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The website 538.com has posted an essay (found here) about the great state of Alabama. Unlike most click bait-y articles that Alabamians seem to be attracted to on Al.com (i.e. What are the 11 greatest barbecue places within 30 miles of Bryant-Denny stadium?) but instead an in-depth look at healthcare in Greene County, Alabama. Greene county is currently the least populated Alabama county (9,045 people, 81.5% black or African American). In 1860, the county had about 30,000 people. Well, kinda depends on your definition. 23,598 of those “people” were actually enslaved human beings. Although the math works out to approximately 4 enslaved humans for every 1 “person,” in fact it was almost 7000 enslaved humans were owned by about 50 folks. As described in the Encyclopedia of Alabama, this was not a bad thing

In the decades leading up to the Civil War, Eutaw experienced a golden era as the mercantile and legal center of the Black Belt. The first courthouse, built in 1838, burned in 1868. The current courthouse was built in 1993.

The county is in a region of the state known as the “black belt”, named not for the color of the population but for the color of the soil. The slow slide to economic despair over the last 150 years has taken a toll on the region. Immediately after the civil war, the region was home to 40% of the “citizens” of Alabama. The systematic oppression of former slaves and the descendants of former slaves has lead to the growth and development of many civil rights leaders, blues musicians, and story tellers. It has also lead to a bunch of people moving away. The region, once the economic engine for the region, is now home to 12% of Alabama’s population. In the words of one Percy County resident

“The only reason people come to town now is for funerals, and they leave as soon as they’re over ’cause there’s nothing to do and nowhere to stay,” said Walker, 64, the son of sharecroppers

For those who have stayed, economic prosperity has been an uneven proposition. The racial makeup of the Black Belt region was 52.2% African American, 45.8% White, 0.2% Native American.

The poverty rate among [Wilcox] county’s white population is just 8.8 percent, which is lower than all but five counties. The poverty rate among the county’s much larger black population is 50.2 percent. The 41.4 percentage point gap is the largest in the state.

Other Black Belt counties have a similar dynamic. Lowndes County has a 4.1 percent white poverty rate – the lowest in the state – but a 34.5 percent black poverty rate. In Perry County, the white poverty rate is 8.1 percent, while the black poverty rate is 32.7 percent. In Marengo County, it is 5.6 percent and 40.8 percent respectively.

So why worry about these folks? Can’t they continue to vote with their feet?

“The Black Belt is a road map,” said Patrick Sullivan, a professor at the Rollins School of Public Health at Emory University who previously worked on HIV surveillance at the Centers for Disease Control and Prevention. “That’s what’s so tragic and so compelling. It’s an endgame depiction of what happens when you have social and structural inequalities. It’s the vestiges of slavery and inequality, and in the long run those things do play out as health inequalities.” Sullivan and colleagues have studied why HIV rates are so much higher among African-Americans and Latinos than other racial groups3 and found that health insurance is the most important mediating factor. People in both racial/ethnic groups are more likely to be poor and have less education, which are related barriers, but insurance coverage is where the local and federal government could improve access to treatment, Sullivan said.

Alabama is not a Medicaid expansion state. Our Doctor-Felon-Former-Governor decided it was a political chance he did not want to take, even after his re-election into a term limited position. Remember, adults who are employed but make less that 138% of poverty uninsured are not eligible for Obamacare. In counties like Greene, where 40% of the population is below the poverty level, that is a lot of folks, almost all of them black. When the median household income is $20,000, people are going to choose food when having to decide regarding food vs insurance, every time. So what is the right thing to do? In the words of my friend and colleague John Waits, quoted in the article:

“Nothing happens without Medicaid,” Waits said. “It is the No. 1, the No. 2, it is the top 10 solutions.”

I’m beginning to think this is about something other than partisan politics.

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Frandal Wright, who went 27 years without health insurance before getting HIP 2.0 coverage last year, makes his $1 monthly payment at the Wal-Mart in Anderson.

Because the store is on the other side of Anderson from where he lives, Wright tries to pay as much as he can at each visit to minimize the number of times he has to make the trip. Right now, he says, he’s trying to find someone to give him a ride to make his payment and determine if he has enough money to make a lump sum payment.

“I’m a little behind now because I almost forget about it,” said Wright, 46. “I want to pay for the whole year. I’m trying to do that this time. I’ll probably give them $20 if the Lord blesses me.”

Do Indiana’s poor Medicaid recipients really have skin in the game?

As I viewed my electricity bill today I was told by Alabama Power “You pay on average $5 a day for your electricity.” This means I have “skin in the game.” I have the power to determine if I pay nothing per day or $20 per day. Well, only a little as it turns out.  It seems that Alabama Power won’t let me come off the grid easily, so I will end up paying something no matter what. Also, my major non-air conditioner power usage corresponds to my use of the clothes dryer. I can minimize the use of the dryer by hanging a clothesline, I suppose, but elect not to.  What I have decided is that I cannot do  without electricity. So, although I have skin in the game, I can’t say “no, thank you, I’m using a cheap alternative to electricity so go away Alabama Power.” I rely on the Public Service Commission to negotiate fair rates and rely on the government to force my appliances to become energy efficient. Oddly, as appliances become more energy efficient, rates per kilowatt hour tend to go up. I now have less skin in the game (using efficient appliances less frequently still costs the same because I pay more per kilowatt hour) but still reflexively try to use less electricity. Modern life is confusing at times.

