Obamacare is Delivering Some of the Goods in Poor States

Screen Shot 2016-08-14 at 10.37.59 AMNew Orleans   There are now some thirty states that have expanded eligibility for Medicaid under the Affordable Care Act. There are twenty states – and a lot of the Republican Congress — that are still dragging their wagons through the dirt, and, if researchers are right, putting their people under the ground as well.

Researchers connected with Harvard’s Public Health School conducted an important experiment. They surveyed people in Kentucky and Arkansas before Medicaid expansion in 2013, again after the first full year in 2014, and finally at the end of 2015 with another year under peoples’ belts. They used Texas as the so-called control state for comparison, since Texas refused to budge on the Obamacare Medicaid expansion for lower-income, working families. Bottom line: 5% more people in Arkansas and Kentucky, too very different states with different approaches on the expansion, felt that they were in “excellent” health compared to do-nothing-much Texas.

Reading about the researchers work on the Harvard Public Health website and its lead author, Dr. Benjamin Sommers, an assistant professor there, offered a good summary that goes deeper than 5%:

Sommers and colleagues surveyed approximately 9,000 low-income adults in Arkansas, Kentucky, and Texas from late 2013 to the end of 2015. The results showed that, between 2013 and 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with a much smaller change in Texas (39% to 32%). Expansion also was associated with significantly increased access to primary care, improved affordability of medications, reduced out-of-pocket spending, reduced likelihood of emergency department visits, and increased outpatient visits. Screening for diabetes, glucose testing among people with diabetes, and regular care for chronic conditions all increased significantly after expansion. Quality of care ratings improved significantly, as did the number of adults reporting excellent health.

Debate over? Of course not. Many will wonder, and wait, until larger studies, including the government’s own, provide more data on whether or not people really are healthier or just feel healthier.

Regardless, how people feel may not answer the medical questions fully, but could start to provide answers for the political questions. As we find every day, particularly in the Age of Trump, people vote on how they feel, not based on the facts of the matter. If everything were equal, politicians would see that the trend line of how people feel about their own health and Medicaid expansion is now improving annually. If it continues along these lines, politicians will start playing “duck and cover” which might mean more expansion in the twenty holdout states.

There’s a big “if” though. These same politicians would actually have to care about the poor families that are the beneficiaries of Medicaid expansion, and believe, regardless of the evidence, that they vote, and that some of these poor are their voters.

It might be easier to deliver better healthcare than to convince elected officials of the value of the poor and their votes.

Facebooktwittergoogle_plusredditpinterestlinkedinmail

Dutch Fight to Take Health Care Away from Private Insurers

Holland-plus-medicalBrussels   What is the old saying? Something like, I’ve seen the future and it is in the Netherlands at least when we are talking about the inevitable fight to come someday in the United States to seize control of our national health care programs from big health care insurers. On the way between Germany and Belgium, I had the opportunity to meet with several organizers and campaigners who have built a powerful effort in Holland on this issue and are finding the response amazing with the potential to dominate the campaigns in the country’s elections in the spring of 2017.

If you were paying close attention during the health care debates in recent years over the Affordable Care Act or Obamacare, as it is known popularly, you often heard about the health care insurance scheme in the Netherlands which was better in its broad coverage of the population but, unlike many other countries, was provided by private, rather than public, insurers. Meeting with the organizers, I came to understand the situation a bit better. Everyone pays the equivalent of about one-hundred euros or $112 per month to private companies for insurance. I was fuzzy on exactly how this part works but the fact that they mentioned that much of the Dutch public’s opposition was rooted in disgust at the millions and millions spent by the insurers in advertising and promotion leads me to believe that a family chooses an insurer for their coverage.

There’s also a hammer to the head in this program along the lines of the deductibles that come under Obamacare. Everyone has coverage and everyone pays, but when they actually use the insurance, they have to come up with another 385 euros or $429. For some reason it is called an “own risk” payment, since if you don’t need to buy medicine or go to the doctor, your monthly payments are more like a healthcare tax or donation, so that when you do utilize the system, this is more like an admissions fee. Similar to the US experience with high deductibles blocking utilization under Obamacare, estimates are that 20% of the Dutch people are avoiding accessing the healthcare system, even when they need it, because they cannot afford the additional payment.

So the campaign is seeking to get rid of that payment of course, but also to move to a national healthcare fund more along the lines of the national healthcare program enjoyed by other countries. The support for their campaign has surpassed all expectations, and that’s part of what brought us together in this exciting conversation. In less than two months about 60,000 people have signed up to support the campaign either online or directly, and, amazingly, almost half of them are taking the additional step of asking for an “action” package on steps they can take in their communities to build the campaign.

