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“Nobody knew that health care could be so complicated”  @realDonaldJTrump

We are 341 days and some change away from the presidential election which will determine the fate of healthcare in this country. The current president, Donald J Trump, campaigned in 2016 on the “repeal and replace Obamacare” platform. Although there was a flurry of activity which threatened to bring back the fear of preexisting conditions and the creation of an Obamacarelite product (perfect for those not planning on being sick) for the most part Obamacare remains intact. In fact one of the key components, Medicaid expansion, actually seems stronger than it did under president Obama.

As we gear up for the next election it seems that healthcare is once again getting the politician’s attention. The Republicans are still of the mind that “Obamacare doesn’t work” although they are unable to come up with anything better. The Democrats have pushed out seemingly hundreds of ideas. Though somewhat of a moving target, it seems that the ideas can be coalesced into “Medicare for All” (Sanders and Warren), “Medicare for some more” (most folks), and “Better Obamacare for some” (Harris and Buttigeig). What piqued my interest today was what I thought was an arcane mental health discussion. Senator Harris called to:

Repeal the Institutions of Mental Disease (IMD) exclusionThe IMD exclusion precludes Medicaid funding for adults receiving care in psychiatric facilities with more than 16 beds, and has also exacerbated a severe shortage of acute psychiatric care beds nationwide. Repealing the IMD exclusion will reduce the number of Medicaid patients who end up in already strained general hospital emergency rooms when they need acute psychiatric care.

I thought “This makes sense” until I saw this Vox article:

But on Monday, when Harris’s campaign rolled out its mental health policy plan, it had not been nearly so thoughtful. Harris seems to have gone all-in on attacking the freedom, dignity, and privacy of people with mental health conditions. People like me.

I have to admit, although I know little about the Senator, she does not strike me as THAT evil.

As it turns out, back in 1965 when Medicare and Medicaid were being designed, there were a lot of people in mental institutions that were being imprisoned for their mental illness. Congress, fearful of states using the new Medicaid money to build bigger insane asylums, created a mental illness exception for inpatient treatment. Any facility with more than 16 beds that exclusively treated mental illness was ineligible for Medicaid funding. Although there have been some attempts to repeal it, this exception has stuck over the years. In part because of fears of mental health advocates such as those expressed in Vox. In part because of fears of increased cost. From a demonstration project which included Alabama where the exception was waived:

“Overall, we found little to no evidence of MEPD effects on inpatient admissions to IMDs or general hospital scatter beds; IMD or scatter bed lengths of stays; ER visits and ED boarding; discharge planning by participating IMDs; or the Medicaid share of IMD admissions of adults with psychiatric EMCs.

Available data suggest, however, that increased access of adult Medicaid beneficiaries to IMD inpatient care would likely come at a cost to the federal government.

In short, we are likely to find ourselves where we have always been. Folks suffering from serious mental illness (including substance abuse) only able to use their Medicaid for treatment if they are not too sick. This is in part due to a fear that those who are functional have that they will be locked away rather than treated in the least restrictive environment. This is also reflects the reality that the feds fund “healthcare,” not the prisons and underpass encampments where folks with intractable mental illness are now found.

Nobody knew mental health care was THIS complicated…

Business executive at party: “What do you and your friends do?”

Me: “We work at the medical school”

Business executive: “No, I know that. I mean what is it that you guys DO”

Me: “We all work in different areas. For example I train doctors in Family Medicine”

Business executive: “Well, tell me, why do we need Obamacare”

Me: Very long, detailed soliloquy about pre-existing conditions, the contributors to the cost of health care, etc, fueled by lots of wine and ending in the need for Medicare for All if we don’t let Obamacare do what it was designed to do.

Business executive: “So why does it need to be so complicated? Why can’t folks just pay for insurance?”

Me: Sigh. “Excuse me, I’m going inside for a bit. Can I bring you anything?”

It is difficult to discuss health system reform with people not closely engaged in care delivery. Most people have interfaced with the care delivery system and so believe they know how best to fix it. Most people consume under $300 worth of healthcare annually but don’t question the opportunity cost of having access (over $17,000 annually for a private insurance plan). Most people are thrilled when told of a negative test (“Congratulations, it’s not cancer”) but don’t question whether the test should have been done in the first place. Airplane crashes put the focus on the safety of the aviation industry because 300 people dying at a time is newsworthy. Losing 4000 people annually in Alabama to premature heart disease because of a poorly performing health system is a yawner.

In any given year, only 5% or fewer of the US population use the healthcare system for something serious like cancer Most folks who interface the care delivery system (make a doctors appointment) do so for a self-limited illness. They come in either because a) they want assurances they are not going to die and want to feel better or b) they need a note for work. From a survey done in 2014, when a person seeks care here is what they want:

  1. Be seen without an appointment within 30 minutes any time of the day or night for $0 to include labs and x-rays done on site.
  2. Have the same person see them every time and have them spend unlimited time explaining symptoms
  3. Have this magic 24/365 office close to home (next door is preferable).

Business executives, I suspect, pretty much get this type of care. Michael Jackson, for example, had his own cardiologist. Access costs money. In corporations the CEO tends to have the same insurance as the lowest wage earner. What happens when a large corporation pays for care that includes this type of access? The executive may not be worried by the high premium (average is over $12,000 annually for a family plan) and additional company cost ($5000). The low wage worker, on the other hand, might be willing to trade immediate access for better food or housing choices but isn’t often given the choice. Obamacare was designed, in part, to put the brakes on healthcare inflation.

In states where the Affordable Care Act has been fully implemented more employers are paying for health care and more people are covered by other types of coverage. As more people have ended up on public plans (Medicare and Medicaid) health care inflation has reduced. The number of bankruptcies due to medical conditions have fallen precipitously.

Despite all of the rhetoric, it appears that the system reforms put in place by the Obama administration are working. In an essay in Vox, Mae Rice points out that spending some money on a small luxury like Starbucks every day can lead to enhanced responsibility. We, as a society, have a responsibility to people like her. Not to ask her for her Starbucks money. Not to blame her for failing to save for a catastrophic illness that is unanticipatable. Not to ask her to be a prisoner at a minimum wage job so her CEO can get 24/7/365 access to any specialist she wants. We have a responsibility to provide access to quality healthcare at a reasonable cost. Although not perfect, Obamacare is moving us in that direction. As a society, this is a responsibility all of us, including business executives, should take very seriously.

 

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