Archive for the ‘health care’ Category

Rick Scott Is Going To Rescue America!

Friday, April 1st, 2022

Rick Scott is the junior U.S. Senator from Florida. Elected in 2018, Scott has now served in Congress for 39 months. In November, 2020, his Senate GOP colleagues elected him Chairman of the National Republican Senatorial Committee (NRSC). His job is to get Republicans elected and reelected to the Senate.

Prior to the Senate, Scott was a two-term governor of Florida, succeeded by Republican Ron DeSantis. Before that, he was a businessman. We’ll get back to that later.

You would think the Chairman of the NRSC would be lock-step with Republican leadership in the strategy to take the Senate from the tenuous hold of the Democrats in the upcoming mid-terms. But this does not appear to be the case. Senator Scott is marching to his own drummer.

On Thursday, after no consultation with or cooperation from Senate GOP elites, Scott officially unveiled and launched the Rick Scott, 31 page, 11 Point Plan to Rescue America. The Rescue Plan has 117 agenda items.

This is not a surprise to GOP Senate Leader Mitch McConnell. Scott’s Plan has been discussed for more than a month, and as far back as 1 March McConnell publicly rebuked Scott for it. McConnell is fixated on making the mid-terms a referendum on President Biden, not on laying out a Republican plan he and the GOP establishment would have to spend the entire mid-term campaign defending. He wants Biden playing defense. Scott, on the other hand, wants America to know what Republicans will do if given control of the Senate. Right at the beginning of his Rescue Plan he says, “Americans deserve to know what we will do if given the chance to govern.” If Scott gets his way, now they will. And you have to hand it to him; he certainly doesn’t tap dance around the many issues facing the country.

Before diving into his 11 point, 117 agenda item plan, Scott lays out what the future will look like if nothing changes:

The militant left now controls the entire federal government…Among the things they plan to change or destroy are: American history, patriotism, border security, the nuclear family, gender, traditional morality, capitalism, fiscal responsibility, opportunity, rugged individualism, Judeo-Christian values, dissent, free speech, color blindness, law enforcement, religious liberty, parental involvement in public schools, and private ownership of firearms.

Wow! We need a plan to stop all that!

A few of Senator Scott’s 117 agenda items, guaranteed to be saliva-producing red meat for the trumpiest of trumpsters caught my eye.  For instance,

We will secure our border, finish building the wall, and name it after President Donald Trump.

Kids in public schools will say the Pledge of Allegiance, stand for the National Anthem, and honor the American Flag. We must foster national unity.

Teacher tenure at public schools must be eliminated

We will not allow political or social indoctrination in our schools. Teachers who refuse to comply will need to find new jobs.

We will close the federal Department of Education. Education is a state function.

Government will not ask American citizens to disclose their race, ethnicity, or skin color on any government form.

Our military will engage in ZERO diversity training, teachings on critical race theory, or any woke ideological indoctrination that divides our troops.

We will force prosecutors to prosecute. At present, many prosecutors in big cities are allowing criminals to go free with no justice, and they are doing it on purpose.

Immigrants will not be eligible to collect unemployment benefits or welfare for the first 7 years after arriving in the US.

No government assistance unless you are disabled or aggressively seeking work.

If Congress does not pass a budget, the members of Congress do not get paid. Full stop.

Other than disaster relief, the federal government must stop spending money on non-essential state and local projects until the budget is balanced.

All Americans should pay some income tax to have skin in the game, even if a small amount. Currently over half of Americans pay no income tax.

Enact term limits for the Washington ruling class – 12-year limits for Congress and government bureaucrats.

All federal legislation sunsets in 5 years. If a law is worth keeping, Congress can pass it again.

We will immediately cut the IRS funding and workforce by 50%.

Humans are born male and female, there are two genders, and to deny that is to deny science. No government forms will include questions about “gender identity” or “sexual preference.”

We will protect women’s sports by banning biological males from competing.

No tax dollars will be used to pay for any diversity training or other woke indoctrination that is hostile to faith.

We will not pay any dues to the United Nations or any international organization that undermines the national interests of the USA.

The weather is always changing. We take climate change seriously, but not hysterically. We will not adopt nutty policies that harm our economy or our jobs.

There are a few difficulties with a number of these policy tectonic changes. Ending Social Security, Medicare and Medicaid in five years being among the biggest. Also, Scott’s colleagues in Congress might have something to say about going without pay and getting sent home after 12 years. Increasing taxes on 50% of Americans may prove challenging for Republicans on the campaign trail. Pulling billions of dollars from the states until we have a balanced budget might irritate a few Republican governors. And reducing the IRS’s funding and currently understaffed workforce by 50% would have brought tears to the eyes of mobster Al Capone.*

Although Senator Scott’s plan is dead on arrival, the problem is it arrived in the first place. It’s not about getting Republican senators elected; it’s about Rick Scott.

And what about Rick Scott? As I mentioned above, before getting into government, Scott was a “businessman.” He co-founded Columbia Hospital Corporation in 1987. Columbia later merged with another corporation to form Columbia/HCA, which eventually became the nation’s largest private for-profit health care company with Scott as Chief Executive. According to The New York Times, “[in] less than a decade, Mr. Scott had built a company he founded with two small hospitals in El Paso into the world’s largest health care company – a $20 billion giant with about 350 hospitals, 550 home health care offices and scores of other medical businesses in 38 states.”

Sounds good, right? Quite the businessman.

But there were problems. In March of 1997, the FBI, the IRS, and the Department of Health and Human Services arrived with search warrants. Four months later, Scott was forced to resign by his Board. He didn’t leave willingly, but when he did, he left with a settlement $9.88 million and 10 million shares of stock worth $350 million. Columbia/HCA pleaded guilty to 14 felonies and agreed to a $600+ million fine in what was at the time the largest health care fraud settlement in U.S. history.

