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.

Bulletin: Dog Catches Bus! Now What?

June 12th, 2018 by Tom Lynch

We’re goin’ right straight back to 2010
To start the health care war all over again!

It took time, but the GOP has finally learned a thing or two about fighting the Affordable Care Act, or, as they insist on calling it: Obamacare. You will recall that in 2017, after achieving control of all three branches of government, the party of Abraham Lincoln launched, in another Ground Hog Day moment, its biggest ever attack on the ACA, only to see its troops repulsed and annihilated once again by the turned down thumb of a war hero.

And then, after so many defeats there was a “light dawning over Marblehead” moment that would have made Prince Talleyrand proud.  In what the army calls a “triple flank,” republicans:

  1. In their humongously big 2017 tax cut law, zeroed out the penalty for not having health insurance;
  2. In February, 2018, got 20 states to sue the federal government contending that repeal of the penalty obviates the individual mandate making the entirety of the ACA unconstitutional.
  3. In May, 2018, somehow convinced the Justice Department not to defend the government in the suit.

Wow! A trifecta!

If the 20 states prevail, collateral damage abounds. First and foremost, the ACA’s provision that insurers not discriminate against people with pre-existing conditions. There are about 133 million Americans, under the age of 65, who fall into that health care Punji Pit. Prior to the ACA these family members, friends or neighbors of ours could be either denied coverage relating to their conditions, or charged exorbitant premiums. Beginning in 2014, the ACA forbade that. If the states win their suit, that meaty provision of the law, which a Kaiser tracking poll shows 70% of the population supports, gets torn up into little pieces and fed to the crows.

You might ask, “What do insurance companies think about all this?” Well, they do not like it one bit. America’s Health Insurance Plans, the trade association for health insurance companies, supports the pre-existing condition protections under the ACA. “Removing those provisions will result in renewed uncertainty in the individual market, create a patchwork of requirements in the states, cause rates to go even higher for older Americans and sicker patients, and make it challenging to introduce products and rates for 2019,” AHIP said in a statement.

So, here’s the question: If the 20 states actually win their suit, what happens then? Among many groups, the 1.25 million Americans with Type 1 diabetes who need to inject costly insulin every day to stay alive are waiting for an answer.

Health Wonk Review – Instagram Style

May 17th, 2018 by Tom Lynch

A picture’s worth a thousand words, and today Jason Shafrin proves it at Healthcare Economist. Jason has a photo, a chart, a graph and even a cartoon (for you Sponge Bob lovers) to illustrate what Health Wonk Review authors are posting.

We’re heading toward summer, although you’d never know it from the weather we’ve been gifted here in Massachusetts. Regardless, grab a mug of whatever you like, sit back, put your feet up and take a stroll through a Wonk garden filled with some excellent health care policy thinking.

It’s The Zip Code, Stupid! Update

May 10th, 2018 by Tom Lynch

At the end of February 2018, we wrote about a May 2017 study in JAMA Internal Medicine that concluded that where one lives is a bigger factor in health care outcomes than actual health care. This from our February post:

Geography is the biggest X-Factor in today’s American Hellzapoppin version of health care. The study analyzed every US county using data from deidentified death records from the National Center for Health Statistics (NCHS), and population counts from the US Census Bureau, NCHS, and the Human Mortality Databas and found striking differences in life expectancy. The gap between counties from lowest to highest life expectancy at birth was 20.1 years.

And, surpirse, surprise, it turns out if you live in a wealthy county with excellent access to high level health care, like Summit County, Colorado (life expectancy: 86.83), you’re likely to live about 15 years longer than if you live, say, in Humphries County, Mississippi, where life expectancy at birth is 71.9 years.  So, yes, Zip Code matters.

