Closing Racial And Ethnic Disparity Gaps: Implications Of The Affordable Care Act

For all intents and purposes, the Affordable Care Act (ACA), the President’s signature piece of legislation, will provide more health care coverage to poor and underserved populations. Persistently disadvantaged communities have much further to go than those with insurance, and new means of accessing and paying for care will benefit them disproportionately. Nevertheless, with more than 20 percent of the nation’s Black population uninsured, more than 30 percent of Hispanics uninsured and a country still grappling with understanding and properly addressing disparities, just how far does the ACA take us?

By mandating individual health insurance coverage and expanding the list of covered preventative services, ACA legislation should, theoretically, improve the quality of health care for those populations at disproportionate risk of being uninsured and having low incomes. In advance of the January 2014 start of major health reform initiatives, some estimate that more than half of the uninsured will gain insurance coverage.

However, research has shown that having health insurance itself does not have a substantial impact if people cannot find a doctor to see them, do not have proper information about accessing resources, or are not treated in a culturally and environmentally competent manner. Moreover, when the number of uninsured could be decreased by more than half, but being uninsured is not equitable across racial and ethnic groups in the US, what happens to our countries most vulnerable?

It has been well documented that low-income individuals and those without employee-sponsored insurance (ESI) are more likely to be people of color. Kaiser and US Census estimates indicate that there are significant differences in insurance rates by race and ethnicity, with national averages approximating there are almost three times as many uninsured Hispanics as Whites. In Louisiana, for example, it is believed that more than 50% of the state’s Hispanics are uninsured, while only 18% of Whites are. In the same state, it is estimated that 30% of Blacks are uninsured, reiterating just how unbalanced our country remains and how terribly far we have to go to eliminate inequalities.

The oft-cited example of health reform success is Massachusetts, where Blue Cross Blue Shield 2013 estimates indicate that about 97 percent of the state’s population has health insurance thanks to health reform. While this is a grand feat for gaining an insurance card, insurance alone does not constitute affordable, quality care, or improved long-term health and equity. The real successes come from improved statistics on accessing care, preventative care and disease reduction.

For those looking to Massachusetts, data does support a slight improvement in overall access to care by showing that Whites, Blacks and Hispanics all had increases in the number of insured, and further that the percentage of the state’s population that had “any doctor visit in prior year” between 2006 and 2009 rose by more than five percent.

Unfortunately, as many have argued, those for and against health reform, Massachusetts is not necessarily a good representation of other US states or populations, as anyone who has been to Massachusetts knows that the state population looks and behaves very differently from places such as southern California or the Southside of Chicago. Furthermore, even in Massachusetts the number of Blacks and Hispanics that remain uninsured is two and three times that of Whites, respectively.

Many of those who will be left uninsured will be Blacks, immigrants and Hispanics, who will continue to use Emergency Departments for critical care or, worse, go untreated.

Additionally, there are those who are lower middle class (a growing group in this nation) who fall into the economic gap where they cannot afford the employer/exchange insurance offered to them, but earn too much to receive subsidies for offsetting the mandatory cost of insurance, which are often people of color.

Other groups of concern are those minorities who do not have the knowledge of where to access care, do not have the financial or transportation means to access care or still distrust the system due to systemic problems with culturally competent care.

Although the ACA takes us a step forward in giving many of the countries uninsured an insurance card, the US must address what to do about probable provider shortages that will result from a lack of primary care physicians and different utilization in care. We must be prepared to understand both to cultural differences in demand and pent-up demand of the previously uninsured, as well as start to really face how to deal with persistent racial and ethnic inequality in this nation that shows itself in our health care system every day.

In the coming weeks, months and years the US citizens have to do more than champion or attempt to repeal the ACA. Party lines and moderate attempts at change will never fix our broken health care system. We have to start addressing the real issues our country faces, those of injustice, unequal access and treatment and how we properly care for and address the needs of those who are not White and wealthy.

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Health Wonk Review: Sardonic Edition

This edition of the Health Wonk Review is a bit tongue-in-cheek, as I offer some interesting definitions of well-known words and make light of some of the more despair-inducing aspects of the world of health policy. Buckle up, because it’s going to be a bumpy ride!

Insanity (n.) – I’ve always heard that the definition of insanity is doing the same thing repeatedly and expecting different results. Well, if that’s true, then House republicans must be insane, because they recently tried again–for the 37th time–to repeal the Affordable Care Act. They were again–for the 37th time–entirely unsuccessful. Louise, of the Colorado Health Insurance Insider, says “I can understand citizens and lawmakers being concerned and wanting to address the problems that they see in the law. But before they push for another vote to repeal or defund all or part of the ACA, I’d like to see them put forth very specific recommendations for change, including details on exactly how their solutions would work to make sure that everyone in America has access to quality, affordable healthcare.” Similarly, at the Health Insurance Resource Center Blog, Maggie Mahar asks whether GOP House freshmen’s desire to demonstrate their opposition to Obamacare justifies the 37th repeal vote. Moreover, she inquires: Are the Republicans crazy for banging their heads against the wall with repeal votes that realistically won’t succeed? Or is there a method to their madness? (See? Even she thinks they may be insane!)

