Experiment in Oregon Gives Medicaid Very Local Roots
By KIRK JOHNSON
SALEM, Ore. — Some say America has been homogenized, a chain-store nation bereft of regional distinction in dialect or dinner. But now this state, at the pioneer’s end of the road, is testing the idea that local community difference is alive and well, and that grass-roots leadership holds the key to fixing health care in America.
Under an agreement signed with the Obama administration last year, and just now taking shape, Oregon and the federal government have wagered $1.9 billion that — through a hyper-local focus on Medicaid — the state can show both improved health outcomes for low-income Medicaid populations and a lower rate of spending growth than the rest of the nation. If Oregon fails on either front, the consequences are grave, potentially tens of millions of dollars in penalties a year, bleeding a state budget still wounded from recession.
Fifteen Community Advisory Councils have been established across the state, charged with setting local goals. One of them, around the college town of Eugene, will take aim starting July 1 at smoking by pregnant women, hoping to cut neonatal costs through a system of rewards, like gift cards at the doctor’s office for women who go tobacco free. Another council, in Portland, is focusing on something that might sound ho-hum in health care, but that local leaders have identified as a care-and-cost driver: mold in low-income housing. Another group, in an economically depressed rural swath in the state’s center, will try getting people out of their cars, aiming for a payoff in reduced cardiovascular care that is both measurable and relatively quick. Hands-on work with patients is common to all the efforts, including one that is using “patient guides,” to talk through care options with people who stack up in emergency rooms with often routine medical problems.
Other states, notably Massachusetts and Vermont, are experimenting with new models as well, mainly through regulation. But Oregon’s way — one ear to the ground, health care with local input — has always been different, and the Medicaid experiment, health care experts said, has now sharpened those distinctions to an incisive edge.
“We’ve got essentially 15 experiments going around Oregon,” said Gov. John Kitzhaber, who was an emergency room physician before entering public life, and still signs his official correspondence with an M.D. next to his name. “They all have to meet the same metrics in outcome and quality,” he added, but after that the newCoordinated Care Organizations, to which the advisory councils report, are largely being left to their own devices in finding a way that makes sense for them.
Southern states fight Medicaid growth
Governors decry the growth of government programs but are considering a private solution.
By TONY PUGH McClatchy Newspapers
BILOXI, Miss. - Michael White's high blood pressure is acting up again.
The 51-year-old casino janitor has recurring seizures and recently awoke in an ambulance after passing out at a bus stop.
"It doesn't hit me suddenly," White said. "It creeps up on me. I get this feeling like I'm outside of my own body."
If White had insurance, he'd be under the care of a primary physician and taking medications regularly. But he can't afford job-based health insurance on his $8-an-hour wage and he earns too much to qualify for Medicaid, the state-federal health plan for poor people and those with disabilities.
So White takes his place in a growing line of uninsured patients outside the Bethel Free Health Clinic on the grounds of a federal housing project in Biloxi, Miss. It's his off day, so he's in no rush. He just wants to be one of the dozen or so patients lucky enough to see a doctor.
White is one of 300,000 Mississippians who'd likely qualify for Medicaid next year when the health care overhaul extends coverage to adults who earn up to 138 percent of the federal poverty level. That's nearly $16,000 a year for an individual in 2013, or roughly $32,500 for a family of four.
But Mississippi and eight other Southern states, all led by Republican governors, have decided not to implement the Medicaid expansion, even though the federal government has pledged to pay all medical costs for the newly eligible enrollees in 2014, 2015 and 2016 and no less than 90 percent of their costs thereafter.
All of them -- Tennessee, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Louisiana, Texas and Oklahoma -- say they can't afford it under those terms.
The wall of Southern opposition is one of the last major obstacles to President Obama's goal of universal health coverage for all Americans. If it remains intact, nearly 5 million of the newly eligible won't have Medicaid coverage in 2022, according to estimates by the nonpartisan Kaiser Family Foundation, a health care research group.