The company admitted to systematically overcharging the government by claiming marketing costs as reimbursable, by striking illegal deals with home care agencies, and by filing false data about use of hospital space. It also admitted to fraudulently billing Medicare and other health programs by inflating the seriousness of diagnoses and to giving doctors partnerships in company hospitals as a kickback for the doctors referring patients to HCA. It filed false cost reports, fraudulently billing Medicare for home health care workers, and paid kickbacks in the sale of home health agencies and to doctors to refer patients. In addition, it gave doctors “loans” never intending to be repaid, free rent, free office furniture, and free drugs from hospital pharmacies.

And that’s not all. In 2002, HCA agreed to pay the government an additional $631 million, plus interest, and $17.5 million to state Medicaid agencies, in addition to $250 million paid up to that point to resolve outstanding Medicare expense claims. The entire fiasco cost the company $1.7 billion.

All on Senator Scott’s watch.

There’s one last twist. In a civil suit deposition connected to the case (there were a lot of civil lawsuits), Senator Scott invoked his 5th Amendment rights 75 times.

Somehow, all of that has been forgotten, and Scott has managed to be a governor, a Senator, and, I’m guessing, a man, a businessman, who has his eyes on the biggest prize of all, the one up for grabs in 2024.

Rescue Plan, indeed.

*Capone was a nationally famous, Chicago-based killer and crime boss who went to prison in 1931 for tax evasion.

 

Stories I Was Planning To Address. They’ll Have To Wait.

Thursday, March 3rd, 2022

The life and death stories coming out of Ukraine, as its people continue to exhibit fierce and inspirational resistance to Vlad the Invader’s barbaric onslaught, tend to suck the air out of any room. Somehow, Joe Biden’s approval ratings, or America’s vitriolic partisan divide, or who will prevail in the midterms or the desperate state of our infrastructure, or the future of our newest Supreme Court nominee, while important at any other time, just cannot compete with Putin’s intentional and indiscriminate killing of anyone, man, woman, child, beloved pet, anyone in the way of his rapacious army. This is causing the most momentous change on the European continent and throughout the geopolitical world in nearly 80 years. And it’s taken only a week.

So, here are some quick takes of the things I would have written about, and maybe will in the future in more depth, were it not for the blackhole-like gravity of what’s happening in Ukraine.

Tuesday night’s State of the Union

Joe Biden’s speech to the Congress and the nation came in two chapters. Chapter One: Ukraine. Chapter Two: His domestic agenda.

Chapter One was riveting, and it appeared nearly everyone sitting on the floor and in the gallery of the House of Representatives was united in support of the West’s monumental pushback to  Vlad the Villain. I thought it ironic they were all sitting in a sacred building where, just 14 months ago fellow citizens tried to steal American democracy, and nearly did. Ironic, indeed, when one considers so many who were sitting on the R side of the aisle now want to look the other way and pretend it never happened.

Chapter Two was pretty much what you’d expect from any State of the Union speech — until the heckling. Representatives Lauren Boebert, R-Colo., and Marjorie Taylor Greene, R-Ga, put on a disgusting display of crass and boorish incivility. These two ladies have never demonstrated having had an original idea in their lives. Why should they? They’re both travelling on borrowed gas, and inferior gas, at that. Boebert, especially, raised poor taste to a new level when she screamed out accusing Biden of killing 13 soldiers during the evacuation of Afghanistan as he was describing the death of his beloved son, Beau, from cancer attributable to burn pits in wartime. These two, both of whom have about as much empathy as a New Jersey loan shark, would be rejected from Dante’s Inferno for giving the place a bad name. (Pity the poor fellow sitting between them  wishing he were anywhere else on earth — except maybe Ukraine)

Why can’t Medicare negotiate drug prices?

When you insure more than 61.2 million beneficiaries you’d think you’d have tremendous leverage to negotiate the lowest drug prices on earth. But that is not the case in the USA.

The Medicare Modernization Act (MMA) of 2003, the one that created the unfunded Part D drug program along with the infamous “doughnut hole,” specifically forbids Medicare from negotiating prices with drug companies, giving that responsibility, instead, to for-profit insurers and Pharmacy Benefit Managers. Health policy Guru John C. Goodman calls the MMA, “arguably the worst domestic policy decision in the history of the country.” At the time of enactment, the Social Security and Medicare Trustees estimated the long-term (75 years) unfunded liability of the MMA’s Part D program to be $17 trillion. The Trustees project that cost growth over the next 5 years will average 7.3 percent for Part D, significantly faster than the projected average annual GDP growth rate of 4.3 percent over the period.

And, still, Medicare cannot negotiate prices.  Result? High drug prices for Medicare and its beneficiaries.

By contrast, the VA is able to negotiate for its nine million veterans enrolled in its health care program, yours truly being one of them. Result? Low cost drugs.

Since passage of the MMA, there have been repeated attempts to introduce and pass legislation that would allow Medicare to bring the full weight of its considerable power to the price of pharmaceuticals. Two things have prevented any success in these endeavors. First, the bottomless well of pharmaceutical industry cash, and, second, members of congress who are the beneficiaries of that bottomless well of cash.

To quote that eminent American philosopher, Mark Twain, “We have the best government that money can buy.”

Federally Qualified Health Centers. Now there’s a well kept secret!

Federally Qualified Health Centers (FQHC) are community-based health care providers that receive funds from the Health Center Program of the Health Resources and Services Administration (HRSA) to provide primary care services in underserved areas. They must meet stringent requirements, including providing care on a sliding fee scale based on a patient’s ability to pay and operating under a governing board that includes patients. Specifically, at least 51% of their Boards must be patients.

By law, FQHCs must treat anyone, regardless of the ability to pay.