Scandal (n.) – I’m pretty sure that the definition of scandal is when the minority party blames the majority party for doing precisely what the minority party would have done if it were the majority party. The IRS is at the center of one of at least three scandals plaguing the Obama administration, and it has some people up in arms. How, they ask, can a government agency that targeted Tea Party organizations be trusted to enforce the individual health insurance mandate without playing politics? Over at InsureBlog, Hank Stern offers up plenty of reasons to feel uneasy about the role of the IRS in enforcing the individual mandate, including an unprecedentedly large database. Once you read it, you may never sleep again!

Austerity (n.) – Austerity, in the economic sense, is the approach to balancing your household budget by spending less money and quitting your job. In response to the Great Recession, many Americans and their representatives are embracing such policies. When Congress couldn’t agree on what budget cuts to make, and seemed closed entirely to the idea of raising additional revenue, the sequester happened by default. The problem is, we have loads of evidence that demonstrates that austerity policies lead to worse health outcomes. Joe Paduda writes about this and how politicians’ desire to serve only those who vote and have power, leaves the poor and disenfranchised to suffer the consequences at Managed Care Matters.

Kickback (n.) – A word used to make a bribe sound like something a soccer player does to return the ball to a teammate. Apparently, this also happens in health care. In fact, according to Health Care Renewal’s Roy Poses, a recent settlement had all the usual elements: slowness, imposing penalties not as big as they seemed, and providing no negative consequences for individuals who approved, directed or implemented the bad behavior. That a medical device company was apparently giving kickbacks to physicians to get them to use their products, and in this case, thus to give aggressive treatment for patients with prostate cancer, may provide one more piece of the puzzle about why the US has had such an infatuation with aggressive screening for and treatment of prostate cancer, despite any good evidence from clinical research supporting such an approach. This shows that handing over control of most of health care to managers at a time when managers are viewed as unable to do any wrong had not only been very bad for the economy, but very bad for patients’ and the public’s health.

Skeptical (adj.) – The special type of lens used to make glasses through which health care economists (okay, all economists) view the world. As an example, THE Healthcare Economist, Jason Shafrin, writes about how HealthPartners in Minnesota launched an online health clinic that it claims will save lots of money. The Healthcare Economist believes that online tools can reduce cost, but—wait for it—is skeptical of the HealthPartners large savings estimates.

Safety (n.) – This describes a new incentive under the Affordable Care Act, whereby health care providers who actually abide by the Hippocratic Oath of “first, do no harm” are awarded two points and the ball. Dr. Jaan Sidorov of the Disease Management Care Blog may be misapplying Dr. Baumol’s lessons about health care labor costs to argue that cockpit safety lessons are not the panacea for increasing health care quality?  He says the simplest patient is more complicated than the most advanced jumbo jet and doubts that systems engineering will temper the numerous FTEs that still surround every patient.

Equality (n.) – The quality of sameness across persons, places, or things, which in the context of opportunity, is especially prized in the United States of America along with such liberties as the freedom of speech, and explains the inclusion of Dr. John Goodman’s post on inequality in this edition of the Health Wonk Review. (Though I might add that I am a professor, and I–and many others–do NOT get the summer off, or spend our days doing pretty much whatever we please.)

Questions (n.) – A sentence worded to elicit information. It is vitally important not to ask two questions in the same room together–especially if the lights are off–as they are likely to produce more questions than answers. The Health Affairs Blog post by Al Adelman and Lew Morris takes a closer look at  Jonathan Welch’s Narrative Matters essay. They write: “Dr. Jonathan Welch’s Narrative Matters essay in the December, 2012 edition of Health Affairs, regarding the cascade of errors and omissions he witnessed in connection with the care provided to his mother, should raise profound questions about how the hospital allowed those failures of care to happen. Dr. Welch, an emergency medicine physician, watched helplessly as his mother received indifferent care from various nurses and doctors and ultimately died. Despite having classic signs of evolving sepsis, she was not closely monitored by the nursing staff which ignored alarming signs, was not put on a sepsis treatment protocol by her oncologist, and was not put in an intensive care unit where she could receive more intense monitoring and aggressive treatment from specialists. While it is tempting to blame the nurse (for not taking vital signs frequently enough and not reacting to abnormal vital signs) and the oncologist (for not following the patient closely enough, not initiating appropriate treatment, and not involving other specialists), Dr. Welch’s story suggests that there were more deeply rooted systemic problems at the hospital that went beyond the shortcomings of the individuals involved in his mother’s care.” Adelman and Morris then go on to list questions that the hospital in question, and all hospitals, should ask themselves.

