Over at healthinsurance.org, Maggie Mahar hosts the latest edition of the Health Wonk Review, with the theme “Waste, Warnings, and the Future.” She includes one of our posts on proposed Medicaid cost-sharing that falls under the “warnings” category. There’s loads of other good stuff, too. You can check it out here.
Monthly Archives: January 2013
From 1974 to 1982, a group of researchers conducted the RAND Health Insurance Experiment. In lay terms, what they did was assign people to different levels of insurance coverage, with a particular focus on the amount of co-payments, co-insurance, and deductibles that people had to pay, and then they observed their use of the health care system. As you might expect, those who had to pay more out of their own pockets used less health care. More importantly, they didn’t make a distinction between necessary and unnecessary care. If you’re up to the challenge, you can read some of the publications here and here.
This is why insurance companies use these methods of cost-sharing to help keep utilization and costs down. The reasoning goes that when people have to spend some of their own money at the time that they are deciding whether or not to utilize the health care system, they will be more judicious in their use of resources. In other words, if you are feeling a little bit under the weather and you don’t have to pay anything to go to the doctor, you are more likely to go than if you have to fork over $20. On the other hand if you are “truly” sick, paying the $20 will be totally worth it.
But what about the very low-income? For them, even when they are extremely sick, $20 may be too much money to spend on health care. They may have the money, but need to spend it on other things like food, or–if they are very poor–they may not have the money at all. In other words, for the low-income, cost-sharing goes from being a motivator of the judicious use of resources to a barrier to accessing the health care system. For this reason, Medicaid–the insurance program for low-income Americans–has historically limited the amount of cost-sharing that states can impose on beneficiaries.
States, meanwhile, complain of the burden that the Medicaid program places on their budgets, and they want the federal government to permit more cost-sharing. After all, they say, the economic principles that motivate cost-sharing do not play favorites. They work for those of all different income levels.
The problem is, that’s not true. Cost-sharing is not based relative to income, but rather is a fixed amount and/or a percentage of health care charges. Therefore, common sense points out that the overall burden of any given level of cost-sharing decreases as an individual’s income increases. Translation: cost-sharing hits the poor the hardest.
Now, in an effort to woo states that have so far declined to participate in the Medicaid expansion under the Affordable Care Act, the Department of Health and Human Services has published a proposed rule that would permit states to charge “higher than nominal levels” of cost-sharing to Medicaid beneficiaries earning more than 100% of the federal poverty level. While this does continue to protect the poorest of the poor, it exposes those marginally less poor to a significant cost barrier, which the RAND Health Insurance Experiment tells us means they will seek less care. As we know from the Oregon Health Study, when the uninsured suddenly gain Medicaid coverage, they have better access to care, use more of it, and it costs more money than leaving them to go without altogether. Unfortunately, the current political compromise is likely to throw a wrench into the works. Expanding coverage for low-income Americans, while shifting more of the financial burden of their care directly onto them, is a recipe for a disaster of underinsurance, where individuals are covered in spirit, but remain vulnerable in practice. We would do better to be honest with ourselves and just deny them coverage.
It seems like just yesterday I was hosting the Health Wonk Review. Now, there’s already a new edition, and it’s a good one! Christopher Fleming put it together and hosts it at the Health Affairs blog. As usual, this is all the stuff you need to read, and thanks to Chris for including our Wright on Health post about the recent IOM report on the U.S. health disadvantage. Follow this link for the latest review.
It’s been a couple of weeks now, so I can finally bring myself to write about it. What, you ask? The dreaded Christmas flu of 2012. You see, while I’m a faculty member in a College of Public Health at a major research university, I somehow managed not to get my flu shot this year. Remarkably, however, the flu virus did not forget about me. After our flight home to Georgia was delayed from the 20th of December to the 24th because of winter storm “Draco”–the blizzard that brought snow, ice, and wind gusts in excess of 50 miles per hour–we finally made it to our destination, but not before traipsing through four different airports in Cedar Rapids, Detroit, Atlanta, and Jacksonville. Christmas was lovely, and then, the very next day, as we were out and about, I started to feel like I needed to sit down. The same day, that had devolved into a fever and needing to lie down, and it just got worse from there.
I spent the remainder of my time at home quite sick. My fever was consistently in the vicinity of 102.5, I had chills, my throat burned with every involuntary swallow, and I was just miserable. As I said, this all started on Wednesday, and after not being able to sleep through the night for several days, I made a trip to the doctor on Saturday morning. I was told that I had the flu and a possible sinus infection, and prescribed Tamiflu and antibiotics. I got them filled, and started taking them–even though I read that neither was particularly likely to be of much help this far along in the illness. Still, it seems that it was around this time that I slowly began to turn the corner. I was able to sleep through the night, but I was still very weak. When Monday morning rolled around and it was time to head to the airport and fly back to Iowa, I wasn’t entirely sure if I would be able to do it. Fortunately, with the help of one of those airport golf carts, I did.