There are 1,368 FQHCs in the country. Most have a number of locations, called Service Sites, bringing the total health care locations to 14,200. They welcome people with insurance, but their main targets are poor people who could otherwise not afford health care.

In addition to FQHCs, the Health Center Program also funds Rural Health Centers (RHCs), whose mission is to increase access to primary care services for patients in rural communities.

FQHCs and RHCs are funded annually by congressional approval. Additionally, Section 330 of the Public Health Service Act provides grant awards to eligible health centers and outlines the requirements the centers must meet to be eligible .

Taken together, FQHCs and RHCs are Community Health Centers. They are ubiquitous throughout the country. For example, in my home state of Massachusetts, there are 52 community health center organizations providing high quality health care to some one million state residents through more than 300 sites statewide. For perspective, there are 351 cities and towns in Massachusetts.

Given the woeful state of our nation’s public health system, as was amply demonstrated by our response to COVID-19, it might not be a bad idea to consider the Community Health Center model as we attempt to re-engineer how we deliver health care to all of us.

Just a thought.

 

 

 

News You Might Have Missed To End Your Week

Friday, February 4th, 2022

Interesting weather today, here in the heart of the Berkshire mountains. A little rain, a little sleet, a little freezing rain, a little snow and a lot of ice. The very definition of my newly coined word, quinaryfecta (I toyed with pentafecta).

Governor Baker has asked everyone to stay off the roads, so, here I sit putting together a few stories that might have slipped under your radar.

The cost of health care continues it ever-upward trajectory

In November, the Kaiser Family Foundation published the results of its annual Employer Health Benefits Survey, and 2021 continued what appears to be an unstoppable trend.

More than 155 million Americans get their health care from Employer Sponsored Insurance (ESI). That’s 55% of the working population. There are two facts about this year’s survey I would like to highlight:

First, the annual cost of health insurance for a family is rising faster than both wages and inflation.

To their credit, employers have been absorbing most of the rise in premium costs, but this prevents them from using those funds now going to health care insurance for other worthwhile endeavors, like growing their companies, enhancing their risk management programs, or raising wages.

Second, annual premium costs in 2021 rose 4% over 2020 to a record high $22,221. That’s $1,852 per month. Workers are paying an average of 28% of the cost, or about $500 per month. But that’s before a 2021 average deductible of $1,669, which is 92% higher than ten years ago. In 2021, 85% of workers in ESI plans were subject to a deductible.

As these costs continue their stratospheric rise it’s like employers and employees are side by side trying to outswim a Navy Destroyer ―  with every stroke they fall farther behind.

Speaking of upward trends, let’s consider traffic deaths in 2021

The Department of Transportation just released a statistical projection of traffic fatalities for the first 9 months of 2021 showing an estimated 31,720 people died in motor vehicle traffic crashes nationwide. This represents an increase of about 12% as compared to 28,325 fatalities that were projected in the first nine months of 2020. This is the highest percentage increase over a nine-month period since the Department began recording fatal crash data in 1975. The numbers in 2021 are 32.5% higher than they were a decade ago.

Something weird is happening on our roads. Over the last 45 years, traffic safety engineers and automakers have made remarkable progress in improving the safety of our roads and cars. But they haven’t been able to change the human element, about which we wrote a week ago.

Don’t go by raw numbers, however. The important statistic is the rate of traffic fatalities per million miles driven. From 2011 through 2019, the rate didn’t waffle much, going from 1.09 to 1.10, with a blip up to 1.17 in 2016.

All that changed in 2020, when the rate jumped to 1.35. In 2021, it inched up to 1.36 to prove 2020 wasn’t a momentary aberration.

Secretary of Transportation Pete Buttigieg announced the Department will dedicate significant resources to attack these daily tragedies. We will be paying close attention to this.

Another example of our fragmented health care

The Biden Administration has made it easier for people to get free at home rapid tests. Here at our home, we applied on Day One of the program, and four days later our tests arrived. And the Administration has distributed millions of tests to pharmacies and states. People can go to CVS or Walmart or any other participating entity, buy tests, and get reimbursed by their insurance company. That’s not how other countries are doing it, and they’ve been doing it longer. They’ve cut out the insurer middleman, and have just gone directly to their people with the tests. In the the UK, for example, testing has become a way of life.

The insurer reimbursement issue has become a Medicaid problem for the states. The rules of Medicaid do not allow for it, and, because each state administers the program in its own way, they’re all approaching the problem differently.

Some states have made it easier for the safety net program to reimburse pharmacies for providing the tests at no cost. Others are experiencing what CMS described in an 11 January call with the states as “operational considerations and challenges.” Here’s one such challenge: Some states require a prescription for Medicaid enrollees to get anything from a pharmacy. To deal with this, states are making what they are calling “standing orders” to allow enrollees to get free tests at pharmacies without a prescription.

Another challenge for the states: How to get tests to homebound enrollees. Some states are attacking this by setting up temporary mail order programs.

My point here is that each state has to create its own solution. That is counterproductive. All the states are facing the same COVID problems, but each is attacking those problems differently. Throughout, one thing has become clear to the various Medicaid State Directors: the more they communicate with each other, the better off they are.

It is becoming more and more evident that the absence of one cohesive system to guide everyone wastes time and money, and jeopardizes the health of Medicaid enrollees all over the nation.

Have a nice weekend.

 

Medicaid Expansion: An Addendum To My Two-Part Series

Thursday, February 3rd, 2022

Long ago in 2009, I wrote about  a PBS special hosted by Journalist T. R. Reid, in which Reid analyzed the health care systems in five other countries: The UK, Japan, Germany, Taiwan and Switzerland. Reid had spent a full year in those five countries trying to figure out how they provided universal health care at much lower cost than the U.S. with better results. He later published a book about it, The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care (available on Amazon).

