Arkansas is one step closer to being the first state to use Medicaid expansion dollars to buy private coverage for many of its 250,000 newly eligible residents rather than enroll them in the existing Medicaid program. This week the Arkansas House of Representatives approved the plan, leaving only the Senate to decide whether the state will be implementing this “market-based approach” to expanding Medicaid.
The idea of buying private insurance for Medicaid recipients is emerging as a “conservative compromise” for some of the 24 states (home to more than 25 million uninsured residents) leaning toward rejecting federal funding the Affordable Care Act provides for the expansion. In the original legislation, the ACA required states to expand Medicaid to adults earning up to 138 percent of the federal poverty level, $15,870 for an individual or $32,499 for a family of four. The federal government would fully cover the costs of this expansion for two years, with states gradually having to contribute 10% by 2020. Last summer, the Supreme Court struck down the Medicaid expansion requirement, allowing states to refuse federal funding and opt out of the expansion.
But most of these states, including Florida, Texas and Indiana, are leaving a lot of money on the table—from hundreds of millions to $1 billion or more in federal funding. Under pressure from healthcare providers and other interested parties, some governors view premium assistance programs that move the poor, disabled and frail elderly to the state insurance exchanges to buy private insurance as a way to capture this windfall without appearing to embrace ObamaCare. Read more…
By James Burdick
(A version of this post appeared April 8 in the Baltimore Sun)
There are a plenty of reasons why health care in the U.S. is so expensive and uneven in quality. But the direct marketing of expensive drugs, tests and even medical conditions to consumers is something we actually can—and should—do something about.
One ubiquitous advertiser in my neck of the woods promotes walk-in ultrasound testing of blood vessels and whatever other asymptomatic part you may choose to pay for. Worried older folks can feel lucky that Medicare will often reimburse for these tests. But in fact, the whole course of tests and treatments encouraged by these ads will not improve their life expectancy — and could even have some chance of decreasing it.
Shouldn’t we read these solicitations as symptoms of a very readily eliminated illness that plagues our health care system? An asymptomatic 65-year-old found to have an arterial abnormality in this profit-driven testing facility is almost certain to succumb, eventually, to something else. That is, of course, unless he is told of the findings, goes to his doctor scared, and the doctor injudiciously arranges an angiogram or other invasive procedure. And so this harmful and lucrative practice of persuasion keeps our country’s medical wheels turning.
It is worth wondering: If this test is medically indicated, why has the patient’s regular doctor not already ordered it? And if the testing is done and produces a normal result, how often should the patient get rechecked? Read more…
If you haven’t had a chance to read Steve Brill’s excellent investigation “Bitter Pill: Why Medical Bills Are Killing Us” in Time magazine, it’s a great example of why long-form journalism is still relevant and indispensable. It gives a personal face to the perverse economic forces that have created what Brill calls “the ultimate sellers market” in the healthcare industry. Much of what he exposes is what we in the health policy field have been railing about for several years now. But the graphic way in which Brill lays out the issues leaves no question that before we talk about making wholesale cuts to government programs or rationing care to lower costs, we must fundamentally reform provider payment, confront prices and provide incentives that promote far more accountable care.
Brill’s article is very comprehensive, but there are some key points that I want to expand on. They include:
1) Prices for goods and services are often wildly out of line with what is actually delivered–$15 for three gauze pads, $108 for bacitracin, $9,400 for a 6-hour visit to the emergency room for a woman with a broken nose, and a $49,000 charge for a device to treat back pain. As hospital spokespeople told Brill, patients with insurance do not pay these prices because their carrier, whether private, Medicare or Medicaid, negotiates deep discounts. But as Brill points out, perversely those who are uninsured and can afford it the least are charged the highest prices. These inflated prices, which vary from hospital to hospital, are recorded in so-called “chargemasters,” proprietary price lists whose origin remains mysterious.
