Worries Over Expanding Health Coverage May Be Unfounded

Opposition to health reform tends to come from those who are happy with the way things are and worried that change represents nothing more than the risk of losing what they already have. That’s precisely why the opposition rhetoric focused on “death panels” and “rationing” of care. Stories were told of how our health care system would become like the Canadian system where people die waiting in line for care. Such stories are vastly overblown, I assure you, having spoken with a fair number of Canadians who love their system and who, having come to the U.S. for one reason or another, are appalled at the convoluted way our system works.

But for those who fear that expanding health insurance coverage means long lines and wait-lists, Chapin White of the Center for Studying Health Systems Change has good news: Expanding coverage doesn’t necessarily mean that overall health care utilization increases. Instead, that depends on how much physicians are reimbursed. Pay doctors more and, it seems, we visit them more often (rather, they are willing to see us more often).

The Affordable Care Act expands coverage, but it doesn’t dramatically increase physician reimbursement rates. Ergo, we’re not likely to see large increases in physician utilization, and that means we won’t likely see a lot of rationing or wait-listing. Sadly, it means that many of the newly insured will have a hard time finding someone to care for them. Medicaid doesn’t pay doctors well. It never has. So, a lot of doctors don’t accept Medicaid patients. Giving low-income uninsured persons Medicaid coverage may shield them from high out-of-pocket expenses, but it doesn’t mean they will be able to go to any doctor they choose. So, the rationing that exists will be the rationing that largely remains from the stratified system we have had for decades, where those with private coverage get more than they need, while those with public coverage often fail to get enough. That is not new rationing. It is the status quo.

 

 

Is Your Doctor Lying To You?

The doctor-patient relationship, like any good relationship, is built on trust. After all, the patient is naturally at the mercy of their physician in most cases, because the physician is the expert. Sure, the patient should have the ultimate say in their care, but the information they are basing their decisions on typically comes from the physician, and they must trust that what they are being told is the truth. Unfortunately, a recent study by Lisa Iezzoni and colleagues finds that doctors aren’t always so honest with their patients.

In a survey of a representative sample of physicians, more than a third of doctors fail to completely agree with the statement “Physicians should disclose all significant medical errors to affected patients.” Nearly one-in-five fail to completely agree with the statement “Physicians should never tell a patient something that is not true.” That’s right, more than 17% of doctors felt that there were times when it was okay to lie to patients.

As for their actual behavior, 11% of physicians reported rarely, sometimes, or often (in contrast to never) telling a patient something that was not true, and 55% reported rarely, sometimes, or often describing a patient’s prognosis in a more positive manner than warranted. Admittedly, the latter case could be perceived as compassionate rather than dishonest depending on the circumstances.

What are we, as patients, to make of these findings? Well, on the one hand, the truth could be even worse than the results suggest because of “social acceptability bias.” In other words, doctors know that admitting to being dishonest isn’t the “right” answer to give, so they may ironically be dishonest about reporting their dishonesty. At the same time, the framing of the results may actually be misleading. By taking four responses (never, rarely, sometimes, and often) and grouping them into two categories (never vs. not never), important information is obscured. If most of the doctors who admit to lying are in the “rarely” category, perhaps that’s not so bad. If, on the other hand, most of them reported lying “often” that’s a little scary. Unfortunately, the way the data are presented, it isn’t clear which is the case. I think it would have been better to put two responses in each category so that “never” and “rarely” were combined and compared to “sometimes” and “often.”

My sense is that doctors, like all people, sometimes lie–perhaps more often by omission rather than commission–but that we should not be too worried about the results of this survey. Don’t assume your doctor is lying to you or that they are always being honest. That’s what second opinions are for.

 

 

Would More Americans Support Health Reform If Obama Was White?

Would more Americans support health reform is President Obama was white? According to a recent study conducted by Michael Henderson of the University of Mississippi and D. Sunshine Hillygus of Duke University, the answer is yes. The researchers modeled changes in support of health reform between 2008 and 2010, and what they found was striking. According to Henderson and Hillygus, among a group who supported health reform in 2008, whites were 19 percentage points more likely than blacks to be opposed to health reform by 2010. Keep in mind that this race effect is seen after controlling for party affiliation and political ideology. It also controls for income, age, gender, education, and worry over the cost of health care. Said another way, this race effect isn’t likely to be biased by the usual suspects.