Many folks have asked me what I think is going to happen with health care. Conventional wisdom is that the people appointed dictate policy. Seema Verma, who helped design the Medicaid expansion in Indiana, is the new director of CMS (the agency responsible for Medicaid and Medicare). The buzzwords for poor people and perhaps all sick people will likely be “personal responsibility.”

Ms Varma has written on the philosophy she has used to design the system in Indiana (article found here). It seems that this is not just about making sure poor, sick folks have needed care but importantly involves  bootstrap repair as well:

[M]any of Medicaid’s enrollment and eligibility policies, which might make perfect sense for certain vulnerable populations, are not always appropriate for able-bodied adults possessing different capabilities and earning potential. Able-bodied adults need coverage, but not the same set of policy protections.

One of the precepts of President Lyndon Johnson’s War on Poverty, from which Medicaid arose, is that government assistance should exist to provide a temporary pathway for people to lift themselves out of poverty toward a state of self-sufficiency.

The recipients are given a Health Savings Account and are required to make their personal contribution to teach them responsibility (as was the client in the anecdote above). Finding frequent rides to the insurance payment window and personally making a payment which provides continued access to lifesaving insulin and health failure medications, apparently, is freeing:

HIP respects the dignity of each member by setting a fair expectation of personal investment and engagement in his or her own well-being. Contributions are a way for members to demonstrate personal responsibility, but they also encourage members to stay engaged with their health plan, providers, and overall personal health. Because HIP Plus members’ own dollars are at stake, they have “skin in the game” and therefore an incentive to make cost-conscious health care decisions.

Well, maybe not…Turns out that for “frequent flyers” hospitals are seeing to it that the $1 premium is being paid. Because, if you miss a payment, you are kicked out. So it does seem that someone has skin in the game, just maybe not the patient.

As a pragmatist, I believe that the motive is unimportant if the desired result is achieved. Results to date are mixed. Ms Varma points out that those who have paid their premium continuously (folks with “skin in the game”) are more likely to have a primary care doctor, less likely to go to the ED, and more satisfied with their care. Critics point out that enrollment is not by any means what it should be as many folks can’t get a monthly ride to pay their dollar. Also, less that half of folks who were enrolled knew that they even HAD a health savings account much less how to use it. As they say, further study is needed.

In my professional experience, people believe they are healthy until they are sick. A monthly trip to Walmart to pay a dollar is likely not to change that. I hope that we choose to look at real measures of health and not try to do social engineering with our healthcare dollars.

Uwe Rheinhart, a noted health economist, was asked to predict what would become of healthcare under Trump leadership. He said “My hunch is that the “replace” in what is coming will reflect that conservative vision. It is bound to spell more hardship for the poor, the old, and the sick.” I am afraid that that is what “skin in the game” means.

Jean, an Arizona teacher whose employer provided group health benefits but did not contribute to the cost for family members, gave birth to her daughter, Alex, in 2004 and soon after applied for an individual policy to cover the baby.  Due to time involved in the medical underwriting process, the baby was uninsured for about 2 weeks. A few months later, Jean noticed swelling around the baby’s face and eyes.  A specialist diagnosed Alex with a rare congenital disorder that prematurely fused the bones of her skull.  Surgery was needed immediately to avoid permanent brain damage.   When Jean sought prior-authorization for the $90,000 procedure, the insurer said it would not be covered.  Under Arizona law, any condition, including congenital conditions, that existed prior to the coverage effective date, could be considered a pre-existing condition under individual market policies.  Alex’s policy excluded coverage for pre-existing conditions for one year.  Jean appealed to the state insurance regulator who upheld the insurer’s exclusion as consistent with state law.

From a 2005 Wall Street Journal article

People hate Obamacare. People in “real” America really hate Obamacare. Kaiser Family Foundation convened a series of focus groups in counties that voted for Trump to find out what EXACTLY Trump voters hated about Obamacare (article found here).  They hated that those that were really poor and on Medicaid didn’t have the same barriers to care (high co-pays and deductibles) as did those who were working hard. This was even when the groups included voters on Medicaid. They hated how expensive their premiums were, how high their co-pays were, and how much was not covered. They hated how complex the system is and how when you think you have it figured out someone throws another thing at you. They hated the mandate to purchase insurance.