The good news is Reid did a wonderful job, both in his book and on his PBS special. The bad news is things in the U.S. have only gotten worse since then. Health care costs as a percent of GDP have increased three percentage points since 2009 to about 20% (the Opioid epidemic and COVID haven’t helped), and our health care outcomes have remained sub-par to the rest of the Organization for Economic Co-operation and Development (OECD), the 38 country organization of which the United States was a founding member 60 years ago.

I was reminded of Reid’s work while preparing my two-part Medicaid expansion series published over the last two days, and I couldn’t help thinking the ACA’s Medicaid expansion provision, for all the good it has done, only aims to put a band-aid on a mortally wounded patient.

In America, health care has become a commodity, a market-driven enterprise. Throughout the rest of the developed world, it is an essential human right; something governments were created to provide and protect. In America, 55% of us have earned the right to health care by working for an employer who provides it. Another 18% of us have earned health care by reaching the age of 65. A further 3.7% have earned it by serving in the military. The remaining 23.3% are on their own, which is where Medicaid comes in. Sadly, it appears many powerful people resent that final group and our inclination to provide them what the rest of the world views as a moral duty.

In America, legend, myth and vulnerable gullibility influence many of our citizens, who have been led to believe any government intrusion into health care will lead to draconian tactics typical of a fascist state (remember Sarah Palin’s death panels?). They don’t seem to realize that health care provided by our Veterans Administration, treating millions of our veterans every year (including this one), is a direct copy of Britain’s. Or that Medicare, our largest insurer with more than 62 million members who, in poll after poll, report high satisfaction with their health care, is modeled on the health care system of Canada.

Maybe American health care is just too big to be redesigned into something that would make us all proud. Too many vested interests, each making boatloads of cash. Each saying they support creating a better system ―  just as long as we don’t touch their sacred slice of the profitable pie.

But when I’m tempted to say, “A plague on their houses,” I think of the Taiwanese, who went from nothing to one of the most technologically advanced, yet inexpensive, health care systems in the world in just fourteen years. And I think of the Swiss, the bureaucratic, economically driven, bankers-of-the-world Swiss, who took off their stuffed shirts and came to see high-quality, affordable health care as the absolute right of every Swiss citizen.

The health care systems in Taiwan and Switzerland have flaws, but, even so, they are light years ahead of the U.S. in terms of quality, cost and universal coverage. If these two totally different countries can do that, I ask you, why can’t we?

Eventually, America is going to have to decide if good quality health care is a basic human right, or a privilege to be earned.

ACA Medicaid Expansion — Part 2: The Opposition

Wednesday, February 2nd, 2022

Yesterday, I wrote about the proven benefits of the Affordable Care Act’s expansion of Medicaid to provide health insurance to millions of our previously uninsured fellow citizens. By way of background, I began yesterday’s column with the following:

According to the Department of Health and Human Services (HHS), there were 48 million uninsured in 2010 when the Affordable Care Act (ACA) became law. Over the next nine years, 38 states, using ACA funding, expanded their Medicaid programs. During that time, the numbers of uninsured fell to 28 million before rising to 30 million in the first half of 2020 due to policy changes to the ACA by the Trump Administration that made it harder to qualify for coverage.

There are now twelve states left that have refused to take advantage of the ACA’s provisions to expand Medicaid, a move that would significantly lower the number of uninsured people within their borders.

The states in orange are the states that have refused to accept Medicaid expansion and the significant federal dollars that go with it. The orange states are all “red” states.

Today, we’ll examine the reasons governors and legislatures in those 12 states give for not accepting the massive federal funding coming with ACA expansion. Tomorrow, I’ll offer an opinion and a plea for building a better system.

But first, we’ll need to set the stage.

The rate of uninsurance in non-expansion states is nearly double that of expansion states.

A word about the uninsured in non-expansion states. As the above chart shows, nearly 22% of them live in rural areas. The majority of these Rurals are registered Republican voters. They are also white/non-Hispanic and less educated than their urban counterparts. Medicaid expansion would be of great benefit to them. But their governors and legislators refuse to expand Medicaid to help these people and the rest of their uninsured populations. Why?

What is even more perplexing is why the rural uninsured continue to vote for people who refuse to help them improve their health care lot in life.

There is another darker result of not expanding Medicaid, and it concerns people of color. People of color, especially the uninsured, have faced longstanding disparities in health coverage that contribute to disparities in health. The states that expanded Medicaid following passage of the ACA saw significant decreases in these disparities from 2010 through 2016; the non-expansion states did not. Beginning in 2017, the Trump administration implemented policy changes that made it harder to qualify for Medicaid. The result was a reversal of progress made during the prior six years; the number of uninsured began growing again, and, once again, people of color were the hardest hit.

Just another example of the cultural and moral divide in America.

Governors and legislators opposing expansion offer 3 primary arguments:

The state cannot afford it.

This is political theatre. The federal government pays 90% of the cost of expansion, the state the remaining 10%. States that have expanded coverage have demonstrated affordability by moving  funds from other areas that, because of expansion, will not need as much money. In Michigan, for example, the state budget realized substantial savings in correctional health care and community mental health when some of the expenses of these programs were shifted to Medicaid. Taking into account other economic effects of expansion, such as increased tax revenues from increased economic activity, Medicaid expansion was a net benefit to the state’s budget. Moreover, the Families First Coronavirus Response Act, which was signed into law on 18 March 2020, included a provision for the federal government to assume a larger share of existing Medicaid obligations in every state, freeing up state Medicaid funds for other uses — like expanding coverage. The “We can’t afford it” line does not hold water.

Allowing people to access Medicaid will discourage them from working.

Multiple studies have found no evidence that expanding Medicaid is a disincentive to working. A typical finding is, “We find that although the expansion increased Medicaid coverage by 3.0 percentage points among childless adults, there was no significant impact on employment.”*

Expanding Medicaid will only add more people to a broken system.