Moreover, the researchers included a measure of racial resentment, and those with the highest levels of racial resentment were 29 percentage points more likely to go from supporting health reform in 2008 to opposing it in 2010. These effects are additive. That means that whites with high levels of racial resentment are a whopping 48 percentage points more likely to switch from supporting to opposing health reform in the course of two years, compared to their black counterparts with low levels of racial resentment. That’s a big deal, to paraphrase Joe Biden for a general audience.

That doesn’t mean that people’s concerns over health reform aren’t legitimate. It’s perfectly reasonable to be opposed to an individual mandate, for example. The question opponents of health reform need to ask themselves, though, is how they would feel about the Affordable Care Act if the man who signed it into law looked like them. I don’t think opposition to reform would disappear–after all, when Clinton tried to pass reform legislation in the 1990s, it failed spectacularly–but I do think the tone of the debate would have been a little different, and I don’t think we’d be seeing the continued opposition after passage that we’re seeing now. Just look to the recent past for proof: Medicare Part D is all the evidence you need that a white President can pass a budget-busting piece of legislation without so much as a second glance from the American people. If George W. Bush had been black, perhaps America’s seniors would still be without adequate prescription drug coverage.

 

 

 

In Health Reform Polling, Even Undecideds Have Opinions

If you’re at all familiar with opinion polls, you know a few things: How the questions are asked matters; The results are always within a certain margin of error thanks to probability sampling; and there are always some people who profess to have no opinion on the question being asked. When we interpret the results of polls, it’s easy to keep the margin of error in mind, and it’s not even that difficult to assess the impact of question wording by comparing the results from differently worded polls that are asking about the same thing. No, the real challenge is figuring out what those undecideds are actually thinking. A little example shows why this can be so important.

Let’s say a poll asks respondents about their support of health reform. Now imagine two sets of results, both with a margin of error of +/- 3%.

Support Health Reform – 25%
Oppose Health Reform – 25%
No Opinion – 50%

In this case, we clearly want to know what the undecided respondents are thinking, because there are so many of them. The results simply aren’t very informative when we only know what half of people are thinking. Now, consider a case where we might be inclined to ignore this lack of opinion:

Support Health Reform – 46%
Oppose Health Reform – 49%
No Opinion – 5%

In this case, we would consider the public evenly divided on the issue, because the difference of 3% is well within our combined margin of error. We probably wouldn’t think much of the 5% with no opinion, although the reality is that how that group broke out if people were forced to choose one position or the other, could make a difference. If all 5% went to the support camp, we’d still have a statistical tie. If they broke for the opposition, the difference between the two groups would no longer overlap. The undecideds matter.

Fortunately, there’s something that researchers can do to get around this. As Adam Berinsky and Michele Margolis from MIT write in a recent issue of the Journal of Health Politics, Policy, and Law, it is possible to impute the opinions of those who profess not to have an opinion. Here’s how it works: Most people don’t answer “no opinion” to every question. So, you use their responses to the questions they did answer to match them up with other respondents who answered those questions the same way they did. Then you look at the way those people answered the question that the others expressed no opinion on. That gives you a sense of how they would have answered the question if they had done so. Make sense?

Here’s a silly example: Let’s say you asked people three questions about which foods they liked to eat. First, you ask if they like lettuce. 80% say yes, and 20% say no. Then you ask if they like cheese. 50% say yes, and 50% say no. Then you ask if they like hamburger. 40% say yes, 20% say no, and 40% have no opinion. When you look at the data, you see that the 40% with no opinion all like lettuce and dislike cheese. Others in the sample who like lettuce and dislike cheese report that they dislike hamburger (it turns out they are strict vegetarians). Therefore, it’s not a certainty, but there’s a good chance that the folks with no opinion actually dislike hamburgers. They may also be vegetarians who answered no opinion because they felt the question wasn’t relevant to them, for example. Make better sense? Good.

 

How Wealthy Should America’s President Be?

I’m venturing away from health policy for a moment and into the world of politics more generally, and with that I feel the need to make it clear that I am not endorsing any candidate through this post. Rather, I want to pose the question: How wealthy should America’s president be? The fact of the matter is that no one with truly modest finances has ever actually been elected president. That’s because getting elected requires education, intelligence, work and leadership experience, connections, and campaign finances. The positive association between these things and wealth is generally strong. So, a wealthy president is likely to excel in at least some of these other areas that we consider integral to effective executive leadership.

But presidents are also supposed to be accountable to the public. That’s why they are elected, not appointed. That’s why we have term limits, not dictatorships.Yet how accountable can someone be when they cannot even begin to relate to the average member of the populace? In other words, is there a point at which a candidate’s wealth stops being an indication of their fitness for the office and starts becoming an indication that they are out of touch with mainstream America? Again, all presidents are “different” from the majority of us, and in that sense, they are all at least a little bit out of touch. But might some be far more out of touch than others, and might wealth be a good way to tell them apart?