There is currently a bill  being formulated to “repeal” significant parts of the ACA and replace it either with a “To Be Named Later” or with a mismash of proposals which would be labeled “replacement.” How pre-existing conditions fit into this bill remains unclear but is worth understanding (Kaiser article here). Prior to the passage of the ACA, insurance companies were state regulated, and in all states were able to do medical underwriting, This meant that they could effectively eliminate people with preexisting conditions. Although it would be possible to repeal the ACA and keep in the current underwriting rules, it is not likely this will happen. In the case of our pre-Obamacare insurance at our work, the “lookback” was “270 days, known or unknown, manifest or unmanifest.” This meant that, the human gestation being 270 days from conception, if you had your first day of work and went home and celebrated with your significant other (and one thing lead to another) you had best hope the baby was a week late. If not, you were paying cash. Much worse was the patient we had whose cancer was manifest 4 months after his employment commenced and we got to tell him that he had to pay $100,000 up front or die of his cancer. Kaiser estimates that 52 million people will be denied coverage if the old rules are put back into place. Perhaps not denied outright but effectively denied by bringing back these old favorites:

  • Rate-up – The applicant might be offered a policy with a surcharged premium (e.g. 150 percent of the standard rate premium that would be offered to someone in perfect health)
  • Exclusion rider – Coverage for treatment of the specified condition might be excluded under the policy; alternatively, the body part or system affected by the specified condition could be excluded under the policy. Exclusion riders might be temporary (for a period of years) or permanent
  • Increased deductible – The applicant might be offered a policy with a higher deductible than the one originally sought; the higher deductible might apply to all covered benefits or a condition-specific deductible might be applied
  • Modified benefits – The applicant might be offered a policy with certain benefits limited or excluded, for example, a policy that does not include prescription drug coverage.

Some have suggested that a “high risk pool” would allow these folks to obtain coverage and keep the cost down for the 50% of the population who have no need to access the healthcare system in a given year. We actually tried that before, turns out. As the Kaiser article points out, these didn’t work for a number of reasons. First is the nature of health care expenses. Some folks have a lot of expense in a single year (car crash) and the next year are perfectly fine. Others have a lot of expense in an ongoing fashion for a very long time (think Magic Johnson and HIV).

Planning for these disparate situations was tough and no one got it right. The reasons for failure included:

  • Premiums above standard non-group market rates – All cost a lot, the states with the most success provided a substantial subsidy.
  • Pre-existing condition exclusions – Once again, how do you deal with folks who wait until they get sick to pick up a policy
  • Lifetime and annual limits – Most ranged from $1 million to $2 million and others imposed annual dollar limits on specific benefits such as prescription drugs, mental health treatment, or rehabilitation.
  • High deductibles – The plan options with the highest enrollment had deductibles of $1,000 or higher.

The conclusion was that they could work but it’ll cost a lot to get it right.

Back to the focus groups. What Trump voters said they wanted was low premiums and little out-of-pocket expense for drugs, visits, and procedures. They wanted no mandate and no increase in taxes but felt that not covering pre-existing conditions was “un-American.”

They expressed confidence that as a businessman President-elect Trump could pull this off. Hope they are correct.

I had to quit my job because of the stress I had to endure was putting me at high risk for a stroke or heart attack and I couldn’t physically keep up anymore
I’m 56 years of age
My job was 32 hours a week
But because of Obama care my insurance was costing me $600 dollars a month for just major medical!
No dental no eye care no life insurance
So by the time I paid my rent, electric, water, sewer, garbage, car insurance, house insurance etc, I had enough money to put gas in the car to get to work and buy ramen noodles and some cheap hot dogs for food!
Over 60% of my net pay went to insurance that covered nothing!
Now I am unemployed with ZERO insurance
Its pretty damn sad when all the damn medicaide and dissabilty cheats are eating steak with perfect teeth and new glasses and are in perfect health while I have to bust my damn ass just to eat ramen noodles wityh bad teeth , basbasd eyes, and life threatening health problems!!

So here I am, no job, no insurance, no hope

Patient’s story as posted on Obamacare stories

The average household income in the United States is $51,000. From that you pay for our food, shelter, children’s education, and movie tickets. Oh, yeah, and $5000 for a health insurance policy. One of the things that Obamacare did was begin to put a cost on our insatiable healthcare consumption. Turns out, that cost is VERY high.

If you are an average American, boy are you ticked off. Half of all Americans spend under $400 a year on healthcare. Pretty much a round of antibiotics for a sinus infection and, for women, a year’s worth of contraception. Not only that but because of high deductibles (to keep the cost down by discouraging consumption) you are paying $5,000 to the insurance company AND paying cash for your sinus infection visit and medicine. Then there are the drug companies and insurance companies that are colluding to raise the prices of formerly cheap antibiotics to get even more of your household income.

About 1% of the people in this country account for about a quarter (27%) of the health care spending. In 2014, this  was about $100,000 per sick person. Those in the top 5% of sick people were responsible for  almost $50,000 in health care costs. These numbers are unchanged since Obama was elected. So what has changed? Before, the costs of these people were hidden. They would get the care for “free” at a safety net hospital who would get money in other ways to pay for it. Or a sick person would use an insurance card then the payment would be denied as a pre-existing condition and the hospital would eat the cost. More likely, the sick person would get on disability, suffer for 2 years, and become Medicare eligible so we the taxpayer would pay. The care still cost money but was hidden in taxes. Insurance companies kept costs low, in other words, by shifting them to the federal government. Now folks under 65 who are sick can pick up an Obamacare policy and get exceptional care. Also on Obamacare stories are ones like this:

Thank you President Obama thanks to your healthcare plan I was able to continue to see specialists, this resulted in a diagnosis of a rare intestinal infection and even more concerning, two stage three colon cancer tumors, one on each side on each side of the colon. This required almost total colon removal from a top notch physician that was able to do my surgery without having to have a bag.

