What Price Life?

November 29th, 2018 by Tom Lynch

Part One

“Insulin is my gift to mankind” – Frederick Banting

A Quick Quiz

Question 1: Name a chronic disease requiring medication, which, if not taken every day, guarantees death within two weeks.
Answer: Type 1 Diabetes.

Question 2: Name the medication.
Answer: Insulin.

Question 3: What is the monthly cost of insulin for a Type 1 diabetic?
Answer: As we shall see, that depends.

Question 4: If Type 1 diabetics cannot afford the cost of insulin, without which they will surely die, what should they do?
Answer: This is happening at this moment, and people are dying.  In these two blog posts we’ll examine why and what can be done about it. But we need to first posit some truths about diabetes, and then describe how, in 1922, Canadian doctor Frederick Banting made the ground-breaking discovery that allowed Type 1 diabetics, for the first time in history, to live.

Ten Fast Facts

  1. Insulin is a hormone made by the pancreas that allows the body to use sugar (glucose) from carbohydrates in the food we eat for energy or to store glucose for future use. Insulin helps keeps blood sugar levels from getting too high (hyperglycemia) or too low (hypoglycemia). Type 1 diabetics, T1Ds, can no longer produce insulin. They have none of it. Although older adults can also contract Type 1 diabetes, it usually strikes children and young adults. Without insulin, whether old or young, they die.
  2. There are about 1.3 million T1Ds in the U.S. They comprise one half of one percent of the population. Currently, there is no cure for any of them. Without insulin, they will die.
  3. There are about 29 million Type 2 diabetics. T2Ds still make some insulin. In most, lifestyle changes will improve their health, sometimes to the point where they will no longer require insulin or any other medical prescriptions. Some will become insulin-dependent, and without it, they face life-changing complications.
  4. Diabetic Retinopathy is the leading cause of blindness.
  5. Diabetes is the leading cause of non-traumatic amputation.
  6. Diabetes is a leading cause of heart attack and stroke.
  7. Diabetes is the leading cause of kidney failure.
  8. Complications from diabetes sometimes cause workplace injuries and often exacerbate the severity and length of recovery.
  9. In 2017, the nation’s total direct medical costs due to diabetes were $237 billion. Average medical expenses for diabetics were 2.3 times higher than for non-diabetics. The extent to which diabetes added to workers’ compensation medical costs is unknown.
  10. Based on information found on death certificates, diabetes was the 7th leading cause of death in the United States in 2015, with 79,535 death certificates listing it as the underlying cause of death, and 252,806 listing diabetes as an underlying or contributing cause of death. However, diabetes is underreported as a cause of death; studies have found that only about 35% to 40% of people with diabetes who died had diabetes listed anywhere on the death certificate and only 10% to 15% had it listed as the underlying cause of death. An example of best practice would be, “Death caused by infection contracted from hemodialysis due to kidney failure, a complication of the patient’s diabetes.”

Banting and Insulin

Image result for photo of frederick banting

Frederick Banting is perhaps Canada’s greatest hero. Born in 1891, he graduated medical school with a surgical degree in 1915 and found himself in a French trench by the end of 1917. In December of that year, he was wounded during the Battle of Cambrai, the first great tank battle in history. He remained on the battlefield for 16 hours tending to other wounded soldiers until he had to be ordered to the rear to have his own wounds treated. For this action he won the British Military Cross, akin to America’s Silver Star. After returning to Canada, he continued his studies and, in 1920, secured a part time teaching post at Western Ontario University. While there, he began studying insulin Why? Serendipity. Someone had asked him to give a talk on the workings of the pancreas.

Banting became interested – and then obsessed – with trying to come up with a way to get insulin to people who couldn’t make any of their own. In November 1921, he hit on the idea of extracting insulin from fetal pancreases of cows and pigs. He discussed the approach with J. R. R. MacLeod, Professor of Physiology at the University of Toronto. MacLeod thought Banting’s idea was doomed to failure, but he allowed him to use his lab facilities while he was on a golfing holiday in Scotland. He also loaned him two assistants, Dr. Charles Best and biochemist James Collip. Collip devised a method to purify the insulin Banting and Best obtained from the fetal pancreases.

To MacLeod’s surprise, Banting’s procedure worked, and in 1922 Banting and Best successfully treated the daughter of US Secretary of State Charles Evans Hughes.

