Posts Tagged ‘uninsured’

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The ER is no way to manage health care

October 1st, 2012

During a recent interview on “60 Minutes,” correspondent Scott Pelley asked Republican presidential nominee Mitt Romney  whether the government has a responsibility to provide care to the 50 million uninsured. Romney replied:

“Well, we do provide care for people who don’t have insurance…If someone has a heart attack, they don’t sit in their apartment and – and die. We – we pick them up in an ambulance and take them to the hospital and give them care. And different states have different ways of providing for that care.”

Last night in Santa Monica, I saw the excellent documentary The Waiting Room, after which, director Peter Nicks held a Q&A session. Upon seeing the film, Romney’s comments immediately come to mind. Everyone should see this film, especially anyone who thinks, like Romney, that the hospital emergency room is an adequate place for providing health care.

The Waiting Room, which is playing in Santa Monica through Oct. 4 and in the Bay Area Oct. 19-25, follows 24 hours in the lives of staff and patients at Oakland’s Highland Hospital. Most of the people who come to Highland Hospital are uninsured. Some have lost their jobs. Others are just barely getting by. And because they don’t have insurance, conditions that could have been treated under the care of a regular physician, instead become full-blown problems later on.

Fortunately, federal law mandates hospitals treat people in severe emergencies regardless of whether they are insured. But, as the film shows, most uninsured use the emergency room as their only source of primary care. The ER becomes their only option for treating chronic illnesses. What Romney and others who think like he does don’t recognize is that the ER isn’t designed or equipped to effectively manage people’s health care. The ER is designed to treat traumas. Yet emergency rooms all over the country are being flooded every day with people seeking treatment for minor illnesses and chronic diseases. The wait to be seen can take hours. And when trauma patients are wheeled in, those with less severe ailments are immediately bumped down the list, prolonging their agony and frustration. This is no way to do health care. But in the United States, we have put up with this intolerable situation for decades.

Nicks said that his film is deliberately apolitical. He said he wanted to show the human stories behind the health reform debate. I believe he was effective in doing that. The film has very little commentary. The viewer isn’t emotionally manipulated in one direction or another. The stories of the characters are simply presented as they unfold. Just showing how people navigate through the maddening bureaucracy of our broken healthcare system is enough.

After The Waiting Room‘s theatrical run, it will be shown on PBS. I think the film will open a lot of eyes into a world that is largely invisible to those Americans who have always had the privilege of continuous health coverage. But with the loss of a job, any of us could end up in the ER as the provider of last resort. Once the new federal healthcare law fully kicks in in 2014, the number of people inundating emergency rooms will ease somewhat, as more people become insured through the health exchanges. Yet, the ER will then mainly serve undocumented immigrants, who were shut out of federal health reform. And despite reform, some American citizens will still be unable to access insurance, because their income is too high to qualify for Medicaid or subsidies. The only way to completely ease the burden on our emergency rooms is to establish a national healthcare system, so all people in the U.S. can be treated for their illnesses in a controlled and timely manner.

Sylvia@californiaonecare.org

 

 

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Don McCanne, MD: New Census Bureau numbers on the uninsured

September 19th, 2012

Income, Poverty, and Health Insurance Coverage in the United States: 2011

By Carmen DeNavas-Walt, Bernadette D. Proctor, Jessica C. Smith

United States Census Bureau, September 2012

Health Insurance Coverage – 2011

48.6 million or 15.7% – people without health insurance
• 7.0 million – children under 18 uninsured

193.7 million or 63.9% – people covered by private health insurance
• 170.1 million or 55.1% – people covered by employment-based insurance

99.5 million or 32.2% – people covered by government health insurance
• 50.8 million or 16.5% – people covered by Medicaid
• 46.9 million or 15.2% – people covered by Medicare

Poverty

9.5 million or 11.8% – families living in poverty
• 31.2% – families with a female householder living in poverty

Income Inequality

Income inequality also increased between 2010 and 2011 when measured by shares of aggregate household income received by quintiles. The aggregate share of income declined for the middle and fourth quintiles. The share of aggregate income increased 1.6 percent for the highest quintile and within the highest quintile, the share of aggregate income for the top 5 percent increased 4.9 percent. The changes in the shares of aggregate income for the lowest two quintiles were not statistically significant.

http://www.census.gov/prod/2012pubs/p60-243.pdf

Comment:

By Don McCanne, MD

The numbers of uninsured decreased from 50.0 million in 2010 to 48.6 million in 2011. That might be good news for the net 1.4 million newly insured, but it is terrible news for the 48.6 million who remain without health insurance.