Technology (n.) – The application of scientific knowledge for practical purposes to make things more confusing and expensive before ultimately improving them. The Healthcare Innovation Council and the American Hospital Association both think the current federal health IT plan needs some rethinking. Providers are chasing dollars instead of outcomes, but ultimately, Peggy Salvatore writes at the Healthcare Talent Transformation blog that health IT will happen and it will be done well.

Transparent (adj.) – A quality that allows light to pass through something so that you can see just how expensive it really is and what you are getting in return. David Williams of the Health Business blog presents a podcast with Eric Schultz, CEO of Harvard Pilgrim health plan to talk about consumer engagement and transparency.

Congress (n.) – A group of elected representatives specifically chosen for their inability to understand logic, reason, and the scientific method. At Wing of Zock, Dr. Ann Bonham, chief scientific officer at the Association of American Medical Colleges, discusses the proposed “High Quality Research Act” (currently in draft form in Congress). The Act, she reveals, would institute a layer of Congressional review of research funding proposals by the National Science Foundation and NASA. Dr. Bonham notes that most members of Congress are not equipped to judge the research priorities established by trained scientists at agencies that have already established their worth in scientific discoveries that save lives. The post also includes a video clip of an interview with Vivian Lee, MD, dean of the University of Utah School of Medicine.

Average (n., adj., v.) – The result one gets by summing the values for every observation and dividing it by the total number of observations; or what no one wants to be below, and everyone thinks their kids are above. At the Hospital Leader blog, Dr. Bradley Flansbaum takes a deeper look at hospital demographics, and asks “What is an average hospital?

Safety net (n.) – A device used to catch people who fall through the cracks, that is itself full of holes. The Workers’ Comp Insider’s, Julie Ferguson, writes about the nation’s safety net for injured workers and explains how workers’ comp covers both occupational medical costs and replacement of lost wages. Jon Coppelman of Workers’ Comp Insider takes the pulse of the market via the NCCI’s annual State of the Line report. Things are mostly looking up but there are a few looming issues of concern.

 

America Spends More on Emergency Medicine Than Previously Thought. Good or Bad?

American emergency departments take a lot of heat from critics who assert that they are one of the places in our health care system where resources are wasted in abundance. These arguments have less to do with the emergency departments themselves, and more to do with people using emergency departments for non-emergent conditions. One estimate puts the excess spending at $38 billion a year. By contrast, the American College of Emergency Physicians (ACEP) claims that care received in emergency departments accounts for only 2% of national health expenditures. However, new research from Michael Lee and colleagues appearing in the Annals of Emergency Medicine, finds that, because of data limitations, previous estimates of emergency department spending are misleading.

The 2% figure appears to be based on a faulty interpretation of the Medical Expenditure Panel Survey (MEPS) conducted by the Agency for Healthcare Research and Quality. The MEPS figures that ACEP uses for their calculations did not include more expensive admitted patients (only those that were seen in the ER and released), did not include institutionalized patients such as elderly nursing home patients, and significantly undercounts the total number of ER visits nationally compared to a number of other established surveys.

In their study, Lee and colleagues use a variety of data sources and construct estimates using several different assumptions to generate a more reliable range of emergency department spending in the U.S. Their conclusion is that emergency department care likely represents 5 or 6% of national health expenditures, although the true figure could be as high as 10%. That’s a figure 3 to 5 times as great as what the American College of Emergency Physicians is reporting, so it’s safe to say that, to the extent one trusts these new numbers (and I do), the argument that emergency care isn’t a big contributor to national health expenditures pretty much falls apart.

What is left, then, is the question of whether that level of spending is inherently wasteful. On this point, the authors review the economic literature on the costs of providing emergency care. The accepted paradigm had been that the ER was a high fixed cost, low marginal cost enterprise. But the authors show that empirical studies testing that hypothesis using regression analysis have been variable and poorly designed. They favor an accounting-based approach rather an econometric one, using principles from time-driven activity based accounting popularized by Kaplan and Porter. That approach puts greater emphasis on the scalability of resources such as labor, space and equipment that might otherwise be viewed as fixed.