In 1923, one year later, Banting, at the age of 32, won the Nobel Prize, which, to his disgust, he had to share with MacLeod. To this day, Frederick Banting is the youngest person ever to win the Prize in Physiology or Medicine.

His discovery could have made Banting mind-numbingly rich, but he would have none of that. Along with Best and Collip, Banting patented his method and then the three of them sold the patent to the University of Toronto for the princely sum of $3.00. When asked why he didn’t cash in on his discovery, Banting said, “Insulin is my gift to mankind.” With Banting’s blessing, the University licensed insulin’s manufacturing to drug companies, royalty free. If drug companies didn’t have to pay royalties, Banting thought they would keep the price of insulin low.

And they did. For decades.

But patents expire, and capitalism being what it is, people get greedy, and greed is why we have no generic, low-cost insulin today and why, over the past 20 years, insulin prices have risen anywhere from 800% to 1,157%, depending on the variety and brand. It’s why, lacking health insurance, some Type 1 diabetics have recently been driven to ration their precious insulin. Some of them have died.

More about all that in Part Two.

 

 

 

Violence In The ER: A Big Problem Getting Worse

November 26th, 2018 by Tom Lynch

Men and women who yearn to follow in the footsteps of Hippocrates, Galen and Banting are taught many things in Med School, but there is no course called Violence In The ER, And What To Do When It Happens To You. 

Until recent times that hasn’t been much of an issue for the doctors and nurses who take care of us when we need critical care in a hurry. But in the 21st century, violence in the ER has become less the exception and more the rule.

In a 2018 American College of Emergency Physicians (ACEP) survey of 3,539 ER doctors, 47% reported being assaulted at work, 60% of those within the last year.

Why is this happening? According to ACEP, there are at least three problems with no easy solutions causing the sharp uptick in ER violence.

First, America has a tremendous shortage of psychiatric beds for people in profound mental stress. That means people in serious need of behavioral and mental health care can languish on a gurney in the ER for days, even weeks until a bed becomes available somewhere. Second, patients who’ve become addicted to opioids often show up in the ER demanding medication, and when they don’t get it things can get dicey in a hurry. Third, hospitals haven’t done enough to protect physicians and nurses from attacks by highly-stressed knife and (sometimes) gun wielding patients. Some hospitals have installed metal detectors at entrances, but the detectors and the labor required to screen incoming people can be pretty expensive, especially to a cash-strapped community hospital. Even with the metal detectors, many doctors in the ACEP study reported being kicked, punched, bitten and spit upon by deranged patients. This is a difficult issue for hospital risk managers to confront successfully.

We’ve known for many years that nurses and nursing aides are much more likely than other professionals to be victims of violence in the workplace. According to the US Bureau of Labor Statistics, “intentional injury’’ by another person rose nearly 50%, from 6.4 per 10,000 hospital workers in 2011 to 9.0 per 10,000 hospital workers in 2016, the most recent year of data. The rate across private industry is 1.7. OSHA has analyzed this and published Guidelines for dealing with it. But the ACEP survey is one of the first to shine a light on the stark potential for violent harm confronting Emergency Physicians.

One wonders if the threat of violence in the ER will dissuade med school graduates from specializing in Emergency Medicine. This would certainly be unfortunate, because a shortage already exists for rural ER physicians as documented in a June 2018 study published in the Annals of Emergency Medicine. At the time of the study, more than 27 percent of US rural  counties did not have emergency medicine clinicians and 41.4 percent of counties did not have any emergency physicians reimbursed by Medicare fee-for-service Part B, according to the study.

We’ll continue to follow this phenomenon and occasionally report on progress or lack of it in protecting these highly trained and dedicated life savers. For, now, consider this graphic from the aforementioned ACEP study.

November Health Wonk Review and other news of note

November 16th, 2018 by Julie Ferguson

Lisa Lines is hosting this month’s dose of health wonkery at The Medical Care Blog: Health Wonk Review – November 2018. There’s a good roundup of health issues submitted by the usual subjects – check it out. Lisa is an ongoing contributor to HWR but a first-time host. Be sure to kick the tires on the hosting blog while you are visiting. The nonprofit, volunteer blog is sponsored by peer-reviewd journal Medical Care and sponsored by the Medical Care Section of the American Public Health Association.