Opponents of expanding coverage often deride Medicaid as a low-quality program. Yet a majority of people in the U.S. — Democrats, Republicans, and independents alike—believe that the program is working well. In states that have not expanded Medicaid, a clear majority favor doing so. Most Medicaid enrollees are quite happy with their coverage, reporting higher rates of satisfaction than people with private insurance.

The arguments listed above are the three reasons most often cited by leaders in the 12 non-expansion states for their opposition. There is one argument that goes unexpressed, but is often present: People who are uninsured are uninsured because they lack the money to become insured. They lack that money because they never worked hard enough to get it. They are irresponsible. Consequently, society does not owe them a free health care lunch.

Over the last two days, I’ve tried to counter that “thinking” with clear, hard, proven, factual data. None of it has been opinion (if you ignore my comment yesterday about Senator Ron Johnson, that is). I’ve tried to demonstrate that all the arguments in opposition are nothing more than groundless opinion.

I end with these questions: Is health care a basic human right? Does society owe its poorest decent health care, or must they earn the privilege? How do we answer the murderer Cain’s question in Genesis 4:1-13, “Am I my brother’s keeper?”

We need answers to those questions.

*Leung and Mas, Employment Effects of the Affordable Care Act Medicaid Expansions, 25 March 2018, in Industrial Relations, A Journal of Economy And Society.

 

 

 

The Proven, Credible Benefits of ACA Medicaid Expansion — Part 1

Tuesday, February 1st, 2022

According to the Department of Health and Human Services (HHS), there were 48 million uninsured in 2010 when the Affordable Care Act (ACA) became law. Over the next nine years, 38 states, using ACA funding, expanded their Medicaid programs. During that time, the numbers of uninsured fell to 28 million before rising to 30 million in the first half of 2020 due to policy changes to the ACA by the Trump Administration that made it harder to qualify for coverage.

There are now twelve states left that have refused to take advantage of the ACA’s provisions to expand Medicaid, a move that would significantly lower the number of uninsured people within their borders.

The states in orange are the states that have refused to accept Medicaid expansion and the significant federal dollars that go with it. The orange states are all “red” states.

The ACA was passed in 2010. We now have 404 studies in the seven year period 2014 through 2020 producing 440  findings resulting from Medicaid expansion (A number of studies looked at more than one area).

There have been five studies concluding ACA Medicaid expansion has brought negative results in two areas ―  Provider Capacity and Positive Health Outcomes; remember that; they’re the ones in orange in the chart below (Good luck finding them). This is opposed to 435 findings of positive results in eight areas. These include 25 positive findings in Provider Capacity and Positive Health Outcomes (compare to the five mentioned above). The Kaiser Family Foundation summarized the studies in this chart:

There are three overarching benefits to Medicaid expansion nearly all experts agree on:

Expanding Medicaid helps low-income families’ health and financial well-being, especially those in which someone has lost a job.

In states that expanded Medicaid under the ACA, unemployed workers experienced large gains in coverage. Further, there are spillover benefits for economic well-being: lower debt and better credit scores. Physical health and financial health are inextricably linked. Expanding Medicaid improves both for low-income families. This has been doubly so in the time of COVID.

Expanding Medicaid reduces hospitals’ uncompensated care.

I write from experience. I was once a Director at a Massachusetts major hospital system. At one meeting, I asked our CEO what the system did when an indigent person showed up in the ER very sick or injured. By law we had to take care of them. So, given that, how did the system get paid? He replied, “We charge them the most we possibly can.” I said, “But they can’t pay.” He said, “That’s right, but the state’s Uncompensated Care Pool can.” This was a big drain on Massachusetts, eye-opening to me, and an obvious wrinkle in health care policy. Medicaid expansion dramatically reduces this burden for hospitals. In Michigan, uncompensated care was cut in half after Medicaid expansion in 2014. In 2016, Dranove, Garthwaite and Ody, publishing in Health Affairs, found uncompensated care decreased at hospitals in Medicaid expansion states but not at hospitals in non-expansion states. Moreover, in April 2021, Karpman, Coughlin and Garfied found significant reductions in uncompensated care in ACA expansion states:

Reflecting a significant decline in the share and number of people who were uninsured at any point in the year, the average annual share of nonelderly individuals who had any uncompensated care costs fell by more than a third following ACA implementation, going from 7.3 percent in 2011-2013 down to 4.8 percent in 2015-2017. This change represents a decline in the number of people with uncompensated care costs from 20.2 million to 13.1 million.

Correspondingly, the aggregate annual cost of uncompensated care provided to uninsured individuals dropped by a third following implementation of the ACA’s coverage provisions, from an average of $62.8 billion per year in 2011-2013 to $42.4 billion in 2015-2017. The cost of implicitly subsidized uncompensated care—or care that had no payment source, including a non-health insurance source—dropped from $21.6 billion to $15.1 billion per year on average before and after the ACA, respectively.

Expanding Medicaid is a highly effective form of economic stimulus.

An often-overlooked benefit of Medicaid expansion is that it creates jobs. During a recession, the infusion of federal spending gives a boost to a state’s economy. Evidence from the Great Recession shows that Medicaid spending is a highly effective form of stimulus: for every $100 000 of additional federal Medicaid spending, two workers gained a year of employment.

There are other intangible benefits, but we won’t go into them here, because they’re fuzzy, and it will give naysayers a hook, albeit a painted one, on which to hang their negative opinions. Let’s just say that being able to provide health care for your family, not having to forgo necessary care for you or your child because you need that money to eat, is psychologically significant. Contrast this with a recent statement from Senator Ron Johnson (R, WI): “People decide to have families and become parents. That’s something they need to consider when they make that choice. I’ve never really felt it was society’s responsibility to take care of other people’s children.” Compassion like that is disgustingly reminiscent of Ebenezer Scrooge before the spirits arrived.