Only problem is, this type of care costs A LOT more than $5,000. .

So, if you bought an Obamacare policy and feel ripped off, let me tell you what your $5000 paid for. It wasn’t eye glasses and dental work for poor people that jacked up your bill. You spent your $5000 on people under 65 with heart disease and lung disease. You purchased them a lot of expensive tests, some time in the hospital, and some expensive drugs. You paid for the person with breast cancer’s $300,000 tab whose $5000 premiums were paid by the cancer treatment facility.  You paid for the person helicoptered in after rolling their car on Interstate 65 while trying to avoid a deer.  You paid for some very expensive medication for people with mental illness to keep them out of a mental hospital.

Did you pay too much? Yes. Other countries can do the same thing better for half as much or less. Perhaps the new adminstration will look at this as an opportunity to further retool our expensive, not very effective care delivery system and reign in some of the profiteering. Or maybe we’ll just continue to blame the poor…

 

Healthcare is almost 20% of our economy. A future President Clinton or a future President Trump will, through executive action, have a lot to say about how that money is spent. Commonwealth fund (found here) has an exceptional comparison of the two candidates’ proposals and how they would effect the budget. If you care about fiscal responsibility, for the record, the balance sheet is found below:

screen-shot-2016-10-10-at-3-28-22-pm

So, the Trump plan is not, despite what he claimed in the debate, the way to fiscal solvency.

Kaiser Family Foundation has put together a specific list of issues (found here) that folks appear interested in and has evaluated each camp’s claims.  The Cliff’s notes version is as follows:

Health insurance coverage and cost – Issues include overarching reform of health system remains unpopular in a partisan manner. Affordability hampered by a glitch where family coverage became more expensive, “cost sharing” was not controlled by the law, enrollment was not implemented well, and transparency provisions not implemented. Market place competition is limited, especially in rural areas.

  • Clinton
    • supports policies to maintain and build upon the ACA.
    • increase premium subsidies in the marketplace so no participant is required to pay more than 8.5% of income for coverage.
    • fix the “family glitch” and allow people to buy coverage through the marketplace regardless of their immigration status.
    • make a public plan option available in every state and give people the option of buying into Medicare starting at age 55.
    • invest $500 million annually in outreach and in-person assistance to enroll more uninsured in coverage, and she would enforce ACA transparency provisions.
    • authorize the federal government to review and disapprove unreasonable health insurance premium increases in states that do not have such authority, repeal the Cadillac tax.
    • proposed new private plan standards to waive the annual deductible for at least three sick visits per year, limit monthly cost sharing for prescription drugs to $250, and protect against surprise medical bills when patients inadvertently receive care out of network.
    • proposed a new refundable tax credit of up to $5,000 to subsidize out-of-pocket health expenses (including premiums in marketplace plans) for all Americans with private insurance.
  • Trump
    • complete repeal of the ACA, including the individual mandate to have coverage.
    • create high risk pools for individuals who have not maintained continuous coverage.
    • provide a tax deduction for the purchase of individual health insurance.
    • promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply.
    • promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs.
    • would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for health care procedures and other services.

Medicaid – Issues include states’ concerns regarding financing and unwillingness to expand to those too poor to qualify for a tax rebate required coverage

  • Clinton
    • encourage and incentivize states to expand Medicaid by providing states with three years of full federal funding for newly eligible adults, whenever they choose to expand.
    • would also continue to make enrollment easier and launch a campaign to enroll people who are eligible but not enrolled in coverage.
  • Trump
    • supports a Medicaid block-grant and a repeal of the ACA (including the Medicaid expansion).
    • would cover the low-income uninsured through Medicaid after repealing the ACA.
      • The House Republican Plan, which is part of a larger package designed to replace the ACA and reduce federal spending for health care, would offer states a choice between a Medicaid per capita allotment or a block grant.

Medicare – Issues include prescription drug costs, fate of provisions in ACA, public option for those 55-64

  • Clinton
    • supports maintaining the current structure of the Medicare program and opposes policies to transform Medicare into a system of premium supports. On the issue of prescription drug costs
    • supports allowing safe re-importation of drugs from other countries, allowing the federal government to negotiate drug prices in Medicare, especially for high-priced drugs with limited competition, and requiring drug manufacturers to provide rebates in the Medicare Part D low-income subsidy program equivalent to the rebates provided under Medicaid.
    • does not support repealing the ACA or any of the Medicare provisions included in the law; rather, she supports expanding the law’s value-based delivery system reforms.
    • proposed to allow people ages 55 to 64 to buy into Medicare.
  • Trump
    • No position on the issue of Medicare program restructuring or whether to allow older adults ages 55 to 64 to buy in to Medicare.
    • supports repealing the ACA, which would presumably mean repealing the law’s Medicare provisions.
    • supports allowing safe re-importation of prescription drugs from other countries.