 

illustration of man reading the news

And in other noteworthy news

Don’t miss: Joe Paduda’s four-part series on claim counts: 1) why claims are down; 2) claim frequency; 3) OSHA reportables, and 4) BLS data

Kudos: We’ve been a long-time fan of Ken Ward Jr.’s investigative reporting … we’ve linked his Coal Tattoo blog in our sidebar and he has been our go-to source on various topics, including the Upper Big Branch mining disaster and the subsequent trail of Don Blankenship. We were so pleased to see that he was awarded a MacArthur fellowship (aka a “genius grant”) — from the John D. and Catherine T. MacArthur Foundation.

Jury weighs in: Jacobs Engineering endangered Kingston disaster clean-up workers
“More than 30 workers who cleaned up the December 2008 spill at the Tennessee Valley Authority Kingston Fossil Fuel Power Plant in Roane County are dead, and more than 250 are sick or dying. They sued Jacobs Engineering, a global contractor TVA put in charge of cleaning up its mess and keeping workers safe. TVA ratepayers paid the firm more than $64 million.”
Related: At Confined Space, Jordan Barab highlights an interview with investigative journalist Jamie Satterfield who is covering this story.

New:  Chemical Safety Board ‘Safety Digest’ focuses on emergency planning, response

FMLA, ADA: Attorney Jeff Nowak of FMLA Insights blog is offering a free Webinar providing a roadmap to create your own FMLA & ADA manager training on December 12.

 

 

At The Bottom Looking Up

November 13th, 2018 by Tom Lynch

What does a nation owe its citizens with respect to health care?

For nearly all members of the Organization for Economic and Cooperative Development (OECD), the answer is guaranteed, high-quality, universal care at reasonable, affordable cost. For OECD founding member America, the answer seems to have become an opportunity to access care, which may or may not be of high-quality at indeterminate, wildly fluctuating and geographically varying cost.

It is indisputable that the US devotes more of its GDP to health care than other countries. How much more? For that answer we can turn to many sources, roughly all saying the same thing. The OECD produces annual date, as does the World Health Organization, among others. Another reliable and respected source is The Commonwealth Fund, which conducted a study of eleven high income OECD members including the US. The collection of health care cost data lags, so data from this study is mostly from 2014. Here is the cost picture:

As you can see, in 1980, US spending was not much different from the other ten OECD countries in the study. While high, it was at least in the same universe. But now, at 50% more than Switzerland, our closest competitor in the “how much can we spend” sweepstakes”, we might be forgiven for asking, “What in the name of Hippocrates happened?” As if this weren’t enough, the 2014 GDP percentage of spend, 16.6%, has now risen to nearly 18%, according to the CMS.

So, what do we get for all that money? We ought to have the highest life expectancy, the lowest infant mortality rate and the best health care outcomes in the entire OECD. But we don’t.

For many readers, it is probably galling to see both the UK and Australia at the top of the health care system performance measure and at the bottom of the spending measure. In the early 2000s, each of these countries poured a significant amount of money into improving its performance, and the results speak for themselves.

Consider all of this mere background to the purpose of this blog post.

Last week, we wrote about the terrible, 40-year stagnation of real wage growth in the US, pointing out that in that period real wages in 1982-1984 constant dollars have risen only 4.5%. But, as we have seen, health care spending did not follow that trajectory. This has resulted in tremendous hardship for families as they have tried to keep pace with rising health care costs. For, just as US health care spending has risen dramatically since 1980, so has what families have to pay for it.

To put this in perspective, consider this. Since 1999 the US CPI has risen 54%, but, as the chart above shows, the cost of an employer offered family plan has risen 338%. If a family’s health care plan’s cost growth had been inflation-based, the total cost to employer and employee would be $8,898 in 2018, not $19,616. In 2018, the average family in an employer-based plan pays 30% of the plan’s cost ($6,850), plus a $2,000 deductible, plus co-pays that average $20 whenever health care is accessed, plus varying levels of co-pays for drugs.

On top of all that is the enormous difficulty people have in trying to navigate the dizzying health care system (if you can call it that). American health care is a dense forest of bewildering complexity, a many-headed Hydra that would make Hesiod proud, a labyrinthine geography in which even Theseus with his ball of string would find himself lost.