Besides shared borders and conservative political leadership, most of the nine states have something else in common: By a host of measures -- from obesity to infant mortality -- all but North Carolina and Georgia are among the unhealthiest in the nation, according to the 2012 edition of America's Health Rankings.
High poverty typically has dragged down the Southern rankings. So have risky health choices, such as poor diet and smoking. But so can the impact of public policy decisions, such as whether the social benefits of the Medicaid expansion are worth the costs.
A new report by the philanthropic Robert Wood Johnson Foundation finds the nine anti-expansion Southern states among the 21 that would benefit most from broader Medicaid eligibility, based on their higher levels of working poor adults who struggle with medical bills.
"I think it's very foolish from a health perspective, from an economic perspective, for these states to be turning this down," said Joan Alker, a co-executive director of the Center for Children and Families at Georgetown University. "It's playing politics in the worst sense of the word. There are no big interests that are against this. The hospitals are for it. The managed care industry is for it. Most of the employer groups are for it. The opposition is purely ideological. It's the tea party faction of the Republican Party."
The nine Southern anti-expansion states aren't the only opponents. Republican governors in six other states -- Maine, Pennsylvania, Michigan, South Dakota, Iowa and Idaho -- have said they won't participate, either, although pressure is mounting for them to reconsider.
The Republican governors of Florida and Arizona already have dropped their opposition.
Some states such as Arkansas, Oklahoma, Tennessee and Nebraska are inquiring whether health care overhaul dollars may be used to expand private coverage rather than Medicaid.
"From a social or humanitarian perspective, you could argue Medicaid expansion is a winner. But from a purely financial perspective, it's clearly a loser," said Charles Blahous, a senior research fellow at the Mercatus Center, a market-oriented research center at George Mason University in Virginia.
Next to education, Medicaid is the largest expenditure for most states, and many Republican governors fear that an expanded Medicaid base would crowd out spending for other vital services.
"I continue to believe that Mississippi should not expand Medicaid because doing so would result in tax increases for hardworking Mississippians or cuts to critical spending in areas like education, public safety and economic development," Gov. Phil Bryant said in a recent statement.
From 2003 to 2012, Mississippi spent more than $9 billion on Medicaid and the state's poor health indicators have remained unchanged or worsened, Bryant spokesman Mick Bullock said.
"The data show that throwing money at the issue -- money the state does not have -- is not working," Bullock said in an email. "So why would we throw even more money we don't have at the issue and expect some miraculous change in outcomes?"
Instead, he said, Bryant has focused on promoting personal health responsibility, recruiting more doctors and fighting teen pregnancy to reduce low-birth-weight babies.
Experts say all expansion states probably will see their Medicaid rolls grow as working poor adults stop paying for job-based health coverage when they realize they now qualify for Medicaid.
States also will incur additional costs due to a likely enrollment spike among adults who are currently eligible for Medicaid but aren't signed up.
Overall, Kaiser estimates that if the nine anti-expansion Southern states dropped their opposition, their Medicaid spending would rise 3 to 7 percent from 2013 to 2022. But those spending hikes would be partially offset by savings for hospital indigent care, since more now-uninsured patients would have Medicaid.
Higher state spending on Medicaid also would bring states more than 10 times as many federal dollars, which could bolster the state economy and help create jobs.
By 2022, Kaiser estimates, while Mississippi would spend an additional $1 billion to expand Medicaid coverage, the federal government would pay $14.5 billion of the costs. Other states would enjoy similar windfalls.
Blahous countered that even though the states' costs are small, "it's a fiscal push in the wrong direction right at a time when the states can't very well afford it."
Maine needs a rockstar physician leader
Posted April 11, 2013, at 11:30 a.m.
If there is a Mick Jagger of medicine, it is Don Berwick, M.D., America’s health care safety and reform rockstar. More than any other American physician, he has led us to improve safety in health care and led the debate about transforming the American health-care system into something that is just, accessible and affordable for all.