Prescription drugs – Issues are pricing (generally more expensive in US than in other countries despite being manufactured in the same facility) and out-of-pocket costs (many plans have gone to a cost sharing rather than a deductible strategy

  • Clinton
    • proposes prohibiting “pay-for-delay” deals whereby companies make payments to competitors for agreeing to delay market entry
    • increasing funding for the FDA Office of Generic Drugs to reduce their approval backlog
    • reducing the market exclusivity period for biologics
    • and directing the FDA to prioritize biosimilar drugs with few competitors. To address price increases for generic drugs
    • proposes to establish consumer oversight in federal agencies
    • penalize drug companies for unjustified price increases
    • allow importation of lower-cost drugs from countries with similar safety standards.
    • She also supports eliminating tax deductions for direct-to-consumer advertising
    • requiring FDA approval of advertisements
    • tying federal support for drug companies to their investment in R&D
    • increasing transparency of the additional value new drugs have over existing treatments
    • allowing Medicare to negotiate drug and biologic prices. To address OOP spending on prescriptions,
    • proposes a $250 per month cap on cost sharing for covered drugs; and a rebate program for low-income Medicare beneficiaries that mirrors those in Medicaid.
  • Trump
    • supports allowing importation of drugs from overseas that are safe and reliable but priced lower than in the U.S.
    • supports greater price transparency from all health providers, especially for medical exams and procedures performed at doctors’ offices, clinics, and hospitals, but does not specify whether this policy would also apply to retail prescription drugs, which typically are not considered services or procedures.

Opioid epidemic – Issues include increased use (1 in 20 nonelderly adults used opioids for nonmusical purposes), increased addiction ( 2 million non elderly adults with of the level of opioid use increases to the level of opioid use disorder, often referred to as abuse, dependence, or addiction), increases in overdose deaths (those involving opioids have quadrupled since 1999).

  • Clinton
    • released a $10 billion (over ten years) plan to fight drug addiction.
      • includes a federal-state partnership to support education and mentoring programs
      • development of treatment facilities and programs
      • efforts to change prescribing practices, and criminal justice reform.
      • direct federal action to increase funding for treatment programs
      • change federal rules regarding prescribing practices
      • enforce federal parity standards
      • promote best practices for insurance coverage of substance use disorder services
      • issue guidance on treatment and incarceration for nonviolent and low-level federal drug offenders.
  • Trump
    • Will build a wall on the U.S.-Mexican border
      • will help stop the flow of drugs and thus address the opioid epidemic.

Reproductive health – Issues include access to preventive services, publicly funded family planning, and abortion services

  • Clinton
    • supports policies that protect and expand women’s access to reproductive healthcare, including affordable contraception and abortion.
    • defends the ACA’s policies, including no-cost preventive care and contraceptive coverage. promised to protect Planned Parenthood from attempts to defund it and would work to increase federal funds to the organization. called for the repeal of the Hyde Amendment which she believes limits low-income women’s access to abortion care.
    • would appoint judges to the Supreme Court who support Roe v. Wade, ensuring a women’s right to choose an abortion.
  • Trump
    • called for defunding Planned Parenthood if they continue to provide abortion
    • He states he is pro-life but with exceptions when the pregnancy is a result of rape, incest, and life endangerment.
      • has promised to appoint pro-life justices to the Supreme Court that seek to overturn Roe v. Wade
    • would also work to make the Hyde Amendment permanent law
    • would sign the Pain-Capable Child Protection Act, legislation that would sharply limit access to later term abortions.
    • would also repeal the ACA, which would eliminate minimum scope of benefits standards such as maternity care in individual plans and coverage of no-cost preventive services such as contraceptives in private plans.

 

 

  1. Ebola
  2. 9/11
  3. Stealing grease
  4. Batman and Robin “Ice to meet you”
  5. The lemon tree theft
  6. Farmville
  7. Miley Cyrus’ “Wrecking ball”
  8. GMO tomato-nicotine hybrid
  9. Horse meat in commercial food
  10. Donald Trump’s presidential run

10 things predicted by the Simpson’s before they became “a thing”

There is a running gag over several years in “The Simpsons” television show about series of movies which included an action hero named “McBain.” Loosely based on a combination of Bruce Willis and Arnold Schwarzenegger, in the movies McBain’s nemesis is Senator Mendoza from some unnamed Central or South American 1980s drug cartel country. In one of the most “haunting” scenes, McBain’s long-term partner is shot as he is outlining his plans for retirement. In fact,he actually takes a bullet intended for McBain while showing a picture of his recently purchased retirement boat, aptly named ” Live-4-ever.”  McBain is shown holding the body of his fallen comrade, crying out “MEEEENNNDDOOZZAAA!!!!”

Federally Qualified Health Centers (FQHCs) have been around since the 1960s. They were modeled on a South African system for effective care delivery to the disenfranchised. One of the first was started not too far from me in Mound Bayou, Mississippi.

The health center model that emerged targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics in both rural and urban areas around America. It was a formula that not only empowered communities to establish and direct health services at the local level via consumer-majority governing boards, but also generated compelling proof that affordable and accessible healthcare produced compounding benefits.

