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Monday, March 17, 2014

Health Care Reform Articles - March 17, 2014

Where Income Is Higher, Life Spans Are Longer

As incomes have diverged between the country’s richest counties, like Fairfax County, Va., and its poorest ones, like McDowell County, W.Va., so have the life expectancies of their residents. 

Every U.S. county is represented by a dot.
Men
1990
Today
85
years
85
years
Fairfax County, Va.
80
80
Fairfax County, Va.
75
75
Life
expectancy
70
70
65
65
McDowell County, W.Va.
McDowell County, W.Va.
60
60
$0
$0
30,000
60,000
90,000
30,000
60,000
90,000
120,000
120,000
Median household income
Median household income
Women
1990
Today
Fairfax County, Va.
85
years
85
years
Fairfax County, Va.
80
80
75
75
Life
expectancy
McDowell County, W.Va.
McDowell County, W.Va.
70
70
65
65
60
60
60,000
60,000
$0
$0
30,000
90,000
30,000
90,000
120,000
120,000
Median household income
Median household income



Sources: Institute for Health Metrics and Evaluation (life expectancy); socialexplorer.com (income data from the 1990 decennial Census and 2008-2012 American Community Survey)


Health insurance startup gets most of Maine enrollees

Maine Community Health Options is the only rival of Blue Cross in the state’s new insurance exchange.

By Alex Wayne
Bloomberg News
WASHINGTON — In Maine, the insurer that has enrolled the most Affordable Care Act customers isn’t the state’s well- established Blue Cross Blue Shield plan, owned by WellPoint Inc. It’s WellPoint’s only rival: Maine Community Health Options, a startup that didn’t exist three years ago.
The newcomer, funded primarily by taxpayer money lent under the U.S. health-care law, has won about 80 percent of the market so far in Maine’s new insurance exchange, exceeding its own expectations, said Kevin Lewis, the CEO.
Health law opponents predicted early on that insurance co-ops created by the law would fail, and that much of the $2.1 billion they were loaned to get started would be lost. Instead, the 23 co-ops that now exist nationally have enrolled about 300,000 people in health plans by combining low premiums with a certain homespun appeal, according to company executives.
“We’re doing really well,” Lewis said in a telephone interview. Taxpayers face “no risk whatsoever” that Maine Community will go under, he said. “A lot of those early, dire concerns just need to be re-examined.”
Kristin Binns, a spokeswoman for Indianapolis, Ind.-based WellPoint, declined to comment on her company’s co-op competition.
The 2010 Patient Protection and Affordable Care Act refers to these new companies as “Consumer Operated and Oriented Plans,” or co-ops. To be sure, not all of them have thrived. Some, such as Maryland’s, have struggled to sign people up because of problems with their state’s exchange while others, including Michigan's, have set premiums too high.
The successful co-ops “emerged as price leaders,” responsible for more than a third of the lowest-premium plans offered on U.S. exchanges, according to an October report by McKinsey & Co. consultants.
Executives from these nonprofit groups in part credit innovative benefit designs, including features that offer free doctors’ visits and generic drugs, and even $100 gift cards for people who get an annual physical. In Wisconsin, many customers of Common Ground Healthcare Cooperative appreciate the company’s nonprofit, member-governed business model, CEO Bob DeVita said.
“There’s a long-standing upper Midwest tradition with co- ops,” DeVita said in a telephone interview. “I think there was a lot of pent-up demand for that.”

Expanding Medicaid would be 'sinful,' LePage says

Two challengers for the governor's seat criticize his comments made on the day he submits petitions to get on the ballot for re-election.