As a result, while I’ve gotten to work a lot of nights, he has been knighted by the queen of England. If there was a Health Care Hall of Fame, he would be in the lobby exhibit, next to the inventors of penicillin and discoverers of DNA.
It should therefore come as no surprise to anyone that when Dr. Berwick came to Maine recently, some 700 of Maine’s health care leaders listened to him speak for an hour, gave him a standing ovation, and would have marched him out in a sedan chair on their shoulders to be anointed King of Maine if given permission to do so. If he’d asked, I’d have personally hot waxed his car.
Maine needs a Dr. Don Berwick, a physician leader with statewide prominence whose sole purpose is to help the rest of us accelerate Maine’s journey toward an affordable health care system that provides care for all Mainers. That physician needs to be dedicated to facilitating our difficult discussions, educating the public and the politicians about the truth behind health reform rhetoric and bringing together the health care stakeholders to compromise and do other difficult work in ways sometimes only a physician can.
Maine has many extraordinary physician leaders, but they are often limited in what they can do either by their stance on issues, their obligations to help run their organizations, or by the competing agendas of those organizations. All of those constraints are legitimate, none completely prevents any of Maine’s current physician leaders from credibly contributing to efforts to improve health care in Maine (and most actively do), but those constraints limit what physician leaders can do for us.
What’s the perfect Dr. Don or Donna Berwick for Maine? Some characteristics are obvious: he or she must be a gifted communicator, be the Ronald Reagan of realpolitik, have the hide of a rhino and more gonads than God gave horses, and be as comfortable in a bait shop as in a boardroom. That’s just to start.
Our Dr. Don or Donna needs to be a health care policy wonk — as boring as that sounds, you have to understand health care policy and policy options to be able to work on them and explain them to others. You must be able to translate simple sentiments such as “health care for all” or “Let the free market work in health care” into workable and working policy. In order to do this job, you have to understand health insurance, brain-deadening topics such as community ratings, and that “CMS,” in the context of health care discussions, stands for Centers for Medicare and Medicaid Services, not Compact Muon Solenoids (the former runs Medicare in Washington, D.C., the latter is a particle physics detector in Switzerland).
He or she needs to be emancipated from the constraints imposed by working for an existing health care organization, because working for one would take up most of Dr. Don or Donna’s time, limit involvement in the reform work or limit what he or she can say or do. At the same time, a credible physician broker of health care issues must understand the diverse and legitimate perspectives of those same health care stakeholders, seek to find the overlap of their needs and pursue that path forward.
Austerity and the Unraveling of European Universal Health Care
By Adam Gaffney, M.D.
Dissent, Spring 2013
A great human disaster is now unfolding in the many Eurozone countries that have agreed to slash spending, wages, and living standards to meet the demands of fiscal austerity. One facet of this story that has received far too little attention, however, is the effect of these measures on the health of these nations.
Austerity derives from the Greek austeros, for harsh or severe; but, in the area of health care, it has veered into the cruel: health expenditures dwindle, hospital budgets shrink, health care needs rise, and human suffering worsens. Suicide is on the rise; basic hospital supplies are missing; potentially life-saving surgeries are delayed; the rate of new HIV infections increases; drug shortages are ubiquitous; the prevalence of mental illness spikes. And these are just the obvious results.
The effects of austerity on health care are both immediate and long-reaching. Deep cuts in public health spending clearly exacerbate the suffering caused by the prolonged economic depression. At the same time, the cuts contribute to a more pernicious, slow-moving, and decidedly political process.
For austerity is being wielded to initiate the unraveling of one of the great and humane achievements, indeed inventions, of modern Europe: the universal health care system. To understand why this is the case, let us take a brief look at how Europe came to have what it has today, before we return to the dangers of the present course.