With wages and health care costs growing ever farther apart, America has a crisis of epic proportion. Yet all we can seem to do is shout at each other about it. When do you think that will end? When will we begin to answer the question that this post began with: What does a nation owe its citizens with respect to health care? When will our nation’s leaders realize we can actually learn from countries like Australia, the UK, Switzerland and all the other high performing, low cost members of the OECD? Continuing on the present course is no longer a viable option.

 

Note: You may be questioning The Commonwealth Fund’s research. To put your mind at ease about that, here are the study sources:

Our data come from a variety of sources. One is comparative survey research. Since 1998, The Commonwealth Fund, in collaboration with international partners, has supported surveys of patients and primary care physicians in advanced countries, collecting information for a standardized set of metrics on health system performance. Other comparative data are drawn from the most recent reports of the Organization for Economic Cooperation and Development (OECD), the European Observatory on Health Systems and Policies, and the World Health Organization (WHO).

 

 

It Is Time

November 5th, 2018 by Tom Lynch

This is not a piece about insurance or health care. It won’t make the cut for Health Wonk Review and it will probably cost us readers (Well, 15 years has been a pretty good run). What this piece is is one that addresses the health of our nation.

Today, the Bureau of Labor Statistics (BLS) released a chart showing gains in productivity and hourly wages from Q3 2017 to Q3 2018. It looks remarkably similar to the chart BLS released at the end of Q2. Impressive Productivity and Output gains in both quarters. And, if you didn’t know better, you’d think Hourly Compensation is rising pretty well, too.

However, look to the far right of both charts to see the change in Real Hourly Wages, which are wages after inflation is factored in. The Trump administration and most of the press have trumpeted (pun intended) the nominal wage increase of 2.8% for Nonfarm Business and 2.2% for Manufacturing in Q3, 3.2% and 2.5%, respectively, in Q2, without saying a thing about the negligible, and in some cases decreasing, Real Wages.

Real Wages for Nonfarm Business during this one-year period (Q3 to Q3) are up a measly 0.1%, after rising an anemic 0.5% in Q2; Manufacturing Real Wages in Q3 are actually down 0.4% after being down 0.2% in Q2. And this is not a new phenomenon. In the 40 years since 1979, Real Wages for hourly and non-supervisory workers have increased by a total of only 4.5%. During that same period, the CPI has risen 247.7%.

These are not “alternative facts.”

Since the day Donald Trump and his cronies got the keys to the kingdom, Real Wages per week have risen from $349 to $351 in constant 1982-1984 dollars. Two bucks! For the mathematically inclined among you, that’s an increase of 0.005%. During the same period, the Dow Jones average has grown 20.9%, and that counts the recent decline. I like the stock market as well as the next guy, but barely one-third of families in the bottom 50% of earners own stocks, according to the Federal Reserve. The fact is, lower-income Americans don’t have extra money to put into stocks, and a third of workers don’t have access to a 401(k) or another retirement plan, according to Pew.

The facts make clear that since Republicans took control of everything, the economic gains  have gone to the top earners. Folks in the middle and lower end have, to a large degree, been left by the wayside. Inequality reigns supreme. It is beyond baffling that these people who continue to get the smelly end of the stick resolutely remain, seemingly unperturbed, in the center of Mr. Trump’s base. Look at the enthused, smiling faces at his rallies. Sociologists have written about this, but I have yet to see anything that explains it fully.

Regardless, tomorrow is Election Day. Many of us have already voted. Many more will exercise the option tomorrow. Predictions call for a large turnout, large being defined, God help us, as perhaps a little more than half. I’m now in my eighth decade, and I cannot recall a more consequential election.

Many Americans (as well as some of my friends) are highly satisfied with the tax law changes, the rise in the stock market and the new makeup of the Supreme Court. In exchange for those they allow, without condemnation, the bullying behavior, the constant hyperbole, the ad hominem attacks and the non-stop lying.

It is time for the better angels of our nature to rise to the challenge. It is time to demand decency, and it is time to reject the abject vulgarity that oozes from the awesome edifice where John Adams, Thomas Jefferson and Abraham Lincoln once lived and guided the nation. It is time to raise up America to its true potential. It is time for America to become once again the world’s beacon of hope. Maybe tomorrow America will say, “It is time.” To quote John Milton, “Hope springs eternal.”

