Belhaven, NC walks to Washington, DC to save Pungo Hospital and becomes a national voice for Medicaid expansion.

Republican mayor of Belhaven, NC walks to Washington, DC to save Pungo Hospital and becomes a national voice for Medicaid expansion.

New Orleans   For all of the continuing polarization in Congress over Obama’s Affordable Care Act and the “last stand in the hospital door” strategy of one Republican governor after another, there are realities in the heartland of the Republican base that some of the politicians are continuing to miss from their sky high perches as they survey the battleground. A fight in North Carolina by a Republican mayor, Adam O’Neal, in small town Bellhaven in the eastern part of the state, to save his town’s rural hospital should be sending a message about the political price the resistors will pay with their base voters, even if they are missing the life-and-death message that adequate and accessible health care represents. As the Mayor has made clear, health care is an issue that defines bipartisanship because both Republicans and Democrats get sick.

The private healthcare corporation Vident closed the local hospital, Pungo that served Bellhaven. Since the viability of so many hospitals was based on expanding health care coverage not restricting it, Pungo is just one of many early warning signs of what could become a widespread calamity. As noted in the Daily Kos, the Rural Health Association counts 283 rural hospitals as on their own kind of deathwatch to survive.

To save the hospital, Mayor O’Neal pulled pages from the history of the civil rights struggle and joined hands with contemporary activists. They hit the streets and marched to the state capitol in Raleigh to ask for a modification of the certification to allow the hospital to reopen. They also marched to Washington totaling hundreds of miles. They were joined by Rev. William Barber and his Moral Majority who have been central in recent struggles in North Carolina and beyond. They were also joined by former civil rights activists, like the legendary Bob Zellner from early SNCC and Freedom Rides fame. I can remember reaching out for Zellner in 1976 when we opened ACORN’s office in New Orleans and asking for help then. He was “retired” he said and working for an industrial plant, Godcheaux’s sugar refinery, while living in New Orleans and trying to find some calm after his years of activism. I doubt if he had really retired then, but there’s no doubt that he is back in action now. It was good to read that Zellner had joined this fight in North Carolina and walked with Mayor O’Neal every step of the 238-mile trek to Washington.

Does this kind of bipartisanship work even in the rock-ribbed rural communities of the South that have become the bastion of the Republican voting strength? Can these dusted off tactics still make a difference?

It seems so as Mayor O’Neal tweeted at the end of September:

Great news!!! NC Legislature changes Cert. Of Need law to allow our hospital to reopen. Votes..House 102-8 and Senate 44-0. #savepungo

Seems like part of the message from North Carolina is that we may need to build a movement on health care access for all to finally get the job done here.

New School Methods for Old School Tricks for Disappearing People

11942334_10153577638946575_8114869526653973585_oNew Orleans    In the age of “big data” we are led to believe that eyes are everywhere on all of us. All is known by the all-knowing. NSA is up our nose. It goes on and on.

Yet, somehow we are losing people.

We lost more than 400,000 people on certifications under the Affordable Care Act that was four times the number we lost last year. Ostensibly these are re-verifications of citizenship status, but of course the fine print indicates that people only had 10-days to reply and, trust me on this, many found the forms and requests mystifying, and so it is more likely that people simply dropped through the crack. One immigration health expert essentially said, “Really? who in their right mind would have risked being deported by filing for health insurance? Duh.”

You know who else is disappearing? The elderly it turns out. A group called HelpAge International says old people are slipping through the cracks by the millions. In fact they put out an annual Global AgeWatch Index, and report that almost half the countries in the world – 93 of them — have zero data to offer on their elderly. Worst, unsurprisingly, many of these are the poorest countries in the world where many of us would most like to have some information, including the United Nations which has made raising living standards a huge priority over the next fifteen years. In a Times’ article they mention that “Of 54 countries in Africa…there was enough data available to include only 11 in the index.” Even for the data available of course there’s bad news in that the “gap in life expectancy at age 60 between the countries at the top and bottom has increased to 7.3 years, compared to 5.7 years in 1990.” Talk about “aging out” once you get long in the tooth you just flat out disappear it turns out.  Who knew that was so easily accomplished in the age of big data.