Although the idea that all human beings, whether rich or poor, deserve health care can in some senses be traced to antiquity, it was only in the late nineteenth century, under the combined economic and political pressures of industrialization, working-class organization, and left-wing mobilization, that governments enacted forms of “social insurance.”
Under the government of Otto von Bismarck, Germany was the first to set up a system of “compulsory” health insurance, which obligated industrial employers to provide insurance for their low-paid workers. The health insurance system was funded and administered by workers and employers through the so-called “sick funds.” The Bismarckian system is typically credited with initiating the European tradition of universal health care, and it certainly provided a model for other countries, as with Britain in 1911 and France in 1928.
The truly universal health care system, however, was in general a post–Second World War development and was usually the consequence of the work of labor and left-wing parties. Most Western European nations took one of two paths: gradual expansion of coverage until the system could fairly be called universal or the more abrupt creation of a truly socialized national health service. In Great Britain, the 1946 passage of the National Health Service Act brought about the British National Health Service. Financed through general taxes, it provided health care as a right, with medical services free at the point of service.
Most other nations, however, took a more incremental path. France, for instance, built upon its 1928 National Health Insurance system, passing successive pieces of legislation that covered larger and larger proportions of the population until, in 2000, the remaining 1 percent of the nation that was uninsured received coverage. Germany likewise built upon its nineteenth-century Bismarckian system to create a system of truly universal coverage.
Greece was relatively late to the game. In 1934, it established a Social Security Organization that covered urban and industrial workers, which was expanded to agricultural workers in 1961. But it was the 1983 legislation of the newly elected Socialist Party that put into place a National Health Service (NHS), founded on the principles of universal access. Along similar lines, Spain built upon a 1942 health insurance law with successive expansions of coverage. This culminated in the 1980s, when through a number of measures the Spanish Socialist Party converted the health care system to a tax-based system with universal access and a largely public provision of care.
No doubt, as they entered the twenty-first century, all of these systems had their own flaws, their own inefficiencies, even their own inequities and injustices. But for the first time in human history, the poorest individuals could avail themselves of some of the most advanced medical care in the world without worry that their illness would bankrupt their family, and without the stigma of charity. A true right to health care had been legislated into existence. Universal health care, from this perspective, represented a truly massive and historical achievement.
http://www.pnhp.org/print/news/2013/april/austerity-and-the-unraveling-of-european-universal-health-care
Dissent, Spring 2013
A great human disaster is now unfolding in the many Eurozone countries that have agreed to slash spending, wages, and living standards to meet the demands of fiscal austerity. One facet of this story that has received far too little attention, however, is the effect of these measures on the health of these nations.
Austerity derives from the Greek austeros, for harsh or severe; but, in the area of health care, it has veered into the cruel: health expenditures dwindle, hospital budgets shrink, health care needs rise, and human suffering worsens. Suicide is on the rise; basic hospital supplies are missing; potentially life-saving surgeries are delayed; the rate of new HIV infections increases; drug shortages are ubiquitous; the prevalence of mental illness spikes. And these are just the obvious results.
The effects of austerity on health care are both immediate and long-reaching. Deep cuts in public health spending clearly exacerbate the suffering caused by the prolonged economic depression. At the same time, the cuts contribute to a more pernicious, slow-moving, and decidedly political process.
For austerity is being wielded to initiate the unraveling of one of the great and humane achievements, indeed inventions, of modern Europe: the universal health care system. To understand why this is the case, let us take a brief look at how Europe came to have what it has today, before we return to the dangers of the present course.
Although the idea that all human beings, whether rich or poor, deserve health care can in some senses be traced to antiquity, it was only in the late nineteenth century, under the combined economic and political pressures of industrialization, working-class organization, and left-wing mobilization, that governments enacted forms of “social insurance.”