I asked Lee about the implications for policymakers from their line of work:

On the topic of diverting low acuity care: “Diverting low acuity visits may save payers some money but I’m skeptical that there would be large aggregate savings….Studies that look at ex-ante measures of severity or urgency (as opposed to diagnosis-related measures which are ex-post) generally show that the volume of non-urgent care is lower than the public perceives. And a further point is that the actual reimbursements for non-urgent care is likely to be on the low side to begin with since it’s a population more likely to be uninsured or underinsured. Finally, you have to also take into account the fact that primary care offices and clinics may not have the capacity to see high volumes of unscheduled care, so diverting care will simply shift the cost burden. I think there is far more promise in understanding and questioning expensive decisions ER physicians make such as admitting patients to the hospital or the volume of diagnostic testing ordered.”

Lee and his co-authors want to move beyond the issue of minimizing costs, however, and in their paper they call for a greater emphasis on value, writing:

“With 130 million visits, 28% of all acute-care visits, and accounting for nearly half of all admissions, emergency medicine should be expected to represent a large share of health care spending….More attention should be devoted to quantifying the value of specific aspects of emergency care. Rather than minimize the issue of cost, we should recognize the economic and strategic importance of the ED within the healthcare system and demonstrate that costs are commensurate with value.”

Lee acknowledges that this remains a challenge for the field of emergency medicine. “The core of our business is ruling out critical diagnoses. Many of the things we look for are low probability but highly dangerous conditions. The big question is how do you quantify value when your work is often focused on trying to demonstrate the absence of something?”

 

Joe Paduda Hosts Health Wonk Review

It’s another excellent edition. Check it out here.

 

Making Sense of the Oregon Experiment

Last Thursday, an article by Kate Baicker and colleagues came out in the New England Journal of Medicine. Almost immediately, the article received widespread attention in the media where headlines claimed that giving people Medicaid coverage doesn’t improve their health. This is not exactly what the article said, but most journalists aren’t scientists, so we should cut them a bit of slack. But, before I give you my interpretation of the study’s findings, let me provide you with some background.

The state of Oregon has a waiver to provide Medicaid coverage to a group of low-income adults that would not otherwise be eligible for Medicaid under traditional law. They call this the Oregon Health Plan Standard. The problem is, states are required to balance their budgets annually, and there is more demand for this Medicaid program than there is money in the state budget to meet that demand. So, the state created a waiting list, and in 2008, the state had enough money to expand the Medicaid program slightly. To be fair, they held a lottery among the nearly 90,000 waitlisted individuals, and some 30,000 of them won the right to enroll in Medicaid. The reason that’s important is that the lottery introduces a random selection process that is extremely valuable when conducting research. I’ll spare you the additional details, because if you’re the kind of person who needs to know them, you’ll go read the NEJM article for yourself.

Two years after the lottery, the study authors interviewed both the group that won the lottery and a “control” group that didn’t win the lottery. According to the authors, they asked about “health care, health status, and insurance coverage; an inventory of medications; and performance on anthropometric and blood pressure measurements.” They assessed both depression and self-reported health-related quality of life. The goal, in short, was to see what difference obtaining Medicaid coverage makes compared to being uninsured.

The story making headlines is that people didn’t get healthier by gaining Medicaid coverage. This is because there were no statistically significant improvements in blood pressure, cholesterol levels, or controlled diabetes. Indeed, that is one thing the study found, but that’s not all. They also found that people who gained Medicaid coverage were more likely to have their diabetes diagnosed, which is the first step in getting it treated. Additionally, they found that those with Medicaid coverage were less depressed, reported a better quality of life, used more health care, and were far less likely to encounter financial hardship because of health care.

Since a central component of the Affordable Care Act is the expansion of Medicaid to a population similar to that studied in this Oregon expansion, these findings are being viewed as evidence that expanding Medicaid will just mean more money spent on increased use of health care without anything to show for it. The flaw in that thinking comes from the fact that insurance coverage is a necessary, but not sufficient, cause of improvements in health outcomes. In other words, just giving people Medicaid coverage isn’t going to fix everything. We still need to make sure that they have access to a doctor, have the ability to make and keep their appointments, understand and comply with their doctor’s orders, and help them navigate the complexities of the health care system. We also need to make sure that the treatments they are provided are effective. This is where other components of health reform are poised to play a major role. Accountable care organizations and patient-centered medical homes are designed to focus on integrated, high-quality care that puts the patient first and shifts health care providers’ focus from volume to value. The Patient-Centered Outcomes Research Institute (PCORI), headed by Dr. Joe Selby, is funding comparative effectiveness research that seeks to identify what works and what doesn’t. But this study by Baicker and colleagues provides extremely strong evidence that health insurance insulates people from the financial risk of illness, and that seems to give them peace of mind that makes them report a better quality of life–even if their blood pressure hasn’t yet been lowered.

So, to conclude that Medicaid doesn’t do what it is supposed to isn’t true. It does precisely what it is supposed to. We just have to make sure that all of the other components of a high-performance health care system are in place and doing what they are supposed to. When that happens, the health care outcomes we seek will follow.