As Brill writes; “I quickly found that although every hospital has a chargemaster, officials treat it as if it were an eccentric uncle living in the attic. Whenever I asked, they deflected all conversation away from it. They even argued that it is irrelevant. I soon found that they have good reason to hope that outsiders pay no attention to the chargemaster or the process that produces it. For there seems to be no process, no rationale, behind the core document that is the basis for hundreds of billions of dollars in health care bills.” Read more…
In his response to President Obama’s State of the Union speech, Florida’s Senator Marco Rubio warned; “anyone who is in favor of leaving Medicare exactly the way it is right now, is in favor of bankrupting it.”
Implying that the current administration is in danger of doing exactly that, Rubio asked us, “Instead of playing politics with Medicare, when is the President going to offer his plan to save it?”
First of all, as Sarah Kliff points out in the Washington Post’s Wonkblog, Obama did mention three specific initiatives for achieving Medicare savings in his speech:
1) Restoring the Medicaid drug rebates for so-called dual-eligibles (the mostly poor, sick or disabled people who qualify for both Medicaid and Medicare) that were rescinded once their medications were covered under Medicare Part D. The administration estimates this would save $156 billion over 10 years.
2) Means-testing the Medicare program for higher-income seniors. This boils down to raising premiums by another 15% for the 5% of well-to-do seniors who already pay more for their Medicare premiums. According to the Congressional Budget Office, this would generate $30 billion in savings over the course of a decade.
3) Paying doctors and hospitals for the quality of care they provide, not quantity. Cost savings: Well, that’s complicated—but this could be the game-changer.
It’s true that the President didn’t spend much time on health care in his speech. That’s probably because he knew that studding his State of the Union address with health policy-speak and detailed models would have caused even more of the audience to fiddle with their cell phones or perhaps indulge in a catnap. It’s also because “saving Medicare” and bending the “cost curve” of health care spending in general is a whole lot more complex than is portrayed by politicians and much of the media. Read more…
With election day upon us at last, we are all being deluged with projections as to who will be sitting in the White House come January. I have been watching this process from an emotional distance for at least the last month or so as the media reports the daily ups and downs of approval ratings, possible electoral vote scenarios and political reactions to the monster hurricane that just devastated parts of my city.
For a campaign in which candidates spent a total of $3 billion, the stakes are high for more than just individual issues like Medicare, unemployment, taxes, abortion and all the other hot button items that divide our country. If elected, Mitt Romney and the conservative base of the Republican party stand to fundamentally change the nature of this nation; sacrificing social programs, tolerance and federal responsibility to create a pro-big business, free-market country that cedes important federal powers to self-interested state authorities.
Of course we know how Gov. Romney and his erstwhile supporters in Congress feel about the health reform law. A long-time promise of the campaign has been to immediately repeal Obamacare, legislation Romney calls a “bad law.” He’s said that he plans to immediately grant waivers to all states, allowing them to ignore the law and stop work on setting up mandated health insurance exchanges. The next step is to use Congress’s budget reconciliation process to repeal nearly all elements of the health law over the next several months.
There are serious doubts, even among detractors of the ACA, that a Romney administration could successfully grant the state waivers and cut off funding for the health law. Federal courts are sure to get involved and block these widespread actions. Don’t forget that some popular aspects of the ACA–allowing young adults to stay on their parent’s health plans and requiring insurers to accept people with pre-existing conditions, for example–are already in place. It will be very difficult or impossible to use budget reconciliation to repeal these provisions, especially without an alternative plan in place.
That said, I believe there are key aspects of health reform that will continue to advance whatever the outcome of the election. These are the fundamental changes in how care is payed for and delivered that are already transforming our health care system. Several months ago, I was asked by Columbia University’s Mailman School of Public Health to write an article for a new magazine they were publishing. There have been many changes in Columbia’s public health program and the resulting magazine conveys the breadth of work done by researchers associated with the school and emphasizes a new “life course” approach to education that considers the influence of public health on every age and stage of life.
My assignment was to predict which aspects of health reform would prevail if 1) the Supreme Court ruled that the ACA was unconstitutional, or the individual mandate was unconstitutional (it didn’t) or 2) Obama lost the election (as of today, still don’t know.). After many months and changing predictions, I agree with Michael S. Sparer, chair of Mailman School’s Department of Health Policy and Management who told me;
“There are important trends reshaping the healthcare system that will continue regardless of who wins the presidential election, who controls the next Congress, and whether the ACA survives or is repealed.” He continues in the article, “Indeed, while the ACA supports and encourages many of these trends, there simply is no going back. A healthcare revolution is under way.”