If so, Mitt Romney looks to be so out of touch with America that he ought to just pick up and move to the colony that Newt Gingrich wants us to build on the moon. According to a recent Associated Press article by Connie Cass, Mitt Romney’s wealth is approximately double that of Richard Nixon’s, Gerald Ford’s, Jimmy Carter’s, Ronald Reagan’s, George H.W. Bush’s, Bill Clinton’s, George W. Bush’s, and Barack Obama’s, combined. Considering for a moment that Obama alone is worth something like $5 million, that’s pretty astounding.

Indeed, Romney may be worth up to $250 million. There is discussion of the fact that even though he no longer works, he earns more in a day from capital gains (investment income) than most Americans make in a year. I’m afraid that he can no more identify with my financial situation–or that of tens of millions of Americans who have it far worse than me–than I or they can identify with his financial situation. Seriously. I can’t even begin to know what I would do if I made over $50,000 a day. I wouldn’t have to work, that’s for sure. Perhaps I’d run for president.

 

New Health Wonk Review Is Up

“Louise” over at the Colorado Health Insurance Insider blog hosts the latest Health Wonk Review. The theme this time around is the 2012 Presidential Campaign. If you think you’ve already had enough of that–even before the general election gears up–you’re wrong. You need to read these posts, because they are just that good.

 

Just How Much Do Hidden Health Care Costs Cost Americans?

Most of us have no idea how much our employers contribute to the costs of our health insurance to begin with, so it’s no surprise that we don’t know how much more they end up paying on our behalf each year. If you wanted to get people immediately outraged at the costs of care in this country, all you’d need to do is make the employee foot the entire bill. Employers know this, though, so they continue to compete for employees by absorbing the rising costs of insurance coverage rather than passing them on to employees through higher premiums and increased co-payments. Please don’t think, however, that employers are picking up the tab out of the kindness of their hearts. On the contrary, what they’re doing is passing the costs on to employees ever so subtly, by giving them smaller and less frequent increases in pay. It’s harder to miss the money you never laid your hands on in the first place. But what if that money didn’t go to health care? What if your paycheck got a little bit bigger? What could you have done with that money last year? RAND has put together a striking info-graphic showing just how much hidden increases in the cost of health care are costing Americans.

 

Community Benefit: Holding Non-Profit Hospitals Accountable

With all of the recent scrutiny of Mitt Romney’s tax returns, here’s something you might not know: non-profit hospitals are exempt from paying any federal income taxes. The rationale behind this is that these hospitals deserve a break because they provide significant benefits to their communities. This community benefit can be thought of as consisting of the sum total of a number of things like the amount of uncompensated care the hospital provides, the number of lives it saves, the number of jobs it provides, and the impact it has on residents’ quality of life. If a hospital is creating jobs, restoring people’s health, saving people’s lives, and providing a health care safety net for the community, then perhaps it shouldn’t have to pay federal taxes. Similar to the case for making employer-based health insurance tax-free, this is a way for the federal government to effectively subsidize something that it considers to be beneficial to the public.

Hospitals certainly enjoy their tax exemption, but the bigger question is: Do they deserve it? For more than 40 years, the rhetoric of community benefit has been bandied about without actually defining what it includes, establishing criteria for the amount of community benefit that must be provided to merit non-profit status, or evaluating the extent to which non-profit hospitals are doing so. What has been done is research showing that more often than not, non-profit hospitals behave a lot like for-profit hospitals. And who can blame them? After all, why not take the tax break with one hand and attempt to maximize profits with the other hand? In fact, the former bolsters efforts at the latter.

Since 2009, however, the IRS has required non-profit hospitals to document the dollar amount of the community benefits they provide. In the February issue of the American Journal of Public Health, Karen Principe and colleagues consider what effect health reform may have on the provision of community benefit. For example, as more Americans are covered by insurance, the amount of uncompensated care a hospital provides can be expected to decrease. The authors report that some have called for an end to non-profit status for hospitals. One way to think about this is that the federal government would be shifting its subsidy from the hospitals to the individuals as it helped them to purchase insurance. The authors disagree, however. They argue that hospitals will still need to provide uncompensated care for individuals who move in and out of coverage, and that coverage expansions under the Affordable Care Act will strengthen the financial position of hospitals, leading hospitals to allocate community benefits differently. That is, they will provide less uncompensated care, but more of the “other” stuff that constitutes community benefit.