Perhaps it is fitting to end this non-insurance piece with the words John Adams wrote to his wife Abigail at the end of his first day residing in the yet-to-be-completed new White House in 1800. Franklin Roosevelt had the words engraved onto the mantel of the White House State Dining Room in 1945. Adams wrote, “May none but honest and wise men ever rule under this roof.” I wonder if the current occupant has ever seen those words.

Nurses, Nursing Assistants And Back Injuries: ‘Twas Ever Thus

October 3rd, 2018 by Tom Lynch

“Occasionally the complaint is made that a nurse has injured her back … in moving a patient.”
Nursing: Its Principles And Practices; Robb, Isabel Adams, Mrs.; W.B.Saunders, Philadelphia, 1898.

Lynch Ryan’s very first client was a Massachusetts Community Hospital where the Experience Modification Factor was 2.77, primarily due to nursing and nursing assistant back injuries. The year was 1984, eighty-six years after Mrs. Robb’s observation, quoted above, and the Hospital had two problems: What to do about the employees who were suffering the back injuries and how to prevent them from happening in the future. Pulling a good-sized rabbit out of a small-sized hat, we were spectacularly successful at solving the first problem and pathetic failures when it came to the second. Oh, we knew what should be done. We had grand plans, but execution was beyond all our best efforts. And the problem continues to this day with no end in sight.

When we studied the problem of back injury prevention in the nursing industry back in 1984, these are the things that got in the way of a successful result then and where they stand today:

  • The vast preponderance of  back injuries happened while nurses and nursing assistants were trying to lift or move patients. That is still the primary problem;
  • In nearly all back injury cases, patient lifting or moving was being performed manually. It still is;
  • Although mechanical lifts were available for purchase, they were expensive and took time to set up and use, time that was often in short supply. Today, a Hoyer Manual Hydraulic Lift costs anywhere from $900 to $1,400; slings are about $370. Hospitals should have a couple units per floor. Employees need to be trained in how to use the equipment. A few hospitals, very few, have specially designated and trained teams. Although not a really big ticket item, the costs do add up, and the administrative logistics can be daunting;
  • There was no limit on how much a nurse or assistant would be required to lift, and more and more obese patients were turning up in the hospital. That issue is much worse now;
  • Many nurses and nursing assistants were themselves overweight or obese and, consequently, even more unable to lift overweight or obese patients. Today, in addition to the weight issue, which still remains (a 2012 University of Maryland study found 55% of nurses to be obese), the average age of nurses is higher than it was in the 1980s, and, because of budget constraints, there are fewer of them per patient.

While back injuries are the greatest source of loss with respect to nurses, the situation is even more problematic for nursing assistants, as this chart from the Bureau of Labor Statistics (BLS) shows.

As you can see, nursing assistants suffer more back injuries than any other occupation. And as America continues to age – baby boomers turn 65 at the rate of one every nine seconds – the problem is only going to get worse.

This horrendoma that nobody seems to want to address is so severe that injuries in the health care sector dwarf any other industry, as another BLS chart shows for 2016, the most recent year for which there is data.

As we careen, helter skelter, down the Make America Great Again pothole-pockmarked highway, you’d think some genius would finally figure out how to fix the problem Mrs. Robb identified back in 1898. Then again, maybe not.

The waning days of summer Health Wonk Review

August 23rd, 2018 by Julie Ferguson

 

Through vacations, heat waves, and days on the beach, our health policy wonks are still on the job. As we eke out the remaining days of summer and slouch toward the interim election, they continue their relentless focus on opining about the issues of the day. Check our August edition entries.

  • First up, Joe Paduda unpacks the generic term to uncover the varied approaches to universal coverage currently operating at far lower cost and far better outcomes than our “multi-payer” “system” in his post What exactly is single payer at Managed Care Matters.
  • Louise Norris tells us that the Trump administration has finalized rules that will make it easier for many Americans to buy short-term health insurance plans that may be less expensive – but aren’t as comprehensive as ACA-compliant plans. She explains the rules and how they’ll affect consumers in her post at healthInsurance.org Blog: ‘So long’ to limits on short-term plans.
  • At InsureBlog, Patrick Paule puts paid to the notion that Medicare4All is any great deal or panacea. he makes his case in his post On BernieCare.
  • What’s worse than needing help with gait, mobility and balance? Being told you need a walker. No wonder, when the typical walker basically screams “frail elderly,” and is difficult to use as well. At Health Business Blog, David Williams talks with neurologist Patricia Kavanagh about how she teamed up with a design and production team to a modern device that is more functional and stylish in an effort to get her patients with Parkinson’s and other movement disorders to use a walker.
  • Vincent Grippi pf the CareCentrix’s Homefront Blog submits this month’s episode of #CareTalk, in which David Williams (Health Business Group) and John Driscoll (CareCentrix) discuss Trump’s fight with Pfizer over drug pricing, and more.