Over the years the federal funding has been generous, though much of the funding comes from patient generated revenue (money for seeing patients).  The Centers are also eligible for grant money for facility development, staffing increases, and offsets for seeing the uninsured among other things. The funding streams vary quite a bit from state to state, with those in Alabama being more heavily reliant on federal grants and less so on patient care. Legislators loved them because they put money in local, impoverished areas. Republicans in particular loved them because of the “block grant” nature of the funding. The local folks were best able, so the saying went, to determine where the money could best be spent.

One of the goals of the  Affordable Care Act was to move the money from direct funding programs into programs where the money followed the patient. It was hoped that this would give patients incentives to seek more effective care. It clearly would cut down on shenanigans such as this criminal case in Birmingham where the CEO bought a building, leased it back to the FQHC, videotaped his assistant in compromising positions, and made off with $14 million of federal money. As outlined in an article today, this money was money NOT used to deliver care to homeless individuals, poor folks, and others in need for whom it was intended. In fact, though they were receiving money to care for the homeless, they created barriers of transportation and distance to keep the poor, sick folks away. This money then made its way to the CEO’s pocket.

The ACA, as designed, would allow all the poor, including the homeless, to use Medicaid for their healthcare needs. This would allow a patient to identify the best care for his or her situation. We, in Alabama, have chosen not to accept the law as designed. Instead we have allowed it to be implemented  in a manner inconsistent with the design. We allow those in charge of implementing the law at the state level as well as those in charge of local care delivery to siphon money off. Then, when the system fails, we shake our fists at the clouds and blame Obama.

 

When asked about folks possibly dying from lack of access if we fail to maintain a Medicaid system that meets federal requirements:

“We all die sometime,” Trip Pittman (R-Montrose) said.  “We’re all mortal. We all have a finite period of time on earth. I think sometimes we confuse saving lives with extending lives.”

Wow! The state of Alabama has passed and overridden the Governor’s veto of a budget that, per the Medicaid commissioner, does not allow us to meet the federal requirements to stay in the “voluntary” program. There was a hearing on the impact of the budget on Thursday. In the lead-up to the hearings (found here) Senator Pittman was quoted as saying that the reason was that “I think there are legislators who need to more fully understand the workings of Medicaid.” A fair statement; as I have as I previously explained (here) the funding of Medicaid in Alabama is incredibly complicated. The hearing included a very informative presentation by the Medicaid Commissioner that can be found here.

Highlights of the Commissioner’s presentation are:

  • Counties with the highest unemployment have the highest Medicaid enrollment
  • Administrative costs are only 4%
  • Cost per enrollee have remained the same but the number of enrollees has increased by 30% since 2008 because of Alabama’s sluggish economy

And, the part that got Senator Pittman’s attention:

  • 1% of enrollees account for 30% of costs with 35 tragic cases accounting for almost $40,000,000 in cost to the agency

Senator Pittman’s response (heard here starting at 4:39 and accompanying article by Glynn Wilson here) would have made international news had this been one of Obama’s surrogates. Many of the federal requirements he  finds onerous provide healthcare to the “undeserving.” For example, the Feds require Medicaid to cover those who are receiving Social Security disability checks:

“[The eligibility rules]may be too liberal,” Trippman said, and “not discerning enough on whether somebody is really eligible.”

Giving to deserving people, it seems is OK. It’s  just that those who could get out and work, in the Senator’s estimation, need to get off their disabled rear ends and find jobs that provide health insurance.

He was then asked to reflect on the 35 most expensive cases:

“We’re spending more than 40 percent of the money on children in their first year of life,” Pittman, said, and added: “We’re spending a lot of money on the elderly, at the end of life. I think as a society we need to debate and look at all of these things. If not, you’re going to get into rationing.”

He then proceeds to outline possible solutions, beginning by referencing Bernie Sanders (8:30 on the video):

“[Bernie Sanders] said 80% of the costs are for elderly and for people in this state in the last few months of their lives and for people with chronic illnesses and the elderly. The reality is that we have to have some discussions about quality of life, about the expenditure of money, and about the cost. You know in this country the transfer of wealth from working to non-working, for every dollar you transfer from working to non-working you are transferring $7 from young people to old people. That’s a moral debate and that’s something people need to start talking about.”

He goes on to say that the cuts will be made, the impacts will be felt, and people will react to what ultimately happens.

There you have it. Willing to turn away $5,000,000,000 and dismantle a state’s care delivery system , so we can find out in our own little laboratory of democracy just how people will react. Again, wow!

competition-cartoon1

When the Office of Economic Opportunity, which was funding Geiger’s clinic (the first community health center in Moundville, Mississippi funded by Lyndon Johnson’s Great Society) , found out, they were furious — and sent an official down to Mississippi to inform Geiger that they expected their dollars to be used for medical care. To which Geiger famously replied: “The last time I checked my textbooks, the specific therapy for malnutrition was food.” [Excerpt from “Wellness is More than Not Being Sick” by Rebecca Onie, Chapter 18 in Creating Good Work: The World’s Leading Social Entrepreneurs Show How to Build A Healthy Economy edited by Ron Schultz]

When Dr Jack Geiger got to Moundville in 1964, he found conditions to be reminiscent of those he had seen in South Africa, and not in a good way. The staff of the community health center, who supposed they were going to be dealing with TB, cancer, and other medical problems instead found themselves overwhelmed by the social problems that undermined health in the region, such as hunger and unemployment. In a way that was prescient,  members of the community were included for the first time in decisions about their health and the future of the area through inclusion on the board and the clinic staff.