The five trends I chose to highlight include:
1) “Farewell Fee For Service, Hello Accountable Care”
2) “Playing Up Prevention”
3) “Rewarding Quality, Punishing Carelessness”
4) “Evidence Is the Best Medicine”
5) “Expanding the Reach of Medicaid”
I do point out that despite widespread adoption of innovative payment and delivery models by Medicare and also by commercial insurers, there are serious barriers to reaching universal coverage without the ACA. It is vital that Medicare not be turned into a stingy voucher system, Medicaid be expanded and not made into a block grant program, and that all Americans be offered the chance to have affordable, high quality health coverage. It would be heartbreaking to come this far for naught.
Fingers crossed for tonight’s results; we still have a long way to go.
You can read “5 Trends That Will Shape U.S. Health Care (No Matter How the Politics Play Out” here in Columbia Public Health, and perhaps come up with your own predictions for the future of health care.
It sounds like heresy, but recent evidence challenges the long-held belief that the annual physical is beneficial for healthy adults. Researchers at the Nordic Cochrane Center in Copenhagen wrote last week that although a regular check-up with multiple screening tests might seem to offer the advantage of catching problems like heart disease and cancer early, their review of studies involving some 180,000 adults actually found no benefit. People who had annual check-ups were no less likely to be admitted to the hospital, become disabled or miss work than those who did not have regular physicals. Even more surprising, they were no less likely to die from heart disease, cancer or any other illness.
In fact, subjecting healthy adults to this yearly battery of tests may do more harm than good. The authors write, “One possible harm from health checks is the diagnosis and treatment of conditions that were not destined to cause symptoms or death. Their diagnosis will, therefore, be superfluous and carry the risk of unnecessary treatment.”
The underlying message in this new analysis is that if we go looking for something slightly out of whack, we are likely to find it. That leads to further testing—some of which may be invasive—and possible diagnosis and treatment of disease that might never progress. Finally, wholesale testing for a range of conditions without determining if a patient’s age, medical or family history puts him at risk, raises the likelihood of over-treatment and even harm from unnecessary interventions. Oh, and it also increases health care costs. According to the Centers for Disease Control, in 2009, the routine general health check was the most common reason patients visited their doctor in the United States. Read more…
With the second round of the presidential debates upon us, it struck me that despite the fact that the candidates spent nearly one-quarter of their first debate talking about health care, the dialog was limited to haggling over hundreds of billions in Medicare cuts or savings (depending on the candidate) and personal stories shared by beleaguered Americans who can’t afford care under the current failing system.
Virtually all of the attention has focused on Medicare (no surprise with the all-important senior vote in play) and the stark contrast of the two candidates’ long-term view of the health reform law. There were warnings from the Romney camp about $716 billion cuts in store for Medicare should Obama be reelected, and the specter of nameless, faceless rationing panels who will deny care to innocent seniors. Romney of course has earlier proposed achieving the same savings by turning Medicare into a voucher system, an idea that a new Kaiser Family Foundation study finds would increase expenses for six out of ten seniors.
But as important as those issues are–and there is no question that repealing the Affordable Care Act, gutting Medicaid through block grants to the states and turning Medicare into a voucher-based program would be devastating to the health of the nation–there are so many other issues I’d like to hear about from the candidates tonight. Read more…
If you or a loved one has been to the emergency room lately you might want to request an itemized bill. The highest charge will likely be for what is known in billing parlance as “evaluation and management” services. These services include taking a patient history, performing an initial exam and directing treatment. How much the hospital charges will depend on an all-important choice of billing code—there are a range of codes that coincide with factors like the severity of the problem, underlying health issues of the patient and in some cases, time spent managing this care.
Why take a close look at these charges? According to a new investigative report from the Center for Public Integrity, providers have been increasing their use of billing codes that correspond with care for the most seriously ill or injured patients, adding $11 billion or more to the fees they receive from Medicare over the last decade.