I spent another couple of days recovering before going back to work, and I’ve only felt back to “full strength” for about a week now. The bottom line: The flu is a terrible illness, and I got through it relatively quickly, with milder symptoms than many people experience. Right now, the country is in the midst of a large-scale flu outbreak the likes of which hasn’t been seen for many years–some say decades. But we can fight back.
First of all, get your flu shot. I didn’t, and suffered for it. But yesterday, I went and got the vaccine. Why? Because the shot covers three different strains of the virus. Sure, I caught one, but I might still catch the other two, and that’s not something I would welcome. There are a lot of nonsense reasons that people avoid the flu shot. They don’t like shots. Well, the pain of the shot is a lot shorter-lived than the misery of the flu. They think the shot causes the flu. Really? Aside from the fact that that’s not scientifically possible, why wouldn’t we see a direct correlation between those who got the flu shot and those who got the flu? This makes about as much sense as saying that those antibiotics you took gave you strep throat. It’s just not true. Moreover, you don’t just harm yourself by failing to get the flu shot. Rather, you leave yourself vulnerable, which puts others at risk if you happen to get sick, and that leads to my next point.
If you get sick–especially if you are running a fever–stay home. That means don’t go to work, don’t go to the movies, don’t go to church, and if at all possible don’t travel. No one wants what you have. Stop the spread by staying home. You are advised to wait at least 24 hours after you no longer have any fever symptoms before reintroducing yourself to society, and that’s a minimum recommendation. Longer is better.
Now, you may be saying I should listen to my own advice. Well, as I said, I just got my flu shot yesterday. And I got a flu shot last year, and did not get the flu. So, it’s not as if I regularly avoid getting vaccinated. On the contrary, my story shows just how easy it is to let a simple little thing go unattended, with horribly unpleasant consequences. The flu shot is cheap—even free for most with insurance—and it takes just a moment to receive it. You can get the flu shot at Wal-Mart, your doctor’s office, the health department, the drugstore, you name it. This is not a hard thing to do. So, if you haven’t gotten your flu shot yet. Do it today. If you don’t, you might find yourself terribly sick for a couple of weeks. Consider yourself warned.
Despite the widespread claims from politicians, providers, and even many members of the public that American health care is the best in the world, a new report from the Institute of Medicine concludes that growing up in the United States actually puts people’s health at risk compared to other wealthy nations. There are a number of factors involved. Chief among them are deaths from gun violence, car accidents, and drug overdoses, the rates of which are significantly higher in the U.S. than elsewhere in the developed world.
It appears that these dramatic differences in what are, essentially, preventable causes of death among our young people help to explain much of the reason why the United States routinely lags behind other countries when it comes to life expectancy. And these sorts of issues are more in the domain of public health than they are the health care system, which begins to raise some interesting questions about how we are allocating our limited resources.
We already know from earlier research that medical care is only responsible for about 10 to 15% of the avoidable mortality in this country. Sociobehavioral factors play a much larger role–nearly 50%–with genetics and the environment accounting for the remainder. So, it seems clear that we need to do more to reduce access to guns, keep our kids (and adults) off drugs, promote policies to encourage safer driving (or consider investing in more public transportation so that we drive less overall), and continue to work on getting people to eat healthy foods and exercise regularly. It would appear that we have our work cut out for us.
Of course, many readers will not agree that government has a role in encouraging these activities. To the conservative or libertarian, these personal decisions are just that–personal–and government has no right to intrude. I would be inclined to agree if our American society as a whole didn’t wind up responsible for the costs of those personal decisions. Unfortunately, that’s not the case. Thus, until we decide to shift our focus more in the direction of public health activities, or promote policies of complete and total individual responsibility, we will continue to pour ever-increasing gobs of money down the health care drain, and all of us will have to pay the plumber.
With 2012 and the fiscal cliff now behind us, it’s time to turn an eye to the year ahead. What will 2013 hold? More fights in Congress over the debt ceiling, entitlement reform, and other spending cuts seem inevitable. The Affordable Care Act will continue to move towards full implementation, but what new wrinkles will that process encounter? Will gun control and mental health reform finally get some much-needed attention? It promises to be an interesting–if not exciting–year for health policy. AND it promises to be an interesting year for me personally, as my wife and I are expecting our first child this summer. There is great potential all around as we start this new year, and in that spirit I bring you the “Baby New Year” edition of the Health Wonk Review. This edition features some really fantastic posts from the best health policy bloggers out there, along with a selection of cover art from some vintage issues of The Saturday Evening Post, depicting Baby New Year. Enjoy!
First up is Joe Paduda’s interesting post on the Florida Medical Association. At the Managed Care Matters blog, Joe examines the issue of the FMA supporting physicians’ dispensing of medications to worker’s comp patients, despite the fact that there is no demonstrable benefit for patients. In fact, the practice is likely to increase the risk of drug-to-drug interactions. Why the strong push then? Well, it does greatly fatten physicians’ wallets.