The concept of  zip code influence seems to be gaining traction. Today, from AIS Health Daily, we learn  a number of Blues Plans are planning on targeting the “where you live” problem with innovative strategies. Here is the AIS Daily release:

Blues Plans Work to Combat “ZIP Code Effect”
The Blue Cross and Blue Shield Association (BCBSA) recently launched the Blue Cross Blue Shield Institute, a subsidiary of BCBSA created to address social and environmental issues, as evidence mounts that health outcomes may be affected as much or more by social determinants of health as they are by actual medical care.
The Blue Cross Blue Shield Institute says it will address what it calls the “ZIP code effect,” which encompasses transportation, pharmacy, nutrition and fitness deserts in specific neighborhoods. It is partnering with Lyft, Inc., CVS Health Corp. and Walgreens Boots Alliance to address transportation and pharmacy deserts. The institute says it plans to deal with fitness and nutrition deserts in 2019.
Meanwhile, Highmark Inc. will launch a transportation initiative this summer to provide rides for members with chronic health conditions who live in a transportation desert. The service will begin in Pittsburgh as a pilot.
On April 17, Highmark’s Allegheny Health Network opened its Health Food Center, which acts as a “food pharmacy” where patients who lack access to food can receive nutritious food items, education on disease-specific diets and additional services for other social challenges they may face.
Other Blues plans also are addressing social determinants of health. For instance, Blue Cross and Blue Shield of North Carolina intends to invest part of its savings from the Tax Cuts and Jobs Act of 2017 into community health programs.
At Independence Blue Cross, the Independence Blue Cross Foundation’s Blue Safety Net Program offers “mobilized services” to medically underserved communities. The IBC Foundation sponsors the Philadelphia Eagles Youth Partnership’s Eagles Eye Mobile to conduct free vision screenings and eye exams and provide prescription glasses to under-insured and uninsured children.
We salute the Blues for recognizing the problem and trying to do something productive about it.
Final thought: If you do not subscribe to AIS Health Daily, you should.

On Empathy And Thoughtful Leadership

May 10th, 2018 by Tom Lynch

In his May 1 column for Risk & Insurance, Roberto Ceniceros, evoking the memory of Abraham Lincoln, describes and recommends a leadership style radically different from that of the tweet-driven current occupant of 1600 Pennsylvania Avenue.

Like Mr. Trump, Lincoln had quite a temper. However, over the course of his life he came to recognize it as a weakness. In many cases, when someone caused his blood to boil, which happened frequently during the Civil War, rather than immediately lashing out, he would often withdraw and write a letter to the offending party detailing in stark terms his great disappointment. He would then put the letter in a desk drawer and more often than not never send it. This mental health exercise would calm him and allow him to deal with the issue in a more thoughtful manner.

in his column, Mr. Ceniceros suggests Lincoln’s method defines a highly self-aware and empathic person. He writes that this behavioral characteristic was shared by four other historical figures described in “Forged in Crisis: The Power of Courageous Leadership in Turbulent Times,” written by Harvard Business School historian Nancy Koehn.

As described by Mr. Ceniceros, Keohn’s book:

…includes the story of Ernest Shackleton, hailed in previous business-management books for leading his shipwrecked and isolated crew off Antarctic ice flows. The other biographies feature abolitionist Frederick Douglass; Dietrich Bonhoeffer, imprisoned by the Gestapo and murdered for opposing the Third Reich; and scientist and author Rachel Carson, who raced against cancer to finish her manuscript on the dangers of mass pesticide use.

All five of these courageous people overcame nearly impossible challenges, but Shackleton, who simply refused to let anyone under his commend die on their perilous journey, and Lincoln, who simply refused to let the Union die on his watch, embody an empathy of heroic proportion.

Another person who should be included in this group is Ulysses S. Grant, 18th president of the United States. Grant was a great leader, but a total disaster as an administrator, primarily because of his trustful nature. His presidency is historically noted for profound corruption and scandals. In private life he failed miserably, both before the war and after it. In 1884, after his final business venture left him penniless, he contracted terminal cancer. His friend, Mark Twain, suggested Grant write his autobiography, which Twain would publish, giving Grant extremely favorable royalties (30%). Faced with impending death, Grant simply refused to die and leave his family in abject poverty. He raced to complete the Personal Memoirs of Ulysses S. Grant, an autobiography Twain described this way:

I had been comparing the memoirs with Caesar‘s Commentaries. …I was able to say in all sincerity, that the same high merits distinguished both books—clarity of statement, directness, simplicity, unpretentiousness, manifest truthfulness, fairness and justice toward friend and foe alike, soldierly candor and frankness, and soldierly avoidance of flowery speech. I placed the two books side by side upon the same high level, and I still think that they belonged there.