These numbers, of course, are transitional since new private coverage through the state insurance exchanges and the greater expansion of coverage under Medicaid will not take place until 2014. Even then, the new coverage will be either with private underinsurance plans (low actuarial value and inadequate subsidies) or with the chronically underfunded Medicaid program, with even greater impairment of health care access likely. Worse, 30 million will still have no coverage at all (CBO).

Perhaps even more shocking is that 31.2% of families with a female householder live in poverty – right here in the United States!

And income inequality? The aggregate share of household income has decreased for the middle and fourth quintiles. The middle class is being wiped out!

Of course we knew all this. So why aren’t we doing something about it? Howling in the wind doesn’t seem to be getting us very far.

Re-posted with permission from pnhp.org.

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Affordable Care Act starts to show its weaknesses

August 28th, 2012

This week, the Republicans are feting their presidential and vice presidential nominees in Florida, and you can be sure there will be a healthy dose of Obamacare bashing. Candidate Mitt Romney has already pledged to repeal the Affordable Care Act if elected to the presidency. He won’t be able to do that without a complete Republican takeover of Congress, but there are plenty of ways he could eviscerate it nevertheless.

The Democrats will be re-nominating President Obama in North Carolina next, and rest assured the accolades for the ACA will be as lofty as the Republicans’ attitude toward the law is hostile. Still, two new reports about the effectiveness of the ACA should give the Democrats pause:

Confusing language in the health care reform law has raised the possibility that millions of Americans living on modest incomes may be unable to afford their employers’ family policies and yet fail to qualify for government subsidies to buy their own insurance. This is a bizarre development that undercuts the basic goal of health care reform — to expand the number of insured people and make their coverage affordable.

Even if the GOP doesn’t succeed in repealing the ACA, the law could start unraveling anyway. Thirty million people will remain uninsured after the ACA completely takes effect in 2014, and the law’s cost controls are inadequate. Meanwhile in Massachusetts, the ancestral home of the ACA, costs have still been spiraling out of control since that state’s own health reform law passed six years ago. Gov. Deval Patrick recently had to salvage reform by signing legislation replacing fee-for-service with a global payments system. Doing away with fee-for-service is a good thing, but I don’t think this move will be enough in the long run. After all, the Massachusetts law, like the ACA, unwisely continues to rely on profit-seeking insurance companies as an integral part of its health system. Insurance companies will still try to find ways to wring more money out of the pockets of the people and into those of overpaid CEOs and shareholders. They will continue to waste dollars on advertising and needless paperwork – dollars that should go into care. Massachusetts is the health reform canary in the coal mine.

If the ACA starts falling apart in the next few years – which is quite possible given its flaws – the United States will be forced to rethink the folly of sticking with free-market health care. The profit-seeking model only serves itself, not the people, because that’s what it’s supposed to do. Instead, we need a healthcare system that serves the people, and only the people. The only logical solution is to improve upon and expand the public health insurance model to everyone, whether through SB 810 in California, or Medicare nationwide.

Sylvia@californiaonecare.org

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Don McCanne, MD: Stuart Butler on the 30 million uninsured

August 13th, 2012

The New ACA Score And The Perils Of Letting Cost Estimates Drive Policymaking

by Stuart Butler

Health Affairs Blog, July 24, 2012

If you were expecting the Congressional Budget Office (CBO) recalculation of the Affordable Care Act (ACA) to rival the drama of the Supreme Court decision, you will have been disappointed.  But the new CBO re-estimate underscores the dangers of basing major policy changes on such forecasts.