 

Next issue: September 20 – Andrew Sprung – xpostfactoid

 

Summertime reading: Fresh Health Wonk Review & news on our radar

July 12th, 2018 by Julie Ferguson

Catch up with he latest news and thinking on health care policy issues – Peggy Salvatore has a fresh Health Wonk Review July 2018: Summer’s Coming Around Again edition posted at Health System Ed blog. Topics range from opioids and Purdue Pharma to high deductible plans and the cost of end-of-life care – grab a coffee and check it out!

A few other recent news items on our radar:

NCCI has issued a new a new Insights report on Post-Traumatic Stress Disorder in Workers Compensation. Several states are currently exploring the issue of PTSD injury compensation – it comes up frequently for police, firefighters and other first responders.
Speaking of trauma, if PTSD is on your radar, the New York Times reviews various books on how people recover from trauma, including one by Elizabeth Smart. See Adversity Needn’t Thwart or Define You. Here’s How to Cope.

Work comp drug costs have dropped by over a billion dollars over the last eight years, largely driven by sharply lower opioid utilization. Learn more about this in the 15th annual Survey of Prescription Drug Management in Workers’ Comp via Joe Paduda, CompPharma.

A new Lockton study says that nearly 70% of denied workers’ comp claims are converted and those claims can cost up to 50% more.

Top causes of high-dollar workers’ comp claims. Safety National recently completed a review of its largest workers’ comp claims and uncovered certain trends employers should be aware of.

WCRI Study Compares Hospital Outpatient Payments Across 35 States

Florida’ Supreme Court in Workers’ Compensation – David Langham

12 fast-rising technologies to get ready for

Trump’s trade war has started. Who’s been helped and who’s been hurt?

The U.S. labor shortage is reaching a critical point

Dispatches From the Front Lines of the Battle For Workplace Safety: Short Stuff – Jordan Barab

Cyber-Risk Costs Resist Overall Trend – Businesses’ total cost of risk declined in 2017, but cyber insurance rose 33%.

Cancer prevalence among flight attendants compared to the general population

Who Will Be Sued When A Robot Causes Harm?

Bezos, Buffett, Dimon Name Dr. Atul Gawande CEO of New Healthcare Company

One Man and a Hand Truck

Fentanyls and the Safety of First Responders: Science and Recommendations

Quo Vadis, Kentucky?

July 10th, 2018 by Tom Lynch

June 29, 2018. Thirteen days ago. I’m sitting in the Grand Ballroom of the Capital Hilton Hotel in Washington, DC, soaking in the presentations at the Annual Conference and CEO Summit of the Association for Community Affiliated Plans (ACAP). ACAP has grown to be quite the force for Medicare Advantage and Medicaid health plans around the country. So, the conference is an important event for Medicare and Medicaid professionals.

I’m looking forward to the 3:30 p.m. session, Plans Involvement in the New World of Work Requirements, because Mark Carter and Carl Felix, CEO and COO, respectively, of Kentucky’s Passport Health Plan, are going to describe their efforts to implement the Bluegrass State’s Medicaid work requirements.

In early January, 2018, Kentucky became the first state to win CMS approval to institute work requirements for its Medicaid beneficiaries. As I sit in the Hilton’s ballroom, its new  Medicaid work requirement program, Kentucky HEALTH, is slated to go live in two days (state government is only outdone by the US Army in its genius-like ability to create acronyms; this one stands for Helping to Engage and Achieve Long Term Health; catchy, eh?). There’s a pesky lawsuit lurking in the wings aimed at getting the Court to declare the program unconstitutional, but on June 29 Kentucky bureaucrats are ready to drop the hammer.