Tomorrow, we’ll dive into the reasons governors and legislatures give for rejecting ACA funding to expand Medicaid in the remaining 12 non-expansion states. Hint: There are three reasons most often cited. They are opinions only without any credible supporting data, but in those orange collared states in the map at the beginning of this column, that doesn’t seem to matter.

Can America Fix Its Public Health System?

Wednesday, January 5th, 2022

Despite the cost of health care in America being nearly twice the average of the other 37 countries within the Organization for Economic Co-operation and Development (OECD), we achieve poorer health care outcomes than the average and our life expectancy of 78.9 years is 2.1 years below the OECD average of 81.* The OECD chart below is quite instructive. It shows the nation’s relatively poor health performance, but what I find interesting is the last line: We self-rate our health better, much better, than the OECD average. Friends, we have swallowed the Kool Aid.

If we reach the age of 65 when Medicare becomes available, life expectancy improves to 84.5 years, but that puts us still below the OECD average of 84.9 and 13th from the bottom of the pack. By way of further comparison, the Brits, whose National Health System we so cavalierly denigrate, outlive us by 2.5 years; Canadiens, by 3.2 years. They must be doing something right, and they do it for significantly less money.

One often overlooked and, for the most part, unexamined reason for our high health care costs and sub-par outcomes can be found in our woebegone Public Health System. Of all the gaping holes COVID-19 has exposed in the nation’s approach to health care and emergency preparedness, our Public Health System, fragmented, uncoordinated, underfunded, but critically important, is the deepest.

COVID has turned the health care world upside down, especially in regards to health care funding. CMS reports U.S. health care spending grew 9.7 percent in 2020, reaching $4.1 trillion or $12,530 per person. As a share of the nation’s Gross Domestic Product, health spending accounted for 19.7%, up from 16.8% the year prior.

Less than 3% of that $4.1 trillion went to our Public Health System. Moreover, Trust for America’s Health, a non-partisan organization that tracks health issues, reports public health spending as a proportion of total health spending has been decreasing since 2000 and falling in inflation-adjusted terms since the Great Recession. Health departments across the country are battling 21st-century health care wars with mid-20th-century weapons.

Our Public Health System is supposed to address everything having to do with health, from diseases like COVID-19 to tornados, hurricanes, wild fires, floods, rat infestations, and the like. It lives at the local level, from states, to counties, to cities and towns. My little Berkshire town of Becket, Massachusetts, population of 1,931, has a functioning Health Department.

The CDC, through grants to the states and large cities is the primary funder of federal public health. The system and funding for it worked pretty well until, in 2001, terrorists brought down the Twin Towers on 9/11, killing 2,996 of our fellow citizens. Suddenly, money that had been earmarked for public health was syphoned off for the War on Terror. In attempting to right the ship, Section 4002 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the Prevention and Public Health Fund. Also known as the Prevention Fund or PPHF, it is the nation’s first mandatory funding stream dedicated to improving our nation’s public health system. By law, the Prevention Fund must be used “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public health care costs.” The law mandated funding: $18.75 billion between fiscal years 2010 and 2022 and then $2 billion annually thereafter.

The Fund’s intentional mandatory design was meant to ensure consistent, predictable, and expanded resources for prevention and public health that are not always politically viable in the annual appropriations process, where public health and prevention programs compete against other priorities.

The Fund’s statute is broad and authorizes use of funds for a number of activities and grant programs:

The Secretary shall transfer amounts in the Fund to accounts within the Department of Health and Human Services to increase funding, over the fiscal year 2008 level, for programs authorized by the Public Health Service Act [42 U.S.C. 201 et seq.], for prevention, wellness, and public health activities including prevention research, health screenings, and initiatives, such as the Community Transformation grant program, the Education and Outreach Campaign Regarding Preventive Benefits, and immunization programs.

But nowhere in the statute does it say that the President or Congress cannot redirect the Fund’s money for some other purpose. And that is what has happened.

Redirecting the Fund’s cash for some other purpose would not be, per se, a bad thing as long as the new purpose advanced public health. However, political expediency, partisan grandstanding, the republican-led 63 attempts to repeal the ACA, the law that established and governs the Fund, have done damage. For example, in February 2012, Congress passed and President Obama signed legislation to cut the Fund by $6.25 billion over 9 years (FY2013 to FY2021) to correct the Medicare sustainable growth rate and prevent cuts to physician services in the Medicare program (known as the “doc fix”). To believe these measures actually advanced our Public Health System is to believe pigs really can fly.

A less controversial move that still violated the Fund’s legislative intent happened in FY2013, when Republicans, who controlled the House of Representatives, refused to appropriate funding for ACA enrollment activities. In response, the Obama administration used the Fund’s money to do that.

As congressional partisanship deepened in the following years, Republicans began to question the Fund as government overreach, calling it the “Obama slush fund.” In 2017, the Republican-led House passed the American Health Care Act of 2017, which would have cut the Fund by $1 billion. It was defeated in the Senate, but it exemplifies the rancor in the Halls of Congress.

A government’s first duty is to protect the safety of its citizens. The arrival of COVID-19, laying bare our still woeful Public Health System, showed us we were unprepared to address that sacred duty, and more than 800,000 of us have died to prove the point.

We could have done so much better.

 

* These are 2019 numbers, the latest year the OECD is reporting as of this writing. According to the CDC, U.S. life expectancy dropped to 77 years in 2020, which is partly due to 385,441 deaths due to COVID-19 in 2020. We can expect a continued drop in life expectancy being reported for 2021, as COVID deaths in that year totaled 435,755.