With elections happening in mid-March of next year, this campaign couldn’t have been timed any better, so if it continues to build momentum in the summer, this could be the issue that dominates progressive debate at every level during the election. Meanwhile, regional meetings throughout the country are also pulling in crowds double, triple, and quadruple of organizers’ expectations, more are set coming off the summer with big demonstrations and other actions planned in the fall. They are riding the whirlwind here, and while they are doing so, as I said earlier, they are running the pilot program that organizers in the United States and elsewhere will need to be studying and copying in order to deal with many of the same issues involving national – and better – healthcare in our countries.

Facebooktwittergoogle_plusredditpinterestlinkedinmail

Is Their Hope for Obamacare?

77639392New Orleans     A federal court somewhere gave new hope to the haters that the subsidies the Affordable Care Act to lower income families might be blocked.  The Administration says they will win on appeal.  But, this is only one cloud of many in the building thunderstorm.

            Insurance companies and those that follow them are almost universally saying that there will be significant price hikes in 2017.  Others are dropping by the wayside, largely because of their own bad pricing and marketing decisions, but nothing keeps them from finger pointing as they leave.  In many ways this was predictable.  As the signature legacy of President Obama, they are smart enough to wait until his long goodbye transitions into whatever and both he and Congress are lame ducks caught in a quacking stalemate, and roll up heavy on Clinton or Trump with the fait accompli

            Clinton has flirted towards the left with a vague proposal to potentially allow people 50 or 55 years of age to “buy into” Medicare, which would expand the coverage to millions more, if they have the money.  What it would still not do is solve any of the problems that continue to weigh heavily on Obamacare.

            Drug prices have continued to rise for example.  In fact, drug profiteering still seems a winning business plan despite the problems with Valeant and profiteers. 

            Charity requirements for nonprofits are still largely more pretense than policy.  Modern Healthcare reported 7 of the 10 most profitable hospitals of the top one-hundred in the country, according to a researcher at John Hopkins, were tax exempt nonprofits.  The three most profitable for profits were all part of the HCA chain and all three were in states like Texas and Florida that have not extended coverage under Obamacare.  Nonprofits were very well represented in the top 100, including Herman Memorial which has been the target of campaigns by Local 100 United Labor Unions and community allies in Houston and Ochsner, headquartered in New Orleans, which has also been called out for its miserly charity record.

            Emergency room doctors are reporting that half or more of the patients they are seeing are coming in late and with insurance, but had delayed seeking care because of the astronomical level of their deductibles, equivalent to having no insurance at all.   Employers of lower waged workers continue to develop such minimal coverage programs with impunity.  The coming year will see an even higher level of penalties appropriated against lower income workers who are running from the cost, deductibles, and copays, but will be caught by the mandated penalties.

            The bottom line is that, like any major piece of new potentially groundbreaking, safety net legislation there are problems.  There are pieces that beg to be fixed.  Meanwhile the deadlock in Congress simply lets the sores fester and pain endure without stepping up and fixing what is broken.  Health care continues to be a political football, as politicians maintain the fiction that this is all part of the game, rather than coming to terms with the fact that for many low and moderate income families, it’s life and death.

Facebooktwittergoogle_plusredditpinterestlinkedinmail

Penalties Under the Affordable Care Will Hit Lower Income Workers Hard

tax-penalties-carousel-rappler-20140416New Orleans    The good news in the narrative of Obamacare is that everyone gets covered, there are basic guarantees, and in 60% of the states more people, particularly lower income children, are covered by expanded Medicaid. Those are just the highlights, and they are lifesaving. The controversy continues for conservatives and businesses around the mandates, the fact that all businesses of a certain size are required to provide coverage. In truth, this is largely a fiction. The quieter, more painful, side of the mandates is the fact that everyone is required with some exceptions to embrace the coverage offered and available, and if not are also required to pay a penalty. The penalties were relatively trivial, but are becoming more expensive.

The fictional burden for companies has proven to be Swiss cheese, a drum I’ve admittedly been beating for several years now. Payments for monthly premiums could not be higher than a certain percentage of a worker’s gross payroll, but unlike the Massachusetts model, there were no limits on deductibles and little to none on co-pays. Nursing home chains, janitorial contractors, mental health and home care providers and untold other employers demanded and eagerly received from the insurers bare bones, narrow network plans with deductibles ranging from $4000 to $6500 along with significant increases in co-pays and of course required payment of monthly premiums.

The real cost to employers? Almost nothing in practice, because lower waged workers, making less than $15 or $20 per hour are priced out of such policies both by dollars and common sense. If a nursing home worker is making $10 per hour – and many aren’t! — and works an industry standard 35-hour week while being paid for annual labor about $18,000 in gross wages, and might be facing a $5000 deductible and to be conservative another $1000, she would be losing one-third of her income before she was able to access any benefits from the plan other than the statutory minimums. Why would she enroll in the employer’s plan if she were looking after her own economic self-interest? No reason, and in fact as Local 100  looks at the participation numbers from workers we represent, almost no one is signing except those who anticipate critical or catastrophic care situations like imminent surgery.