So, I am really interested in learning about the looming work requirement program, because three other states have won approval and are putting their programs together, and more are waiting in the wings.

Unfortunately, at the last minute, Mark and Carl (remember them?) have to cancel, because in the mad dash to the finish line for Kentucky HEALTH’s launch, they actually can’t leave the office. But, not to worry. Kentucky HEALTH’s Chief Marketing Officer is here to fill us in.

As she takes us through Kentucky HEALTH’s creation, I have to say that I, and the three or four hundred other people in the room are absolutely astonished at the time, money, manpower and all-around effort involved in giving birth to this behemoth. In terms of planning and implementation preparation, Kentucky HEALTH may perhaps only be exceeded by Operation Overlord (look it up). Some highlights:

  • For the first time EVER, Kentucky’s Medicaid beneficiaries will have to pay premiums. The premiums aren’t a lot (to you and me), ranging from $1 to $15 per month. Pregnant women and children are exempt.
  • Individuals with income above the poverty level ($12,060) who do not pay their premiums in 60 days will be kicked out of coverage for six months. Enrollees can return to the program earlier if they pay two months of missed premiums and make one new premium payment. They also must complete a financial or health literacy course.
  • Individuals must either work, volunteer, be enrolled in schooling or do some kind of “qualified community engagement” for at least 80 hours per month.
  • Beneficiaries must report their work activity each month; failure to do so will cause Medicaid disenrollment for six months.
  • Healthcare providers will have to certify to the Commonwealth the health status of those individuals they deem physically unable to work.

Regarding that last bullet – Kentucky HEALTH created a seven page form providers must complete. Knowing how busy healthcare providers are, I ask, “What’s been the feedback from your providers about this seven page form, and, by the way, are you paying them to do it?” Answer: “We haven’t communicated with the providers about this. We consider it all part of an office visit.”

For a moment, put aside why Kentucky is going to all this trouble. The bottom line question is: What does it get for going to all this trouble? In its need to get freeloaders off Medicaid rolls, just how many people would Kentucky’s work requirements actually put to work?

The nonprofit Kaiser Family Foundation provides some answers. Let’s check the numbers. Nationally:

  • About 10% of Medicaid recipients are elderly, age 65 and older, and many of them are in nursing homes.
  • About 48% are children, age 18 and younger.
  • That leaves about 42% who are of working age and potentially subject to the requirements.
  • Of that 42% who could be subject to the rules, 42% of them are already working full-time, and 18% are working part-time.
  • Another 14% are not working due to illness or disability.
  • Six percent are in school.
  • Twelve percent are caregivers for family members.
  • All of the above would be exempt from Kentucky’s rules.

That leaves about 1% of all Medicaid beneficiaries who would qualify for a work requirement program like Kentucky’s. That’s about 740,000 people nationally and around 12,000 in Kentucky (Since 2014, when Kentucky accepted Medicaid expansion, its Medicaid population has about doubled, rising from around 650,000 to 1.2 million) .

Kentucky HEALTH’s CMO wouldn’t (or couldn’t) say how much the state has spent on putting the program together or how many people have been devoted to it. But its best case scenario is that out of 1.2 million current beneficiaries about 95,000 may be off the rolls in five years, because either they no longer qualify for Medicaid because they either make too much money due to full-time work or they fail to comply with work requirements.

The day after the Kentucky HEALTH presentation at the ACAP conference District court Judge James Boasberg ruled Kentucky’s plan unlawful, because the federal government is obligated under federal law to consider whether a Medicaid proposal advances the program’s objectives, the judge wrote, and the Trump administration failed to meet that standard before approving Kentucky’s plan.

One final thought. When he announced the Trump administration’s approval of Kentucky’s work requirement plan, Governor Matt Bevin said, “I was raised by a father who said, ‘Don’t take something that is not earned.’” So, here’s the question: Unlike the entirety of the rest of the developed world, in America is basic health care something that has to be “earned?”

 

 

Your monthly dose of health wonkery

June 14th, 2018 by Julie Ferguson

Despite vacations, graduations, weddings and all the usual seasonal distractions, the Health Wonks are on the job. The June compendium of health policy news is freshly posted by long-time wonk Hank Stern at InsureBlog — and speaking of weddings, he’s posted A Midsummer Night’s Health Wonk Review. There are many great entries from the usual suspects so grab a coffee and check it out.