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Cartoon of the Day: Trumpcare vs. Obamacare

It has been a while since I have written in this space. Partly this was a result of a personal medical problem (I am OK now and perhaps one day I will regale you with stories of my treatment) and partly because I do not have much new to say. I practice and teach family medicine in the deep south. My state, Alabama, has declined to expand Medicaid. 90% of White Alabamians have the luxury of having health insurance and feeling, well, entitled. 84% of Black Alabamians have health insurance. Only 70% of Hispanic Alabamians report the same. My practice has been colored by these facts ever since the passage of Obamacare. Much of what I have written has been about the passage, implementation, trials and tribulations of Obamacare in Alabama.

My lack of writing in this space recently has been, in part, because health policy wise there has been not much to write about. The last three and a half years have been about the states that have chosen to expand working to correct other gaps in care while those of us in non-expansion states have been watching. In what is likely not a coincidence, many of the people live in the states that have chosen not to expand Medicaid which are also those states which chose to enslave humans (92%). From a policy standpoint, I have to admit that when I am asking for money to study a healthcare problem (hospital closure, unnecessary hospitalization, vaccination gaps) and the reviewers ask “Why not expand Medicaid instead of my giving you money” I don’t have a good answer.

What are we missing out on? Improved health outcomes, for one. This includes patient based outcomes (an improvement in healthy days in the month, reduced overall and disease specific mortality), provider based outcomes (improvement in the physicians’ bottom line), state based outcomes (less money spent on healthcare). In addition, because people are more steps away from bankruptcy, they report in general being better off (reductions in rates of food insecurity, poverty, and home evictions). In short, we in Alabama are much worse off for not having expanded.

In just over a month we will select a president. The incumbent, Donald Trump, ran for office 4 years ago with the promise to “repeal and replace Obamacare.” As part of that he vowed to “block grant” Medicaid. He promised to replace the ACA with something “terrific,” “phenomenal” and “fantastic.” In 2020 alone he has promised an Obamacare replacement plan five times, each time promising to unveil it “within 2 weeks.” The plan has never materialized. Instead, his administration has joined a lawsuit with 18 non-expansion states to gut the law (an unusual stance for the federal government to work towards the nullification of one of the federal laws, but as the kids used to say, WHATEVER). If they prevail they will take health care access away from 25 million people. In addition, for the last six months the lack of federal leadership regarding Covid-19 has also put us in a bind because we are a low tax state, meaning that we rely on the federal government to work on matters such as this. The result of the last three and a half years has been that, in Alabama, we have been in health policy limbo, waiting for President Trump to drop the other shoe.

Joe Biden, on the other hand, had an active role in the passage of the Affordable Care Act. He understands healthcare and healthcare policy. He has a viable plan to effectively get universal coverage in the United States. Although, one can never underestimate the ability of the powers that be to do something dumb, maybe even Alabama can’t screw this up.

Which brings us to last night. I was asked to watch and comment on the health policy aspects of the debate. Here is what we learned: Short answer, nothing new. Long answer, the candidates argued, obfuscated and hurled accusations over a range of health issues, including but not limited to: coronavirus, Obamacare, abortion, drug prices, vaccines, trust in science, stay-at-home orders, private health insurance, the public option, and the Trump administration’s ongoing lack of a health care plan. Specifics were as follows –

The President repeated assertions that he’d done a “great job” managing the public health threat and urged states to reopen, contradicting the head of the CDC whom he appointed.

Joe Biden believes that 200,000 deaths were way too many from Covid-19. The President disagrees.

Joe Biden understands that the future of care access in America is intertwined with the Supreme Court nomination, the President disagrees.

The President believes he has reduced the price of insulin, which, he has not for most people.

The President accused Joe Biden of wanting to take over all of medicine. Joe Biden pointed to the work he had already done and said he would not.

For me, as someone who has watched the poor of Alabama suffer from a failing of the healthcare infrastructure brought on by failed federal policies, needless deaths from preventable illnesses and now from Covid-19, and unnecessary bankruptcies for the past three and a health years, I am ready for a change. Last night did not convince me otherwise.

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.

Price Conscious 512My wife is reading (or listening to, I can never tell which) a book about “private life” (called At Home).  One of the vignettes is about the development of safe drinking water. The central character in this story was John Snow, a physician living in London in the time of cholera (temporally in the 1850s). The legend is that using a map (this was the first documented use of a map to determine the source of an outbreak, very cool stuff) he plotted the cholera deaths and placed them proximate to a fresh water concern on Broad Street. He attempted to get the local government to act on his theory that the water pump was contaminated and the cause of the outbreak. Convincing the authorities (the local Board of Guardians) to remove the handle, he is credited with stopping the outbreak (or at least preventing a resurgence in the neighborhood).

A couple of things about this story. First, Doctor Snow had lived through a previous outbreak of cholera several years earlier, and as a consequence he was unconvinced of the prevailing theory that miasma (bad air) caused the disease. His theory, that the disease was limited to the gastrointestinal tract and death was caused exclusively by dehydration, was consider not a little kooky. He was working on very little evidence as the existence of a cholera organism, though described in Florence roughly at the same time, was unknown to physicians in London. Robert Koch, the man who really put germs on the map as causative agents of disease, would not develop his postulates until 30 years later.  Doctor Snow, it turns out, was looking for an opportunity to test his theory, and the St James Parish outbreak happened to have everything he needed (water contaminated with sewage with little competition from clean water and so delicious that people knew of pump by name, people who were dying of cholera at a fast clip, and a Board that was willing to try new things out of a sense of responsibility to their parishioners). As luck would have it, the water was VERY contaminated (wash water from an infected baby’s diapers and fresh water kinda mingled right where the pump intake was) and so the intervention was successful. John Snow lives on as a medical hero.

Not everyone bought into the “drinking water causes disease” meme for a couple of reasons. First, miasma as a cause of disease had a lot going for it. If God made things smell bad, it must be for a reason, amirite? Second, because bad smells and disease tended to intersect where poor people lived, bad things must be happening to “bad people.” The slums were filled with people moving from the countryside during the Industrial Revolution, people who “were not nice people.” Therefore, in the Victorian age “the miasmas that seemed so prevalent among the poor slums were seen as God’s punishment for immoral lifestyle.” Over time, the sanitarian won and, by first building sanitary sewers and providing drinking water and later providing vaccinations, outbreaks of diseases like cholera and polio were conquered.

So, in this country we are heading into our own Broad Street Pump moment. 26 states have elected to take full advantage of the Affordable Care Act, including expanding Medicaid to those who make below 138% of poverty as a sole qualifying criteria. In these states, Medicaid rolls have grown by 8%. This means that more than 3 million adults will have the security afforded by knowing they are not one illness away from bankruptcy. They will have access to care for complaints such as “blood in my stool” which would have gotten them triaged out of an emergency room before but now, under the right circumstances, a colonoscopy to find and cure their colon cancer. They will get treatment for bladder infections, pneumonias, and cellulitises without needed to get so sick as to require hospitalization.

24 states, including Alabama, have not expanded.Their rolls have expanded by 1%. These folks are mostly working, some at several jobs. They are using their common sense to tell them when to seek expensive care. I f they guess right, bankruptcy and an opportunity continue to work and pay off medical bills. If they guess wrong, death from a preventable illness. Meanwhile many, including public officials, are convinced that they are uninsured because they are undeserving.

So, who will be our John Snow? Who will look at those dying from a lack of access in states like Alabama and say enough? How many deaths from preventable conditions will it take? Anyone know how to use Google Maps?