I like their optimism, but without strong enforcement to hold non-profit hospitals accountable, I think hospitals are about to win big: They’ll keep their tax-exempt status, provide even less uncompensated care, see their revenues increase, and laugh all the way to the bank. And who can blame them? After all, they’ve no incentive to do otherwise.

 

IPAB

Contrary to the title, the IPAB is not a new Apple product. Rather, it is the “Independent Payment Advisory Board” created by the Affordable Care Act to solve the problem of ever-increasing Medicare spending. In people’s worst nightmares, the IPAB is a death panel that will make decisions about how to ration health care for the elderly and disabled. Images of 15 people sitting in a room handing out death sentences flash through the minds of the anti-government crowd. Of course, nothing could be further from the truth, as the IPAB has no authority to limit benefits, increase beneficiaries’ out-of-pocket costs, or otherwise alter the Medicare program in any way that would “ration” care.

So, what can the IPAB actually do to promote slower spending growth in Medicare? They can suggest legislation, that’s what. Legislation that, for example, would reduce or alter the way in which payments are made to providers. It’s debatable if the recommendations from IPAB will work to actually control spending. What’s not up for debate is whether action will be taken, and that’s what I’m most pleased about.

You see, I hear often from family and friends about how Congress “never does anything” and how we should “vote the whole sorry bunch out and start from scratch.” It doesn’t seem to matter which party is in power, either. Congressional disapproval knows no party affiliations. And this isn’t just a trend among my social circle. Americans generally disapprove of the job Congress is doing. The IPAB puts an end to that, and here’s how:

Starting in 2013, the chief actuary of the Centers for Medicare and Medicaid Services (CMS) will report both a projected and a target Medicare growth rate for the next five years. If the projected growth rate exceeds the target growth rate, IPAB is tasked with making recommendations to bring things in line. These recommendations are formally submitted to Congress as proposed legislation. In the past, this is where progress ceased to occur, but no longer.

With the ball in Congress’ court, the options are straightforward. Congress may either enact the legislation recommended by IPAB, introduce and enact its own legislation that achieves the same cost savings as the recommendations from IPAB, or fail to act. If Congress fails to act, however, the secretary of the Department of Health and Human Services must implement IPAB’s recommendations, which cannot be overruled by either the executive or the judicial branches. In short, when Medicare spending increases too rapidly, something will be done to address it, even if Congress fails to act.

 

Health Reform Calendar 2012

Thanks to Sarah Kliff, who writes for Ezra Klein’s Wonkblog over at the Washington Post for her summary of key health reform dates to watch in 2012. Most Americans don’t keep a close on eye on the implementation process after a law has passed, and with something as big as the Affordable Care Act, it can be especially challenging to know what’s happening when. Most folks know that the law was enacted in 2010, and many of them know that the law doesn’t take full effect until 2014, but aside from those mile-markers, things can seem like a mess.

This year, however, stands to be a big one for health reform, and one of the key dates is already behind us. On January 1, the accountable care organizations, or ACOs, came online, with the goal of controlling costs by paying for comprehensive delivery of high quality care. It’s a demonstration project that could move the country away from fee-for-service and towards patient-centered models of health care. That is, if it works, which we won’t know for a while.

Next up, at the end of March, the Supreme Court will hear oral arguments about the constitutionality of the Affordable Care Act, which I’ve written about several times already. The expectation is that a decision will be handed down in early summer.

The final big events of the year take place in the fall and early winter. On October 1, additional Medicare payment reforms will be implemented which will further change how hospitals get paid. This includes things like “pay for performance” and penalties for avoidable rehospitalizations. Then things get interesting. November 3 is election day, and the outcome will go a long way in determining the future of health reform implementation. If the GOP nominee takes the White House and the Republicans retain control of the House and/or gain control of the Senate, the ACA will likely be derailed. I don’t think that the law will be repealed under such conditions, but it may effectively be killed by cutting funding, tying the executive branch in knots, and other such strategies that choke out implementation. On the other hand, if Obama is re-elected, things are likely to move forward, regardless of the outcome of the Supreme Court decision.

In the latter case, December 31, the last day of the year, will retain its current importance as the deadline by which states must have received approval from the Obama administration for their health insurance exchange. Remember: States were permitted to design their own exchanges that met federal minimums. If they failed to do so, Uncle Sam promises to step in and do it for them. When the ball drops in Times Square to usher in 2013, we’ll know which states stepped up, and which stepped out.