While the Court caused political shockwaves by declaring the ACA’s “penalty” to be a “tax”, that in itself did not have major implications for the new score.  CBO projects a net reduction in total federal outlays of $84 billion over 10 years (the new total is $1,168 billion) and an increase in the uninsured of about 3 million, when compared with its earlier estimates.  Significant numbers, but not earth-shattering.  The Joint Committee on Taxation provided revenue estimates for the CBO forecast.

But CBO faced enormous challenges in estimating the impact of the ruling, and its seemingly precise estimate clouds the significant guesses it had to make.

The Challenge Facing CBO

Rather than the tax-not-penalty decision, the part of the Court’s ruling with the greatest budgetary implications concerned Medicaid.  It also gave CBO its biggest headache.  The Court struck down the provision requiring states to expand Medicaid coverage to households up to 133 percent of the poverty level.  So CBO had to figure how many states – indeed which states, given different Medicaid coverage pattern today in the states – would decline short-term federal funding for the expansion (what the Wall Street Journal called the “teaser rate”), knowing they would have to pay a portion of the cost in future years.  The governors of several states, including Texas, Florida and South Carolina, have already declared they would refuse the money.

So what could CBO do?  Take such declarations at face value?  Factor in a bit of politics, consult a political crystal ball, and predict what might actually happen in state houses next year? Give a range to show, say, the different effects of all states declining or all agreeing to expand Medicaid?

To compound the scoring challenge, CBO had to project what would happen to newly eligible Medicaid households in states that decline federal money to expand Medicaid.  Some, but not all, would be eligible for subsidies in the new ACA exchanges, depending on household income.  But how many would sign up (adding to subsidy costs, even though they would not have added to federal Medicaid costs)?

According to former CBO Director Douglas Holtz-Eakin, depending on your guess the potential range of budgetary effects would be large.  If the six states currently saying they will not expand Medicaid follow through with that threat, Holz-Eakin estimates the net budget impact would be $22-80 billion between 2014 (when the expansion occurs) and 2021.  But if all states decide the expansion is an offer they must refuse because of the long-term state cost, the impact could be as high $627 billion.

A False Sense Of Certainty

Faced with the uncertainty about state action, CBO declined to give a range (a bad thing).  Instead it avoided second-guessing states (arguably a good thing for people who wear green eyeshades rather than appear on political talk shows) and projected a number based on “the middle of the distribution of possible outcomes.” That’s defensible, in the same sense as a weather forecaster splitting the difference on the chances of thunderstorms next Friday, but it results in a seemingly precise number that is almost certainly wrong and yet gives a false sense of certainty to policymakers.

This case of CBO scoring highlights once again why it is so important for policy to be driven a bit less by budget estimators generating apparently precise numbers.  That leads to policies based on guesses needed for a computer algorithm rather than on judgment and public discourse about the nature and purpose of government.  But alas, Congress insists that CBO come up with one number for its deliberations, not a range or a zone of probability.  And so even though CBO wisely warns that its number “should not be viewed as representing a single definitive interpretation of how the ACA should or will be implemented in light of the Court’s decision,” regrettably it will be.

Posted response by Don McCanne:

The policies inherent in the Affordable Care Act do create uncertainty as to how many will remain uninsured. Nevertheless, the CBO projection of 30 million uninsured will be the number quoted in policy discussions, since it is the best we have, and it does provide a rough estimate of how short ACA falls in the goal of covering everyone.

To provide a perspective of the enormity of this policy failure, let’s assume that we chose a different set of policies that would cover the same total number of individuals, still leaving 30 million uninsured. Let’s say that we want to have 100 percent coverage in each state, beginning with the largest states since they would have the greatest health care burden in terms of the sheer numbers of patients. Let’s continue to cover 100 percent of each state until we run out of funds to pay for coverage for the last 30 million people – the residents of the least populated states.