Grant died five days after finishing the book. His heirs received royalties of about $450,000, which, in today’s currency, comes to about $12 million.

 

 

Lincoln, with his letters, Shackleton, his loyalty, and Grant, with an indomitable will to provide for his family, personify dedication to others on an heroic scale. Roberto Ceniceros’s column is a poignant reminder that character matters, that a forceful personality can be used for good or ill, that humility is the foundation of empathy.

Donald Trump should start writing letters.

Workers Memorial Day: April 28

April 27th, 2018 by Julie Ferguson

worker memorial day poster

Every year, April 28 is Workers Memorial Day, a global day of remembrance for those who have suffered and died on the job, as well as a day to renew a focus and commitment to safer jobs and workplaces. It’s also an annual reminder that most workplace injuries are preventable in nature. The AFL-CIO first initiated Worker Memorial Day in 1970, the same year that Congress enacted the Occupational Safety and Health Act (OSHA).

For more history on the event, see Jordan Barab’s post at Confined Space: Approaching Workers Memorial Day. He links to both the annual Death on the Job report and the National COSH annual Dirty Dozen 2018 report on “Employers Who Put Workers and Communities at Risk.” There are some familiar names on the list that some may find surprising.

To participate in Saturday’s commemoration or to learn more:

AFL-CIO: Find an event near you

OSHA: find an event near you

National Council for Occupational Safety and Health (COSH) – Events

28april.org – Hazards magazine and the International Trade Union Confederation (ITUC)

 

This Can’t Go On Forever, Right?

April 23rd, 2018 by Tom Lynch

The ratio of wages to the cost of living is what the economist calls real wages; the desirability of having real wages as high as possible, consistent with high employment, is a social objective. Rises in real wages do for the most part come about in fact as a consequence of rises in productivity. In a modern economy, what has [sic] normally to be expected  is rising productivity. – J. R. Hicks: Unions, Management and the Public; New York, Harcourt, Brace, and Co., 1960

What Hicks wrote 58 years ago had been true for more than 100 years. But 13 years later, in 1973, his economic model crashed. Productivity and real wage growth, which had been so tightly bound for so many years, parted company.

The consequences have been enormous. Hourly paid workers comprise about 60 percent of wage and salary workers. In Hicks’s day, nearly a third of all  workers were unionized. In 2017, however, the union membership rate had fallen to 10.7 percent, according to the U.S. Bureau of Labor Statistics. It’s only that high because of public sector participation. The union membership rate of public sector workers (34.4 percent) is more than five times higher than that of private sector workers (6.5 percent). Ponder that for just a moment. Only 6.5% of private sector workers are unionized today. This, despite union members having median weekly earnings about 25 percent higher than earnings for nonunion workers in comparable jobs ($1,041 versus $829).

This presents us with a befuddling paradox:

  1. Since 1973, the year when hourly wages and productivity waved goodbye to each other, real wages have been essentially flat, rising about 4% in the intervening 45 years;
  2. But in the same period, the CPI has risen 586%. That’s right. What you bought for $1.00 in 1973 will cost you $5.86 as of one month ago.
  3. Yet throughout this period, union participation and membership has declined by roughly 50%, despite union membership resulting in considerably higher wages for workers.

In Massachusetts, my home state, union membership was 12.4% in 2017, but 70% of that was in the public sector. At the recent Workers’ Compensation Research Institute’s annual conference I asked Steve Tolman, President of the Massachusetts AFL-CIO, why union membership hasn’t risen like a rocket to the moon given the persistent stagnant growth of real wages. He said he thought legislatures and employers had made it increasingly more difficult to win a union campaign. So, I then asked Keynote Speaker Erica Groshen, Ph.D., former Commissioner of the U.S. Bureau of Labor Statistics, her opinion. She wasn’t sure if there was a link between lack of union membership and stagnant real wage growth and suggested more research should be done. And in yesterday’s New York Times Louis Uchitelle suggested that American manufacturers relentlessly moving manufacturing jobs offshore has led to a steady decline in union membership – you can’t be in a union if you don’t have a job. The title of Uchitelle’s piece was, “How Labor’s Decline Hurt American Manufacturing.” Could have just as easily been titled, “How American Manufacturing’s Decline Hurt Labor.”