 

 

News You Might Have Missed

Wednesday, May 26th, 2021

Immunity Passports and Herd Immunity

As time passes, we are learning more and more about SARS-CoV-2, the virus that causes COVID-19. One of the things we are learning is how much we have yet to learn.

For example, a current and pervasive meme involves antibodies an infected person’s immune system makes to combat COVID-19.

Following his bout with the virus in October, 2020, during which he was given an “antibody cocktail,” Donald Trump famously said, “Now you have a president who doesn’t have to hide in a basement like his opponent. You have a president who is immune. Which is a very important thing, frankly.” Although the disgraced former president also said he wasn’t sure how long his “immunity” would last, the cult-of-Trump within the American public heard his “now I’m immune” message loud and clear.

Even before Trump’s “I’m immune” message, six months before, actually, his White House Rasputin, Scott Atlas, from Stanford’s Hoover Institute, told Fox’s Tucker Carlson it was “good news that the virus spreads widely and without risk to the vast majority of people. That’s good news, because we have a better chance of developing population immunity.” He went on to say this “would allow people to develop their own antibodies, and eventually enough people would develop their own antibodies to block the network of contagion.”

Herd immunity from having had the disease is a belief that won’t die. Two months ago “Health Coach” Christian Elliot published a mega-viral blog post entitled Eighteen Reasons I Won’t Be Getting A Covid Vaccine. One of the reasons? “I already had Covid.”

Reputable journals, newspapers and website have published fact-based research debunking this “I’m immune because I had it” drivel. As far back as 24 April 2020, around the same time Scott Atlas was mythologizing with Tucker Carlson, The World Health Organization (WHO) tried to put the matter to rest when it published Immunity Passports in the context of COVID-19. From the beginning of the article:

Some governments have suggested that the detection of antibodies to the SARS-CoV-2, the virus that causes COVID-19, could serve as the basis for an “immunity passport” or “risk-free certificate” that would enable individuals to travel or to return to work assuming that they are protected against re-infection. There is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from a second infection.

For the article, the WHO reported on 17 studies investigating whether having had COVID-19 produces antibodies (it does) that prevent recurrence of the disease (unknown). Seventeen studies, and not one reporting having had COVID-19 prevents short or long term reinfection.

To make it even clearer, further on the WHO said:

As of 24 April 2020, no study has evaluated whether the presence of antibodies to SARS-CoV-2 confers immunity to subsequent infection by this virus in humans.

But none of this stopped Donald Trump from perpetuating the medical myth the following October after his recovery.

This Alice-down-the-rabbit-hole thinking just confirms once again there has never been a fact that Trumped a deeply held belief.

Fifty-three percent, eh?

The Gallup organization made news this week with its latest poll in which it reported 53% of Republicans believe Donald Trump was cheated out of the presidency. This has been confirmed over and over again in the six months since the election—an election Joe Biden won by more than seven-million votes. Makes it seem as if a big swath of the country thinks a fraudster sits in the Oval Office.

But does it really? Let’s look a little deeper.

For decades, Gallup has surveyed the party affiliation of Americans, that is, U.S. adults identifying with the Democratic Party or who said they are independents leaning toward the Democratic Party; and, U.S. adults identifying with the Republican Party or who said they are independents who lean toward the Republican Party. In recent years, the gap between the two, a Democratic advantage, has been between four and six percentage points. In the first quarter, 2021, that gap grew to nine percentage points.

In Gallup’s Q1 survey, 25% of U.S. adults identified as Republicans and 15% as Republican-leaning Independents, for a total of 40%. This compares with 30% identifying as Democrats and 19% as Democratic-leaning Independents, totaling 49%. Thus, the nine point gap.

Now, back to the 53% of Republicans who believe Trump was cheated. Fifty-three percent of 25% is 13.25%. Fifty-three percent of 40% is 21.2%. Presuming not every, single Republican-leaning Independent believes Biden stole the election, we can say somewhere between 13.25% and 21.2% of U.S. adults believe the stolen election Big Lie. I’m betting it’s closer to the bottom number.

And that, my friends, is Donald Trump’s true base.

Who needs an independent commission?

The last time a violent mob invaded Washington, D.C. was 24 August 1814 during the War of 1812 when the British set fire to the White House and the U.S. Capitol, destroying the Senate Chamber and the Library of Congress. They burned most everything to the ground. Only torrential rains stopped the blaze. President James Madison wasn’t at the White House when this occurred, but his wife Dolly was. She took command and rescued everything she could. After that, with American soldiers escorting her, she was able to make her escape.

Two-hundred-seven years later, on 6 January 2021, a weaponized and organized mob of our fellow citizens stormed the Capitol in a violent insurrection. Five people died and the mob trashed the place to the tune of $30 million, according to the Architect of the Capitol. President Donald Trump wasn’t in the Capitol when the mob arrived, but his Vice President Mike Pence was. With the mob chanting, “Hang Mike Pence,” the Secret Service, like the soldiers who helped Dolly Madison, spirited Pence and his retinue out of the building to safety.

Thus far, 494 people have been arrested and charged for participating in the insurrection. They are from all parts of America and from all levels of society. Knowing the who, what, how, and why of this national obscenity seems to me to be a not too radical idea, the responsible thing to do. However, Republicans in Congress maintain that, because congressional committees are looking into the matter, an independent commission is unjustified and a waste of time and taxpayer money. They say the country needs to look forward, not back.

Being kind about this type of argument, I have to say it is full of what makes the grass grow green and tall. Perhaps the summit of Republican silliness was reached last night when Mitch McConnell, calling the whole thing a “purely political exercise,” told reporters that democrats, “would like to continue to debate things that occurred in the past,” as if investigating an assault on Democracy during which a violent mob was trying to find the Vice President of the United States in order to kill him was something akin to investigating how a new city parking lot strangely came to be on the corner of 6th and 7th. McConnell couldn’t even call the insurrection what it was; for him, it’s now just a “thing in the past.”