Gov. Paul LePage on Friday called a proposed expansion of Medicaid “sinful” during an appearance in Kennebunk, his starkest condemnation of the plan yet.
The comment, first reported in the York County Coast Star, drew criticism from his two challengers for governor, Democratic 2nd District Rep. Mike Michaud and independent Eliot Cutler.
“I’ve given up trying to interpret what the governor says because too often – and this is one of those times – it just makes no sense whatsoever,” said Cutler, who supports the expansion of MaineCare, as Medicaid is called in Maine.
At stake is access to health care for more than 60,000 to 70,000 low-income Mainers that would largely be funded by the federal government as part of the Affordable Care Act.
“What we are talking about here is providing life-saving health care to tens of thousands of Mainers and Gov. LePage is calling it sinful,” Michaud said in a statement. “I don’t know how he explains that to the 70,000 Mainers – including nearly 3,000 veterans – who are counting on him to do the right moral thing and sign the bipartisan Medicaid expansion plan into law.”
Three members of the governor’s staff did not return calls and emails requesting clarification about the remark Friday evening.
LePage’s appearance in Kennebunk, in which he visited three businesses and discussed economic incentives with town and business leaders, came on the same day he handed in signatures to place his name on the primary ballot.

Maine CDC agency chief implicated in shredding controversy

Meanwhile, the deputy director says she ordered junior staff to destroy public documents, but says she didn't know it was illegal.

By Steve Mistler smistler@pressherald.com
Staff Writer
AUGUSTA — Dr. Sheila Pinette, director of the Maine Center for Disease Control and Prevention, ordered junior staff to change the methodology used to award $4.7 million in public health grants after agency officials noted that the original scoring put a preferred recipient in second place, according to Christine Zukas, the agency’s deputy director.
Zukas also told a legislative panel Friday that she ordered junior staff to destroy old scoring documents but ended up doing so herself, claiming she didn’t know that it was against the law.
Those claims and many others emerged Friday after more than six hours of sworn, but often contradictory, testimony from five CDC officials subpoenaed by the Legislature’s Government Oversight Committee. The panel has been investigating the 2012 grant process for the Healthy Maine Partnerships Program that a legislative watchdog agency found had been intentionally manipulated. The agency also found evidence that public documents used to justify the grants had been ordered destroyed by high-ranking officials.

Don’t let dishonesty and ideology block health care for the poor, improvements at DHHS

By Trish Riley, Special to the BDN
Posted March 15, 2014, at 2:15 p.m.
What more can be said about the fight to accept federal funds and provide health care coverage to the poorest among us?
It’s not enough that 70,000 people will go without care; it’s not enough that $1 billion earmarked for Maine will stay in Washington rather than be pumped into the state’s economy; it’s not enough to offer a Republican compromise that wins bipartisan support. The LePage administration and its allies still promise a veto, and there are not yet enough legislators prepared to overturn it.
Our state is poised to be the only one in the Northeast to leave its poorest residents without health care. Why? In some states, conservative governors have proposed purchasing private insurance for some of those newly eligible for Medicaid, but not here. Indeed, the latest salvos from the administration help us understand that this is an ideological fight against the poor and vulnerable. No “able-bodied” need apply for help here — apparently one needs to pass a moral test of worthiness to qualify for health care. That’s not the Maine most of us know and love.
All the noise and fury in this debate may be missing the big question: Is it really the cost of coverage for very poor Mainers that challenges the DHHS budget, or is the loud opposition masking underlying problems that have gone largely unresolved?
The administration argues that it cannot afford to cover about 70,000 Mainers earning less than $16,105 a year. The cost for those newly eligible is fully funded by the federal government, and the state will never pay more than 10 percent of their costs.
We’ve heard that MaineCare is “raiding” other agencies’ budgets; but not about MaineCare’s investments in education or how covering these 70,000 individuals could save Maine millions in state funds. Officials continue to quote the controversial Alexander report, a report that never calculated savings that even a conservative think tank accepts.
For many years, MaineCare has provided savings in K-12 budgets at the state and local levels because it pays for significant services in schools — serving children with special needs, reimbursing school-based rehabilitation, providing speech and other therapies through MaineCare.
Today state funds pay for costly and important mental health and substance abuse services for many whose incomes are just above MaineCare eligibility. MaineCare expansion will create savings to the state when those Mainers become eligible for the program and federal dollars pick up those costs.
Today Maine pays 100 percent of the health costs for our aging prison population. With expansion, MaineCare will pay for those prisoners who meet income eligibility when they are admitted to hospitals. That creates savings in the corrections budget.
When people who are uninsured get sick, the cost of their care is transferred to the rest of us in higher premiums. MaineCare expansion assures that Maine’s hospitals and other providers get paid for service that was previously uncompensated.
We’re told we cannot afford expansion until we cover the waitlists for people who are already receiving MaineCare health services but are waiting for additional supportive services. Why is there a waitlist? MaineCare costs per person are 7 percent higher than the national average. Among states that have moved away from institutionalized care to community services, no state spends more per person on services to the intellectually and developmentally disabled. The tradeoff here is clear — better management of care can reduce high costs and cover the wait list, yet that wait list continues.
Certainly other administrations have had challenges in managing DHHS. And Commissioner Mary Mayhew has launched efforts to reform how services are paid for and delivered. Are they working?