According to the CPI report;
“Use of the top two most expensive codes for emergency room care nationwide nearly doubled, from 25 percent to 45 percent of all claims, during the time period examined. In many cases, these claims were not for treating patients with life-threatening injuries. Instead, the claims the Center analyzed included only patients who were sent home from the emergency room without being admitted to the hospital. Often, they were treated for seemingly minor injuries and complaints.”
A similar analysis by the New York Times that looked at Medicare data from the American Hospital Directory found that “[h]ospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms.” These codes refer to what are called “evaluation and management services” and are separate from physician fees and charges for specific tests and treatments. Read more…
When Rep. Todd Akin (R-MO) made his now infamous claim that victims of “legitimate rape” don’t get pregnant because their bodies will “shut that whole thing down,” his was a particularly egregious but certainly not unique instance of junk science being used to justify a political stance.
In this case, Akin was explaining his support for the Republican Party platform (unchanged in more than two decades) that calls for outlawing abortion in all instances except when the life of the mother is endangered. One imagines that Akin also believes that girls who are the victims of incest can also summon their bodies to create an inhospitable environment for pregnancy. Meanwhile, what expertise backs up Akin’s warped version of basic reproductive biology? As we learned, Akin serves on the House Committee on Science, Space and Technology, and his education includes a BS in management engineering from Worcester Polytechnical Institute and a Master of Divinity at Covenant Theological Seminary in St. Louis.
Was there no high school biology in this educational journey? No sex education or even a frank talk with a parent about where babies come from? Alas, Akin, despite his higher education and election to national office is not immune to the ignorant ramblings of a decidedly (and dangerous) anti-science element of our society. It’s no surprise that Erika Christakis, an administrator at Harvard, writes on Time’s Ideas blog that harmful myths about rape and pregnancy have a long, dark history:
“We heard from periodontist turned lawmaker Henry Aldridge that women who are ‘truly raped’ can’t become pregnant because the ‘juices don’t flow.’ Others, including a federal judge, have called pregnancy from rape as likely as ‘snow in Miami’ and ‘1 in millions in millions,’ while some have embraced specious claims about the effect of emotional trauma on conception from (so-called) ‘assaultive rape’ and other science-bending notions.”
Beyond the rape issue, abortion has been a regular target for anti-science conjectures. There are still prominent people out there who insist abortion causes breast cancer. It leads to infertility. It causes irreversible psychological damage to all women who undergo the procedure. The latest round of anti-choice legislation is founded on the concept that fetuses feel pain. Read more…
When the Supreme Court ruled last month that states cannot be penalized if they refuse to expand their Medicaid programs to meet the new coverage requirements of the Affordable Care Act, the health status of 6 million low-income individuals was thrown into limbo.
The health law directed states to provide Medicaid coverage for residents earning up to 133 percent of the federal poverty level (FPL) or about $14,800 for individuals and $25,400 for a family of three. This provision was expected to provide coverage for some 17 million of the uninsured. Currently, 33 states limit Medicaid eligibility for working parents to less than 100% of FPL, with half of those limiting eligibility to less than 50% of the poverty level. Only 9 states offer any coverage at all for impoverished adults who are not parents.
Since the ruling, 29 governors—all from Republican states—have announced that they are considering rejecting the federal government’s offer to cover 100% of the cost of Medicaid expansion for three years (scaling back to 90% by 2020) in order to maintain the status quo or even reduce benefits for their poorest residents further. According to a survey by USA Today, seven states, including Texas, Louisiana and Florida, have already pledged to sidestep the law. The USA Today survey provides an excellent interactive map that lists the percentage of uninsured in each state, as well as details about where states stand on forming health insurance exchanges and the Medicaid expansion. Not surprisingly, many of the states (like Texas) with the highest percentage of uninsured residents (at 25%, the highest in the nation) are voicing the most opposition to forming exchanges and expanding Medicaid.
Much ink has been used to explain why states oppose the Medicaid expansion but the official line from holdouts boils down to two objections; money and distrust of the federal role in state health programs. (Of course political partisanship is the unstated but always looming background for any discussion of “Obamacare”.) Read more…