The math for the worker in this situation when required to pay penalties, as they are in Arkansas for example, at the 2.5% assessment would be $450. Cheaper to pay the piper than the policy. In Louisiana, Texas, and the other 18 states that did not expand Medicaid, if these workers would have been eligible, and with this income and likely family size, most of them would have been, they are exempted from paying the fine. There are other exemptions, but most are catastrophic in nature as well: homelessness, medical debt, unemployment, and worse.

Everyone is talking about inequality. Politicians, economists, and columnists on all sides of the spectrum make the point about jobs increasing but wages remaining stagnant, so the paradoxical impact of this healthcare conundrum is that the pain will worsen for lower income workers with largely frozen wages. In a ton of states not only will these workers not get raises, but they will pay in this example a fee out of their tax returns collected by the IRS.

For the nursing home worker we have used as an example, a $450 penalty under the Affordable Care Act is equal to twenty-five cents per hour in lost wages. In states throughout the South with strapped budgets and reduced reimbursements for such workers, they would need to win a 2.5% wage increase just to stay even, and without a union that’s not going to happen, and in all likelihood even with a union that’s going to be rare. Such a worker, and there will be millions of them, will wake up in 2016, 2017, and find themselves in a situation where they are in a double bind with a smaller paycheck and still no healthcare coverage thanks to the miserly offering of their employer and the loopholes that allow farcical coverage to mask as real insurance.

This is a huge problem, and it is not going to end well.

 

Facebooktwittergoogle_plusredditpinterestlinkedinmail

Congress is the Undercard, the Real Fight for Healthcare is Still Corporate

imrs.phpNew Orleans   Recently the House of Representatives voted to repeal the Affordable Care Act for something like the 62nd time. They have now almost banned Obamacare from being funded as many times as they have barred ACORN! The more you understand about the continued tug of war behind the scene with employers, hospitals, drug companies, doctors, and insurance companies, the more you realize the political machinations on the front pages are window dressing, just part of the puppet show as the pols are pulled back and forth, up and down by the big players. Not to mix too many metaphors, but they are the weak under-card in this fight, while the heavyweights are the companies punching back and forth for advantage.

Of course we have the scandalous way that some drug companies are trying to play arbitrage with people’s health and hike the prices of rare drugs through the roof, regardless of the body count, not caring about anything other than making Wall Street happy. This situation is so grotesque that Congress may be forced to do something about it. We also have 800 pound gorilla setting on the examining table and continuing to pose the most serious problem, increasingly noticed, but left unattended, and that is the persistent problem that employers did not play fair on Obamacare and have largely squeezed through the loopholes, providing coverage in name only with deductibles, co-payments, and monthly bills all collectively so high that millions of lower waged workers are having to embrace the fines, because actual health coverage on offer is financially out of their reach and unreasonable.

A story in Modern Healthcare about the insurance companies’ tug of war was also depressing and enlightening particularly because the companies continue to play such a huge, daunting role in the exchanges, pricing, and coverage. CMS, the Obamacare administrator, is trying to nail down regulations for 2017, understanding that they need to lock as many backdoors as possible before the Obamas pack out of the White House. They proposed a rule that would require any health insurers to require all insurer networks “to include hospitals and doctors within certain travel times or distances from members. There would also be minimum provider-to-member ratios for some medical specialties. The CMS wanted to make sure consumers had access to enough healthcare providers as more insurers moved to narrow-network products.”

And, that’s when everything hit the fan. The CMS is basically trying to make sure that those who buy into care get a standard package across the country to meet their health needs. The insurers and some of their buddies in the state insurance commission offices, who are most frequently their captive audiences, in some states are crying like stuck pigs. They claim they want to tailor the networks to each state rather than have a federal cookie cutter approach, but the real deal is likely just making a deal that makes the big insurers they are used to currying happier to do business with them. Many hospitals and doctor groups line up with CMS on this one rather than being hammered even harder by the insurance bullies. According to Modern Healthcare some of them even advocate that “the CMS…go a step further and build network standards for appointment wait times.”

Meanwhile hospitals and doctors have their own issues. Doctors employed by hospitals in Oregon have even organized a union because of rough handling by the hospitals. Hospitals are being scored by CMS for service, recovery, and billing and some of the outfits that can’t make the mark are squealing about the scores rather than trying to do better on the tests. Meanwhile hospital requirements for providing affordable care to justify their tax exemptions, enjoyed by many, are still resisting and avoiding any accountability.

My best advice is to not take your eye off of the healthcare fight. It’s a long way from over yet, and any notion that we won, has been gone since the early rounds.

***

Please enjoy Since You Been Gone by The Heavy.  Thanks to KABF.

Facebooktwittergoogle_plusredditpinterestlinkedinmail

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.

Facebooktwittergoogle_plusredditpinterestlinkedinmail