Maine Voices: Universal health care is only fair

We already subsidize the elderly, the poor, politicians and public-sector workers. But all of us deserve freedom from worry.

By Alice Knapp 
RICHMOND — Let’s be clear. We haven’t come close to solving the problems with our health care system. The Maine Republicans’ bill, PL 90, didn’t come close, nor does the Affordable Care Act.
Premium subsidies, altered payment systems, Medicaid expansion and other tinkering around the edges of a hopelessly flawed system amounts to rearranging deck chairs on the Titanic if your objective is preserving health and saving the lives of all Americans, not just the politically favored.
Our health care system is built on political favors. Some favor politicians, corporate profits, insurance companies and hospitals. Others favor teachers, unions, the elderly, public employees, the military and the poor.
The ACA is projected to leave upward of 27 million Americans uninsured, equivalent to about 20 times the population of Maine.
Maine’s two decades of health care system reform – including the elimination of medical underwriting before Barack Obama was president – consistently left some 10 percent of Maine people uninsured while continuing down the path of high-deductible coverage, as was once offered through Dirigo Health and is now offered through the ACA’s exchanges.
SERIOUS ILLNESS A FINANCIAL KILLER
Insurance with high out-of-pocket costs remains the path to individual bankruptcy for those caught catastrophically sick or injured while covered under plans best described by the wag who first said the only thing worse than being uninsured is paying to be uninsured.
Consider, please, Annie, a 60-year-old widow in Washington County, who, with a salary of $47,000, earns less than the average secondary school Maine teacher but too much to qualify for an ACA subsidy. Because the Affordable Care Act, like PL 90, permits discriminatory rating based on age and place of residence, our widow’s cheapest monthly exchange premium runs $685 for a plan with a $5,000 deductible.
Should Annie develop an expensive chronic or recurrent condition, consider her annual health care expense, which is 31 percent of her income ($8,220 in premiums plus the ACA-capped deductible and coinsurance of $6,350), and start her countdown to bankruptcy.

The Unworried Unwell

By ABIGAIL ZUGER, M.D.
She is an organized, punctual patient who makes appointments and keeps them. He drops in whenever he feels like it. Her visits are short and organized; his seem to drag on forever. The two have nothing in common — except that they both leave the office empty-handed.
Most people leave a medical encounter with something to show for it, whether tangible (prescriptions, referrals) or ephemeral (good advice). These two patients accept nothing, especially not the advice.
They both feel fine, although neither could be called well. For her, the problem is blood pressure, with readings so far into the “malignant” zone that we compulsively recheck her with different cuffs, trying to blame the equipment.
No such luck: Her results are permanently stroke-making, kidney-ruining, eyesight-threatening. She declines any form of medication. At first, we figured she was just politely taking her business elsewhere, but no, she keeps coming back. “Just want to see how I’m doing,” she says. She is always doing the same.
His problem is a rapidly accelerating H.I.V. infection. His blood tests are as alarming as her blood pressure, and as suggestive of imminent catastrophe, but he has no interest in any of the ways we propose to avert it. “Just want to see how I’m doing,” he says every few months as he saunters away, lab report tucked into his pocket.
There aren’t many medical situations where doctors’ imaginations trump those of their patients. In fact, when it comes to chronic illness, doctors are notoriously shortsighted, seldom perceiving the seismic effects pain and disability can exert on all aspects of a patient’s personality and family life. The medical problems may be clear, but their context often remains obscure.
http://well.blogs.nytimes.com/2014/03/17/the-unworried-unwell/?emc=edit_tnt_20140317&nlid=1311158&tntemail0=y