Under such a policy, everyone would be covered except all of the residents of Alaska, Arkansas, Delaware, District of Columbia, Hawaii, Idaho, Kansas, Maine, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming.

Who could ever support such a ridiculous policy scheme? Yet since we have buried other ridiculous policies into a highly dysfunctional, fragmented, administratively wasteful ACA financing scheme, we are going to accept those policies as the best we can do? It’s okay to have 30 million uninsured as long as we don’t concentrate them in two-fifths of our states?

Stuart Butler implies that we need policies based on “judgment and public discourse about the nature and purpose of government.” If we were all sincere in such a discourse, and laid partisanship aside, we would end up with a decision to enact a single payer national health program that included everyone.

http://healthaffairs.org/blog/2012/07/24/the-new-aca-score-and-the-perils-of-letting-cost-estimates-drive-policymaking/

Comment:

By Don McCanne, MD

Stuart Butler has a valid point that the variables in the Affordable Care Act and its implementation are great enough that we cannot accurately predict the precise numbers of individuals who will remain uninsured. The information that the Congressional Budget Office relied on to come up with 30 million uninsured does give us a very rough estimate of the total, and enough confidence that we can say with certainty that at least tens of millions will remain uninsured.

So what is Stuart Butler’s point? He indicates that instead of using this precise number to establish policy, we should choose policies based on “judgment and public discourse about the nature and purpose of government.” Well, let’s use the less precise estimate of tens of millions uninsured. What then should be the role of government?

It is clear that the private sector has been incapable of insuring everyone, and that government involvement is required if universal coverage and access are to be our goals. It is also clear that the Affordable Care Act is not an adequate response on the part of government since that is what led to this estimate of the large numbers who will remain uninsured.

So what would Butler propose? In 1989, we thought we knew the answer when he coauthored the report from the Heritage Foundation which called for the principle that, “Every resident of the U.S. must, by law, be enrolled in an adequate health care plan to cover major health care costs,” and “The requirement to obtain basic insurance would have to be enforced,” and “If the family did not enroll… a fine might be imposed.” Yes, an individual mandate.

This did prove to be partisan since the concept was used in proposed Republican legislation designed to counter the health care reform proposal of Bill and Hillary Clinton. The Clinton effort fizzled, and the Republican proposals were never enacted. Little did we realize then that a couple decades later the partisan support for the individual mandate would flip from the Republicans to the Democrats.

In a USA TODAY op-ed this year, Butler indicated that his views had changed based on newer policy research, and that today the individual mandate “means the government makes people buy comprehensive benefits for their own good, rather than our original emphasis on protecting society from the heavy medical costs of free riders.” Sort of, you take care of your own needs but don’t turn to me for help when you can’t meet them – the perpetual conflict between individual responsibility and social solidarity.

He wrote, “health research and advances in economic analysis have convinced people like me that an insurance mandate isn’t needed to achieve stable, near-universal coverage. For example, the new field of behavioral economics taught me that default auto-enrollment in employer or nonemployer insurance plans can lead many people to buy coverage without a requirement.”

We know that default auto-enrollment does result in higher rates of participation, but we also know that an entirely voluntary program for purchasing our often unaffordable private health plans would leave far more uninsured than would the policies contained in the Affordable Care Act.

We should have that public discourse that Butler calls for – the one about what we, as a nation, want. Do we want absolutely everyone to be included in our health care system? Or do we want to continue with policies that provide the equivalent of covering everyone in the most populous states, but none of the residents of Alaska, Arkansas, Delaware, District of Columbia, Hawaii, Idaho, Kansas, Maine, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming?

Heritage Foundation: “A National Health System for America” 1/2/89
http://www.heritage.org/research/reports/1989/a-national-health-system-for-america

USA TODAY: “Don’t blame Heritage for ObamaCare mandate” by Stuart Butler
http://www.usatoday.com/news/opinion/forum/story/2012-02-03/health-individual-mandate-reform-heritage/52951140/1

Re-posted with permission from pnhp.org.

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