Similarly, at Health Care Renewal, Roy Poses draws our attention to a key opinion leader who was paid by a pharmaceutical company to help liberalize the use of narcotics for chronic, but non malignant pain. Said opinion leader is now saying he based his comments on weak evidence from studies that were too small to be meaningful, and that narcotics aren’t actually as safe as he once claimed. But, hey, at least the drug companies are a bit richer for it.
Then, while we’re talking about money, there’s the fiscal cliff, which John Goodman of the National Center for Policy Analysis writes about here. Thanks to some last-minute Congressional action, a crisis was averted, but some things still went over the cliff. One of those was the CLASS Act, writes Harold Pollack at the Medicare Resource Center Blog. CLASS was designed to complement private long-term care insurance, Medicare, Medicaid, and public disability programs. For Medicare recipients living in their own homes, CLASS would cover important services no one else would cover. But, Tuesday night, in the fiscal cliff vote, the CLASS Act was killed by Congress.
The rest of health reform marches forward, however. Maggie Mahar makes a splash with her post from healthinsurance.org that provides an overview of the ObamaCare health insurance subsidies. Beginning in 2014, millions of Americans will discover that they qualify for subsidies designed to help them purchase their own health insurance. The aid will come in the form of tax credits, and blogger Maggie Mahar says many will be surprised by how generous they are. Included in the post is an “infograph” which tells you whether you will be eligible, a “subsidy calculator” which lets you estimate the size of your subsidy, and a table explaining how the government calculates the subsidy.
And speaking of government subsidies, over at the Health Affairs blog, Richard Frank and Jack Hoadley endorse a proposal to require manufacturers to pay a minimum rebate on drugs covered under Medicare Part D for those beneficiaries who receive the program’s Low-Income Subsidy (LIS). They defend the idea against criticisms in a letter organized by the Council on Affordable Health Coverage and based on analysis by Douglas Holtz-Eakin and colleagues.
Health reform is also leading us towards models of high-quality, patient-centered care. As we begin a New Year, David Wilson of Innovative Health Media says now is the time to look at a new paradigm shift occurring in health care. High costs and new research have prompted this shift toward a system more focused on patient education and prevention than ever before. Meanwhile, David Harlow of the HealthBlawg writes about a recent study that suggests that patient-centered care, including improved communication, can improve outcomes, reduce readmissions and thereby improve hospital finances, and Dr. Jaan Sidorov of the Disease Management Care Blog reviews a recently published article that tackles an underestimated challenge for accountable care organizations: the need for an organized approach to communication, including educating docs to give up on their informal ways of doing things. Bringing it back to money for just a moment, Brad Flansbaum explains what parity in Medicaid and Medicare payment rates means for hospitalists at the Hospitalist Leader.
Anthony Wright of the Health Access WeBlog provides a review of how California is leading in implementing the Affordable Care Act–and the significant work to do in this new year, even in such a leading state, to be ready to start enrollment in October 2013–just nine short months away. And, even with all the Affordable Care Act promises to do, there will be unmet needs. That is why, as Louise at the Colorado Health Insurance Insider writes, Colorado State Senator Irene Aguilar is pushing for the state to implement its own universal coverage program.
As we head into the future, we also have new and better ways of tracking personal health data. But for all the potential good that represents, it is not without certain risks. At the InsureBlog, jovial regular Hank Stern writes about “Watching Figures.” From pedometers to GPS, we are facing a new frontier in personal health data, and questions are emerging about who really owns it.
Also with an eye on technology and innovation in health care, is an interview with American Well CEO Dr. Roy Schoenberg. Conducted by David Williams of the Health Business Blog the interview addresses how changes in technology, physician practice and health reform are contributing to the growth of the field. The interview is also available as a podcast.
A couple of entries in this “best of” collection, present their own “best of” posts. Wing of Zock has a blog carnival all its own entitled “Chart Review.” In this monthly feature, the editors highlight their top posts from the previous month. They focus on academic medicine from a variety of perspectives, and welcome your contributions, which you may submit by email. Julie Ferguson of the Workers Comp Insider posts a retrospective of their 20 most popular posts of 2012 – including many occupational health & safety issues, from compensability related to heart attacks and carpal tunnel to policy issues put forth by OSHA and NCCI.
Finally, not everything interesting in health policy happens in the United States. The Healthcare Economist’s Jason Shafrin investigates how the single-payer National Health Service in the United Kingdom may be less centralized than it appears.
Well, that’s it for this edition of the Health Wonk Review. Here’s wishing everyone a healthy and happy 2013! It looks like the next edition on January 17 is still in need of a host at this point……and then it’s Steve Anderson of healthinsurance.org on January 31st!
I’d like to send a very heartfelt CONGRATULATIONS to our brilliant Wright on Health creator Brad Wright and his lovely wife, Laura!
Brad’s writing on Health Care Delivery in the US is going to take on an entirely new meaning, as they have just announced that there will be a Wright family addition in 2013!!!
Congratulations to you both, and we all look forward to your tiny bundle of joy.