Legislature’s budget offers LePage chance to show he’s serious about Medicaid fraud

Posted March 17, 2014, at 11:40 a.m.
Gov. Paul LePage has devoted an inordinate amount of attention to welfare fraud over the past six months. Yet as he has talked about the need to crack down on abuse by welfare recipients, his administration hasn’t taken basic steps until recently to crack down on fraud and improper payments in MaineCare, Maine’s $2.5 billion public health insurance program.
In January, LePage drew attention to what he characterized as welfare fraud by releasing data compiled by the state Department of Health and Human Services showing more than 3,000 electronic benefit transfer, or EBT, transactions made at smoke shops in Maine, nearly 650 transactions made at retail establishments that primarily sell alcohol, plus several transactions at liquor stores and strip clubs over a nearly 36-month time period.
He has now introduced three bills aimed at cracking down on abuse in the welfare system. They would bar use of state-issued EBT cards outside of Maine; prohibit use of benefits on tobacco, alcohol, gambling, lottery tickets and bail; and impose an upfront work-search requirement on applicants for Temporary Assistance for Needy Families.
And while he has refused to put forward a supplemental budget package this winter to keep the state’s budget in balance, the budget package lawmakers are putting together now offers LePage a chance to show he’s serious about reining in fraud in MaineCare, the state’s Medicaid program.
Democratic budget writers have introduced a budget-balancing provision that would implement operational changes suggested by the Office of the State Auditor in a December report about the program integrity unit within DHHS’ audit division. In fact, the report shows that, while LePage has been serious about his fraud-fighting rhetoric, fraud-fighting measures in the state’s Medicaid program have been seriously lacking.
In the report, the state auditor’s office revealed DHHS fell well short of making full use of the surveillance functions included in the $205 million computer system the agency uses to manage MaineCare, the state’s Medicaid program.
“[T]he most valuable of the three tools, Report Generator, is not being utilized for the most essential surveillance activities (large scale data mining, exception processing and data analysis) on a regular basis, if at all,” Pola Buckley, state auditor, wrote in her report.
In other words, because DHHS makes little use of the Report Generator function, its auditing operation is reviewing far too few claims out of the 30 million Medicaid claims made each year for accuracy. As a result, while LePage was talking about the need to crack down on welfare fraud, DHHS wasn’t flagging nearly as many suspicious claims as it likely should have for further review.
In fact, the auditor’s report pointed out that DHHS did make regular use of Report Generator until June 2012 “because management ensured that adequate time was allowed for one specific staff member to perform this level of surveillance on an ongoing basis.” This staff member left DHHS in June 2012, and the employee’s replacement didn’t stick around for long.
“This illustrates the disadvantage of placing sole reliance on a single individual for mission critical activities,” Buckley wrote.
The budget provision being weighed by the Legislature’s budget writers would require DHHS to implement the state auditor’s recommendations: devoting sufficient staff resources to the regular, intensive surveillance that has been lacking at DHHS.
Improper payments represented as much as 9 percent of state Medicaid budgets, or $11 billion, in 2010, according to the Pew Research Center. For Maine, that proportion would amount to $88.5 million in state funds this fiscal year.

How Medicaid expansion will help a Lincoln man, UMaine student and many more like them