These medical folks soon found themselves engaged in food security, developing safe drinking water, and economic development, The clinic developed a farm cooperative to allow community members to grow food for themselves and earn additional money from selling produce to others. They not only saw patients in their offices but went into people’s homes to focus efforts on how to prevent illness. In the days of Jim Crow, they were considered a significant threat to the status quo.

Today, the Delta Health Center has a Facebook presence. The community health movement has spread to almost every part of the country. It is not unusual for the local Center to provide services to all, regardless of ability to pay. However, it isn’t enough. Just as Dr. Geiger saw that food was the treatment for malnutrition, we now know that chronic illness, cancer, and premature death are caused as much by poverty and genetic predisposition as by bad luck. The zip code you are born in predicts whether you will live an additional decade and what that experience will be like. The next Dr. Geiger will need to get into the weeds a bit more.

The Center for Health Innovation at CMS has put together a blueprint to get to the next step. Called Accountable Communities, it envisions health professionals hooking folks up with food, pest control, legal services, and other resources needed to help them overcome the tyranny of the zip code. Health Affairs has outlined what resources we as care providers need to overcome that tyranny:

1) Health Systems Need To Commit To Real Clinical Integration Of Social Needs – If we are going to anticipate the “rising risk” patient, we as care providers need to know something not only about the “really sick” but about all folks in the community and their anticipated needs. Some insurance plans are capturing this on all of their covered folks but doing a terrible job of sharing with other members of the health care team. We need to all know who is suffering so we can match people with resources.

2. Commit To Developing A Workforce That Is Truly Focused On Addressing Social Needs – It will take more and different types of care providers to help folks to not get sick in the first place. What should our outreach strategy be? Do we develop community health workers? Do we recruit volunteers? While it takes a village, more importantly it takes way more than just doctors. Once a need is identified, we need case workers engaged in hooking folks up with services such as food pantries, financial planners, pest control specialists, and legal aid.

3. Commit To Giving That Workforce The Information They Need To Do Their Jobs Well– Community resource availability is an ever-changing picture. Static information sources (books, pamphlets, etc) are rapidly out of date. Medical personnel often are unaware of what the community has to offer. Whose job is it to hook up community agencies with sick people?
4. Commit To Follow Up – For folks at risk of getting sick, repeated contact to help them become motivated to change is the key, even when they don’t want to think about their health. Who makes this contact? Do we aggressively pursue those who feel they don’t need services but clearly do?
5. Commit To Collecting And Analyzing Data – This is a lot of data on people. Target knows when a person is pregnant, often before the baby-daddy does. Do we use this data for the forces of good? If so, who does and how do they use it?
The Great Society didn’t make us great but it sure helped this county. Although still poor, the health markers in Bolivar county are better than 11 other Mississippi counties. For rural Mississippi, that is saying something. Maybe through Accountable Communities we can all take that a step to disassociating illness and poverty.

 

 

'It was a bungee cord accident and I'm having trouble bouncing back.'

‘It was a bungee cord accident and I’m having trouble bouncing back.’

Recently at morning report:

Resident: The patient is a 66 year old woman who had pneumonia and has pretty bad dementia and congestive heart failure and was just discharged from our service 7 days ago. Her family brought her back in.  They had her meds all messed up.

When I was a medical student at Charity Hospital in New Orleans it was also known as The Big Free. The hospital name was derived from the order of religious sisters initially brought in to nurse those in the hospital back to health, the Daughters of Charity. The nickname was derived from the fact that there were no charges generated for the care delivered (Free) and the fact that Huey Long built a series of smaller hospitals throughout the state (Little Charities) that provide less comprehensive care.

Resident: Somehow they gave her the antibiotics but forgot to give the diuretic.

We were not introduced to the concept that care costs money in the entire of medical school. People were admitted, people were discharged, procedures were learned, people were readmitted and no bills were generated. I left medical school knowing little about cost. Fortunately for my patients, because no bills were generated, only the state of Louisiana was responsible for the costs my mistakes generated.

In almost all training programs up until very recently, when a patient came back, whether it was the care team’s mistake or the fault of the patient, it was “bounced back” to the previous team. This at worst meant you had one extra patient on your service and, if the patient had insurance, turns out the hospital made extra money. In some cases lots of money.

A 2009 study published in the New England Journal of Medicine analyzed almost 12 million Medicare beneficiaries and found that approximately one-fifth were readmitted within 30 days of discharge and an even more alarming 34 percent were admitted in 90 days. Wait, it gets worse. If we look a year out from discharge they reported 67.1 percent who had been discharged for a medical condition had been readmitted or had died. This revolving door is expensive and cost Medicare $17.4 billion dollars in 2004.

Beginning 2 years ago, Medicare began docking the pay of those hospitals that have a lot of “bounce backs.” Hospital administrators  were not happy about this. “There are things we don’t control, and we certainly don’t control patient behavior either,” said Nancy Pratt, chief quality and patient safety officer for Irvine, Calif.-based St. Joseph Health System. “You could do everything right and still end up having a patient readmitted.”