Regardless, what we’re left with is this (as I’ve written before): The 60% of the American workforce that is paid hourly resembles a swimmer trying to catch up to a battleship; with every stroke he falls farther and farther behind.

One highly illustrative area where meager wage growth has impacted the American family can be found in the cost of health care.

In 1989, Herb Stein (father of Ben), former Chairman of President Nixon’s Council of Economic Advisors, coined Stein’s Law*, which says, “If something cannot go on forever, it will stop.”

Do you think this can go on forever? What are the societal and political consequences if we see continued flat wage growth, the accelerating decline of private-sector unions, a rising CPI and an increasingly costly health care burden for families? Do you think today’s polarized American society is capable of addressing, let alone reversing, these decades old trends? What will it take for that to happen? I wish I knew.

But here is something I do know. If employers do not begin to do their best to address these issues – wage stagnation and ever rising health care costs that come with ever increasing deductibles – then unions and people like Steve Tolman, dormant for so long, will, and they’ll come with all guns blazing.

 

* Stein’s Law appeared on Page One of the June 1989 issue of the “AEI Economist” under the headline “Problems and Not-Problems of the American Economy.”

 

Fresh Health Wonk Review; plus, a RIMS wrap-up

April 19th, 2018 by Julie Ferguson

It’s Health Wonk Review week for April.

Louis Norris has posted the Spring Is Here! Health Wonk Review edition at Colorado Health Insurance Insider. Not sure how the weather is in Colorado, but Spring has decidedly not yet sprung in Massachusetts, where snow is falling outside the window at this very moment. But wherever you are, don’t let the weather interfere with your perusal of this month’s edition, which has some great posts. Please do not overlook Louise’s submission, which she tucks in at the tail end of her post. She’s compiled a post that is well worth a bookmark for future reference: a guide to Medicaid in each state, including a summary of states to watch this year in terms of Medicaid expansion, work requirements, and other changes.

In other news…recapping RIMS

We weren’t at the 2018 RIMS in San Antonio this past week and sorely missed meeting the San Antonio therapy animals, which were apparently a big hit.

We’ve been following along with some great reports. Here are a few things that caught our eye:

Right from the source, you can follow the day-by-day action from the RIMS Daily:
Monday, Tuesday and Wednesday

Safety National’s Conference Chronicles also has many helpful session and event write-ups – there are about 20 entries, so you can get a sampling of some of the latest issues.

RIMS Bestows Top Industry Honors and Awards

Risk Manager of the Year: Q&A with Rebecca Cady

A.M. BestTV at RIMS: Data and Analytics Leaders Reveal Their Biggest Challenge: Show Me the ROI

Technology Is Outpacing Risk Management: Marsh-RIMS Report

5 Trends to Watch in Construction Technology

Crucial Cyber Peril Defense and Coverage Considerations

Saving Lives—Building A Modern Pharmacy Program Amid A Deadly Epidemic

March 22nd, 2018 by Tom Lynch

Dr. Terrence Welsh, Medical Director for the Ohio Bureau of Workers’ Compensation, flew into Boston for WCRI’s 2018 conference to talk about Ohio’s attack on the opioid epidemic. He began with two slides worthy of reproduction here. The first is scary indeed:

 

So, in 2011, the Ohio BWC decided to do something about it. Here are some results through 2017:

So, much has been done, but much remains to be done. One of the many things that might be making a difference is this: Outside the box of the claim, Ohio BWC will pay for 18 months of treatment as long as the injured worker/patient complies with the treatment guidelines. This is innovative, but the Bureau doesn’t have outcome data yet. Dr. Welsh pointed out that, as you can imagine, the program isn’t very popular with opioid-dependent injured workers. The program asks them to give up the opioids they have come to know and love for the rest of their lives. A wickedly difficult thing to do. Regardless, the Ohio BWC should be complimented for the measures it has taken to attack this national horrendoma.