Speaking about being invisible and besides the elderly we’re back to migrants and refugees. Running errands from the ACORN Farm someone on public radio was going on and on about whether the waves of people coming into European countries from Syria and the Middle East these days are refugees from the civil war or economic migrants. The reporter was arguing that this was a political issue, which it is, but fortunately by the end of the piece they admitted it didn’t change the fact that we had to do the right thing no matter what label was placed on it. Another commentator reminded the American listener that we needed to be careful tut-tuting since during the heart of the depression in 1930 we had forcibly removed an estimated one-million Mexicans, 60% of whom were American citizens, in a so-called “repatriation” to Mexico. These same pictures of people on trains would have been of US trains from Los Angeles and other cities to the Mexican border. This atrocity is news to many, if not most, of us.

The real solution to this invisibility problem for the elderly, poor, immigrants and others is not big data in all likelihood, but being willing to look around us in the first place.


Hospitals Shirking on Financial Assistance

view-overall-inpatient-billKiln, Mississippi    When the doctors’ union, the American Medical Association Journal of Ethics rings the bell on the horrid practices of hospitals, you know we have a tiger by the tail – and we’re in danger of continuing to be hurt badly!

The Journal looked at 140 hospitals to see how they were preparing for the mandatory rule taking full effect this January under the Affordable Care Act of providing financial assistance to lower income families. What they saw wasn’t pretty, although we could have told them that from our close inspection of many hospital IRS 990 forms in Texas, Louisiana, Arkansas, and other states.

First the Journal confirmed the fact that finding the information, even for them, and certainly this has been the case for us, was like finding a needle in a haystack. They looked at a random sample of 140 hospitals across fourteen states. In their survey, they found that half of the institutions did not say on their websites whether they were public, private, or nonprofit. Needless to say, their reporter was web savvy which also wouldn’t be true of many families desperate to find if the hospital offered any help. So, transparency, not! Also, not surprisingly, they found that for-profit hospitals generally had not voluntarily created financial assistance policies in line with what nonprofit, tax exempt hospitals are now required to do.

But here comes the real rub in what the Journal found and it goes to the heart of the vagueness of the IRS requirements for financial assistance in this new rule:

…hospital financial assistance policies vary significantly in terms of generosity and terms. Among the sample of financial assistance policies from 140 hospitals, eligibility cutoffs for financial assistance ranged from an income of 100 percent of the federal poverty level (FPL) to 600 percent of the FPL. Many hospitals with financial assistance policies offered free care to those with incomes up to 100-200 percent of the FPL and sliding scale discounts above that threshold. However, some hospitals did not offer any free care and only offered moderate discounts even to the poorest patients. Of the hospitals in the sample that provided eligibility information based on insurance status, a quarter excluded those with insurance from their financial assistance policies altogether.

Bottom line, if your wallet is a bit light, you better start doing some research so that when you get sick you can find that 600% hospital or you are up a creek with no paddle. And, for those hospitals that exclude any lower income family from financial assistance if they have any insurance at all regardless of the deductible, we, and all those like us, need to start figuring out a way to challenge their tax exempt so-called charitable status.

The Journal was also clear about the hospital rip that starts with the “rack” rates for cares or charge master rates.

Hospitals routinely charge uninsured patients undiscounted “chargemaster” prices, the “rack rates” or list prices of the health care industry, while government and commercial payers receive substantial discounts of 50 percent or more of the chargemaster prices for their members

Yes, you are hearing this right. If you are covered with insurance, your bill is discounted. If you are uninsured and out of luck, your bill is essentially doubled!

The Journal argues that California provided a model that would have been immeasurably better and that has worked well for hospitals and patients in that state.

California’s Hospital Fair Pricing Act… limits how much California hospitals may charge uninsured patients who earn less than 350 percent of the FPL or insured patients whose medical bills exceed 10 percent of household income

Unless a miracle happens in the next several months, like the old song, we’re all going to wish we were living in California. When the doctors of all people in the AMA start calling out hospitals as bloodsuckers, you know we’re in a fight for our lives.


Please enjoy the Wallflowers’ Back to California