Me: People just don’t forget. That’ll count against us.

Resident: Well it was on the medication reconciliation. The visiting nurse went by the house and went over the meds. I don’t know what else we can do short of putting it in her mouth ourselves.

In the post ACA world, there are no more mulligans. More and more, the care delivery system is taking responsibility for the totality of the care. Hospitals are trying a lot of things in addition to reconciling meds, such as discharge coaching and post-discharge phone contact.

Systems engaged in reducing readmissions are now realizing that the cost of care is not random but is aggregated into a very small number of patients. In this recent article from the New England Journal, investigators in Massachusetts (where there is close to 100% coverage) found that, depending on insurance, the costliest 1% of people accounted for between 14% and 22% of total costs. To reduce readmission in this cohort, care delivery systems would have to provide services such as nurse care managers to work with high-risk Medicare patients, integrating mental health services into broader care-coordination and disease-management models for Medicaid patients, and improved access to low cost specialty pharmaceuticals for young folks with severe illnesses.

Improved care delivery just went from a liability (we make our money off repeat customers) to an asset. As the NEJM authors wrote, As reform activities shift payment away from fee-for-service models, the incentives to improve care for high-cost patients will continue to grow.” Now we have the opportunity to not only teach the importance of keeping folks out of the hospital, but get paid for it as well.

From a very good article regarding Obama’s legacy in Politico found here:

  1. First, through the use of the stimulus money, his administration  created the infrastructure necessary for change:

A $25 billion incentive program in the stimulus for health information technology has helped drag a pen-and-paper medical system into the digital age, with adoption soaring from about 10 percent of hospitals and 20 percent of doctors in 2008 to about 80 percent of hospitals and 80 percent of doctors today. E-prescriptions are ubiquitous, and digitization is already reducing fatal errors and unnecessary tests caused by sloppy handwriting and inaccessible files. There have been problems getting electronic systems to talk to each other, sparking a backlash of sorts from irritated doctors, but Farzad Mostashari, Obama’s former health IT czar, is confident online medicine will inevitably produce the efficiencies common in online banking and dating.

2. Then, with the ACA,  a plan to improve access was implemented to address the game of uninsured “hot potato”:

It has already extended medical coverage to some 18 million uninsured Americans. It also closed loopholes that insurers used to deny coverage to insured Americans when they got sick. And it eliminated co-payments for quit-smoking programs, birth control pills, certain cancer screenings and other preventive care. As Obama has suggested, it’s what he was talking about when he talked about change.

3. Despite the reality that the right had no stomach for system change and the left had no stomach for cost controls, the majority of the ACA was about those two things. Improving the care delivery system was attempted by putting every idea, good or bad, tried or not, into the law and incenting folks to “don’t just stand there, do something.” Amazingly, it is working. First, the cost side:

Less than one-fourth of the bill was devoted to access. The rest was stuffed with almost every cost-control idea in circulation, from new competitive bidding rules for wheelchairs to a government Innovation Center to test new payment models to a “Cadillac tax” on pricey employer-sponsored plans. “We did a smorgasbord of just about everything people thought could conceivably help,” says Peter Orszag, Obama’s former budget director.

And so far, the cost curve is bending even faster than White House officials had dreamed. Health care is still getting more expensive, but since 2010, the growth rate has slowed so drastically that the Congressional Budget Office has slashed its projection for government health spending in 2020 by $175 billion. That’s enough to fund the Navy for a year, or the EPA for two decades. “We wanted to throw a whole bunch of stuff against the wall to see if any of it would stick, which probably sounded bogus,” Orszag says. “But if these results continue, they’ll fundamentally change the fiscal trajectory of the country.”

And on the quality side:

One recent report found that infections and other “hospital-acquired conditions” have declined 17 percent since 2010, when Obamacare created financial incentives for hospitals to avoid them. That reduction saved an estimated 87,000 lives and $20 billion. A similar effort to incentivize better management of discharged patients has coincided with a decline in hospital readmission rates that’s keeping 150,000 more Medicare patients at home every day, according to Meena Seshamani, director of the administration’s Office of Health Reform.

When put together, it is leading to a much more rational system. Maryland, for example, is experimenting with an “all payers” system:

A recent New England Journal of Medicine article found the state’s hospital costs increased at less than half the expected rate in the program’s first year, saving Medicare $116 million.

And everywhere there are changes to change the payment from one of paying for volume to paying for value:

There are signs that Obama’s convoluted jumble of changes may be starting to rationalize an irrational system. Patrick Conway, the director of the new innovation center, told me about a new Independence at Home experiment that coordinates nurse and doctor visits for frail and disabled patients—and saved Medicare $3,000 per beneficiary in its first year. One elderly diabetic who had 19 hospitalizations the previous year had only one after enrolling in the program.

When Medicare was signed into law, I guess they could have called it LBJCare. Today, no matter what it is called, no one is calling for us to put Grandma back in the attic and let her die. Medicare is here to stay. I suspect that 20 years from now, no one will even think about going back to volume based care delivery with rationing based on income and willingness to pay. Wonder what we will call our care delivery sustem?

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