It is a tremendously sad commentary on our current society that the U.S. Senate, because of Republican opposition, will most likely not  approve an investigation by an independent commission into the 6 January insurrection. People, what have we come to?

History will not be kind to us in this moment. It will give us what we deserve.

A Day For Gloating!

Tuesday, April 27th, 2021

In early 2003, I was honored to be part of a group that wanted to bring better health care to some of the neediest citizens of the Commonwealth of Massachusetts. Dr. Bob Master, former Commissioner of the state’s Medicaid program, had the idea that if a number of us put our collective heads together we could actually do that. With him leading the effort, we created Commonwealth Care Alliance (CCA), an HMO dedicated to serving people who were dually eligible for both Medicare and Medicaid. These were the Commonwealth’s sickest of the sick and poorest of the poor. Paradoxically, their health care was woebegone, but the cost of providing it was astronomical.

CCA was a Dual Eligible Special Needs Plan, known in the business as a D-SNP. D-SNPs were created by the Medicare Modernization Act of 2003 (MMA), and are overseen by the Centers for Medicare and Medicaid Services (CMS). The potential afforded by the MMA was what intrigued Bob Master. He realized that if correctly harnessed, the power of the MMA could do a world of good for people at the lower end of the health care totem pole. And he was right.

Over the years, CCA took on the persona of The Perils Of Pauline, going from crisis to crisis. Our Board, comprised mostly of academics and clinicians, constantly fought above its weight. But, thanks to health care leaders in Massachusetts who saw the value of what we were trying to do, we were always rescued from our own folly. With their help, we grew and thrived—precariously.

In November, 2015, after Bob Master retired as CEO, the Board made the best decision in its history, hiring Chris Palmieri to take over the reins. Chris was a health care executive possessed of zeal, deep dedication to the cause and profound intelligence. Under his leadership CCA  for three years running was ranked number one in its class of health care providers nationally. I chaired the Board during this time and had a ring-side seat to the growth and respect CCA achieved.

During this time, the Board was deeply concerned about the diversity of our employees. We wanted them to look like the thousands of members we served. Great effort went into making that happen. It wasn’t easy, but management established protocols and stuck to them.

My term as Board Member and Chair ended 31 December 2019, but, as you can imagine, I have avidly followed the organization, especially as it navigated the terrible 2020 COVID-19 pandemic. During the last year, under Chris’s leadership, CCA has continued to perform at a superior level. I never doubted that it would.

Today, though, is special. Today, the Boston Globe published its rankings for diversity in hiring of all Massachusetts firms. When I saw that CCA ranked Number One in the Commonwealth!, I thought my chest would burst with pride. This is a remarkable achievement, brought about by the entire organization taking to heart the idea that all of us, working together, are better than some of us, working in ethnic, gender, racial and demographic silos.

Slowly, America is moving to a more inclusive society. After the darkness of the last four years, we are coming into the light. Although much work remains, diversity accomplishments and the recognition that comes with them, as demonstrated by Commonwealth Care Alliance, will propel us toward becoming all that we can be, not what we have been.

It’s Always Been Tough Being A Nurse. Now It’s Worse.

Thursday, April 22nd, 2021

The OSHA Incidence Rate of work injuries (cases per 10,000 workers) for nurses is 12.7; for all other industries, it’s 3.8. Moreover, 40.8% of all nurse injuries involve physically dealing with patient needs, like moving, turning and lifting them, resulting in the highest rate of sprains and strains of all professions.

That nurses experience high rates of injuries is nothing new. Lynch Ryan’s very first client, the year was 1984, was a community hospital where injuries to nurses caused the hospital’s workers’ compensation insurance experience to be nearly three times worse than its peers in Massachusetts. We solved that by creating the concept of modified duty, returning injured employees to work with physician-specified physical restrictions prior to complete recovery.

What is less well known is that America’s health care workers, principally nurses, are victims of violence in the workplace at three times the rate of all other industries, including manufacturing and construction. Among registered nurses, what the Bureau of Labor Statistics (BLS) calls “violent events” make up 12.2% of all occupational injuries; for all other industries it’s 4.2%. Clearly, nursing has been a challenging profession since the time of Florence Nightingale.

The COVID-19 pandemic has made things even worse. A new Washington Post – Kaiser Family Foundation Poll reveals roughly three out of ten health care workers are considering leaving the profession and more than half report being “burned out” due to the overwhelmingly horrific year they’ve just spent trying, and often failing, to save the lives of COVID inflicted patients.

Couple this potential decrease in health care workers with the BLS’s projection (as of 9 April 2021) that health care jobs will be the fastest growing segment of the economy from 2019 to 2029:

Employment in healthcare occupations is projected to grow 15 percent from 2019 to 2029, much faster than the average for all occupations, adding about 2.4 million new jobs. Healthcare occupations are projected to add more jobs than any of the other occupational groups. This projected growth is mainly due to an aging population, leading to greater demand for healthcare services.

So, we were already facing a future serious shortage of health care professionals. Now, the pandemic threatens to thin the ranks even more. Despite this, enrollment in baccalaureate nursing programs increased nearly 6% in 2020, to 250,856, according to preliminary results from an annual survey of 900 nursing schools by the American Association of Colleges of Nursing. In order to hit the BLS projection of 2.4 million new jobs, nursing enrollment will have to grow at this rate every year. That is a tall order.

Meanwhile, occupational injuries, violence events, and, now, illnesses due to the pandemic will continue to plague the health care sector. Try as I might, I have been unable to find any kind of cohesive national strategy to confront and deal with this looming health care catastrophe.

Just another example of our sweeping a coming disaster under the rug for posterity to trip over.