Here is a chart showing the decline in opioid prescriptions for Ohio’s injured workers:

What about the future. There’s a long way to go, but the Bureau  has charted a way forward, although it’s a mighty hard road with a lot of potholes, deep and wide.

The Ohio Bureau is working tremendously hard on this issue. The people in it are dedicated and committed to doing all in their power to rescue the many workers who have fallen into the opioid pungy pit. The emphasis they place on the last bullet of the last slide is critical for winning the battle.

 

WCRI: Keynote: Dr. Erica Groshen On Future Labor Trends

March 22nd, 2018 by Tom Lynch

Dr. Erica Groshen, former Commissioner of the U.S. Bureau of Labor Statistics, began this year’s conference. She is currently Visiting Scholar at Cornell’s Industrial Labor Relations School, and if anyone knows anything about the future of work, it is Dr. Groshen.

Labor market conditions: Since the end of the Great Recession, the U.S. has added 9.3 million jobs. As most of us have observed, the service industry has seen the most labor growth over the last year: professional, leisure and health services. The country’s unemployment rate is 4.1%. Dr. Groshen peeled that onion in discussing labor “underutilization.” She described how in addition to unemployment, underutilization, which addresses discouraged workers, marginally attached workers and part time workers who would prefer full time. That 3rd group stands at 8.2% of the population. Of the unemployed population, 20.7% are long-term unemployed. As further proof of the tightening of the labor market, currently for every job opening, there is 1.1 unemployed person. This seems low, but it’s about where numbers stood before the Great Recession.

Next, Groshen dove into a subject of great concern to me: wage growth. Essentially, there hasn’t been any since 1974. Real wage growth (wages adjusted for inflation) has been 0.0% over the last 12 months. Additionally, Dr. Groshen expressed significant concern about the relationship between productivity and wages. Until 1973, wages and productivity tracked on a one to one basis. Since then, productivity has soared and wages have been essentially stagnant.

The Gig Economy: BLS doesn’t know much about the Gig economy. You read that right. BLS “periodically” surveys 100,000 workers to determine the prevalence of what are called “alternative work arrangements.” Trouble is, the last time that happened was in 2005 (according to Groshen the failure of BLS to perform a really current survey is due to lack of funding). Given what’s happened to our economy since then, 2005’s data is pretty irrelevant. The BLS Current Population Survey, on the other hand is “current,” but what it shows is paradoxical in that there doesn’t seem to be any effect from what everyone perceives is a major shift in work and employment due to the emergence of the Gig economy. Groshen reported that in May 21017 BLS secured funding to conduct a new Contingent Workers Survey. We’ll have results, which will be of tremendous interest, in the near future.

Artificial Intelligence: Dr. Groshen considers AI as something that “replicates routine brainwork.” When AI is applied to routine work, for example, human coding of information, the result is higher quality work done by fewer people who handle the tricky work that humans need to do (at least, until now). As AI  rises in society, many jobs will be lost, but many jobs will be created. The same thing happened when we moved from an agricultural society to an industrial one. Groshen believes this will happen, but that producing the new jobs will take time, which will make things difficult for those who will be swept aside by growth in AI. Displaced workers, according to Groshen, can lose one to four years of income, which will be devastating for many. This will require government policy changes to help bridge the gap in employment. Good luck with that.

Official Statistics: Dr. Groshen emphasized the importance of “official statistics,” pointing out that, “We do not have a single statistical agency in America. We have 17 of them.” The BLS, established in 1884, is the gold standard and biggest of them all. She claims national stats are a public good. Who uses BLS statistics? The federal government, state and local governments, businesses and households (The most popular part of the BLS website is the Occupational Handbook).

There are challenges facing the BLS. Cybersecurity is, of course, a major one. Groshen reported that BLS has never had a data breech (to which I reply, “That we know of). Another challenge is, wait for it – Funding. From 2009 to FY 2019, nominal funding has been flat, standing at $609 million for FY 2019. However, if BLS had been funded at the rate of inflation, FY 2019 would be $715 million.

Dr. Groshen closed with a plea for help. BLS needs help in the form of money. Business has to do a better job of advocating for better and more data, data it relies on to make important decisions. Amen to that.