By Emily Cain, Special to the BDN
Posted March 17, 2014, at 1:37 p.m.
If you were presented with an opportunity to provide access to affordable health care to 70,000 fellow Mainers, would you say yes? That is at the heart of the basic question facing the Maine Legislature this session.
I have been a strong, vocal supporter of the bill, which would provide access to health care to tens of thousands of Maine residents. It will be paid for using funds that have already been set aside as part of the existing federal budget. If we don’t use them, the funds will go to another state, and we could see our rural hospitals crumble.
The economic development reasons for supporting this legislation — thousands of jobs and millions of dollars — are clear, but it’s the many Mainers who need this health care that are the biggest reason I am saying yes. These are women and men looking for a little relief to help them get by. They are hard-working individuals, and if we could just provide something as basic as the ability to see a doctor when they get sick, they will have a better chance at success.
For example, last weekend I received an email about Dwight from Lincoln. He is one of the 200 people laid off from Lincoln Paper & Tissue after the boiler explosion a few months ago. Dwight is a long-time member of the United Steel Workers, and even though he and his wife have worked hard all their lives, they are now without any real options for health care. Dwight and his family did nothing wrong. They simply are caught in a difficult situation.
While they are working hard to find new opportunities, they are left without health care. This creates an enormous burden of risk. What happens if someone in Dwight’s family gets sick, breaks a bone, or needs a new medication? They will end up requiring care or treatment that they cannot afford, so they will likely not schedule a doctor’s appointment and will end up in the emergency room.
Taking advantage of these federal funds will help Dwight and his family get back on their feet and will allow them to take one worry off their plate.
Tifani, who gave me permission to use her first name, is another example of a life on the line without Medicaid expansion. I first met Tifani at a “Take Back the Night” event at the University of Maine. Tifani has been through a lot. She has experienced sexual assault, domestic violence, substance abuse and poverty, but has persevered through it all to become sober and go to school. She is attending the University of Maine, so she can achieve her dream of becoming a counselor to help others.
I ran into Tifani in the supermarket a couple of months ago and asked how things were going. Tifani is always optimistic and positive, but something wasn’t right. She told me that on Jan. 1, she lost Medicaid coverage because she is a “non-categorical,” a childless adult who doesn’t qualify for coverage anymore. Tifani has been diagnosed with bipolar disorder, post-traumatic stress disorder, depression, ADHD and other conditions. She needs Medicaid to get the essential prescriptions that enable her to attend school, further herself and start a career where she can help others.
Tifani is not in school this semester but instead is training for a job and trying to cobble together some prescriptions with few resources, to try and avoid disaster. You’d never know her life is a daily obstacle course — because she always wears a smile. But right now, her dream of helping others has been put on hold until Maine says yes to Medicaid expansion.
These stories are not the exception; they are the reality for families across Maine. We have an opportunity as a state to help 70,000 Mainers, including 3,000 veterans, right now. Most of these Mainers have jobs and work hard but don’t have access to affordable health care.

Universal coverage remains a big deal

By Philip Verhoef, MD, PhD and Stephen Kemble, MD
KevinMD.com, March 16, 2014
Recently JAMA published a special theme issue on critical issues in U.S. health care. Among the contributors was Dr. Ezekiel Emanuel, the oncologist, bioethicist and former White House adviser on health policy.
In his article, “Going to the Moon in Health Care: Medicine’s Big Hairy Audacious Goal (BHAG),” Emanuel argues that contemporary medicine is in need of vision, an overarching, aspirational goal “like going to the moon that can make an organization — or a nation — stretch beyond what it thought was possible to achieve remarkable things.”
He asserts that medicine has no such vision today. In the past, medicine’s BHAG was universal coverage, but now, he suggests, that’s passé.
The goal of universal coverage may have been “transformative for the U.S. polity but not really for the U.S. health system,” he writes. “The Affordable Care Act may result in universal coverage, but that goal no longer has the qualities of a BHAG.”
We strongly disagree. Universal coverage remains a “Big Hairy Ambitious Goal,” especially in view of official estimates that our nation will still have 31 million uninsured people in 2024.
One has to wonder: When Emanuel argues that the goal of universal care “was not transformative for the U.S. health system,” is he speaking of corporate interests, such as the insurance industry? Clearly he does not mean physicians, a majority of whom now support government action to establish national health insurance, which would assure truly universal coverage.
Offering his own candidate for a winning BHAG, Emanuel proposes the financial goal of capping health care cost increases relative to the GDP, or in his words, “By 2020, per capita health care costs will increase no more than gross domestic product (GDP) + 0%.”
Cost control is indeed a worthy and urgent goal, given that economists are unanimous in predicting that health care costs will continue to rise under the Affordable Care Act. But the remedies that Emanuel has traditionally prescribed for this problem fall far short of what is needed.
In point of fact, a single-payer, government-funded system would be the easiest way to control health care costs — and it would also achieve the appropriate BHAG of universal coverage.




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