Under the government of Otto von Bismarck, Germany was the first to set up a system of “compulsory” health insurance, which obligated industrial employers to provide insurance for their low-paid workers. The health insurance system was funded and administered by workers and employers through the so-called “sick funds.” The Bismarckian system is typically credited with initiating the European tradition of universal health care, and it certainly provided a model for other countries, as with Britain in 1911 and France in 1928.
The truly universal health care system, however, was in general a post–Second World War development and was usually the consequence of the work of labor and left-wing parties. Most Western European nations took one of two paths: gradual expansion of coverage until the system could fairly be called universal or the more abrupt creation of a truly socialized national health service. In Great Britain, the 1946 passage of the National Health Service Act brought about the British National Health Service. Financed through general taxes, it provided health care as a right, with medical services free at the point of service.
Most other nations, however, took a more incremental path. France, for instance, built upon its 1928 National Health Insurance system, passing successive pieces of legislation that covered larger and larger proportions of the population until, in 2000, the remaining 1 percent of the nation that was uninsured received coverage. Germany likewise built upon its nineteenth-century Bismarckian system to create a system of truly universal coverage.
Greece was relatively late to the game. In 1934, it established a Social Security Organization that covered urban and industrial workers, which was expanded to agricultural workers in 1961. But it was the 1983 legislation of the newly elected Socialist Party that put into place a National Health Service (NHS), founded on the principles of universal access. Along similar lines, Spain built upon a 1942 health insurance law with successive expansions of coverage. This culminated in the 1980s, when through a number of measures the Spanish Socialist Party converted the health care system to a tax-based system with universal access and a largely public provision of care.
No doubt, as they entered the twenty-first century, all of these systems had their own flaws, their own inefficiencies, even their own inequities and injustices. But for the first time in human history, the poorest individuals could avail themselves of some of the most advanced medical care in the world without worry that their illness would bankrupt their family, and without the stigma of charity. A true right to health care had been legislated into existence. Universal health care, from this perspective, represented a truly massive and historical achievement.
http://www.pnhp.org/print/news/2013/april/austerity-and-the-unraveling-of-european-universal-health-care
Medical Care, Aided by the Crowd
By NICOLE LaPORTE
TWO years ago, Chase Adam, a Peace Corps volunteer in Costa Rica, was riding a bus through a town called Watsi, when a woman got on board asking for money. Her son, she said, needed medical attention and she couldn’t pay for it. As the woman walked through the bus, she showed people a copy of her son’s medical record. Mr. Adam, who is now 26, noticed that nearly everyone donated money.
The experience gave him an idea.
“I thought it’d be really cool if there was a Kiva for health care,” he said, referring to the crowdfunding Web site that allows donors to provide microloans to entrepreneurs in developing countries.
Over the next several months, he devoted his free time to creating a business plan for an online start-up that he named after the town where he got the idea. Watsi, which started last August, lets people donate as little as $5 toward low-cost, high-impact medical treatment for patients in third-world countries.
The procedures range from relatively simple ones like fixing a broken limb to more complicated surgery — say, to remove an eye tumor. But the treatments generally have a high likelihood of success and don’t involve multiple operations or long-term care.
Operated out of an apartment in Mountain View, Calif., Watsi works with nonprofit health care providers in 13 countries, including Cambodia, Nepal, Guatemala and Ethiopia. The providers identify patients meeting Watsi’s criteria; the providers themselves have been vetted by Watsi and its medical advisory team, which includesDr. Mitul Kapadia, director of the physical medicine and rehabilitation program at Benioff Children’s Hospital of the University of California, San Francisco, and a half-dozen other doctors and medical professionals.
The profiles of the patients are posted on the Watsi site, and the online community begins donating. Medical care is given when the health partners decide that it is “medically appropriate,” Mr. Adam said. Sometimes that care is given before money is raised on Watsi, and the profile remains on the site so that fund-raising can continue. Watsi maintains an operational reserve for this purpose, he said.
Watsi represents the next generation of charities dependent on online donors, evolving the model started by sites like Kiva. With just a few mouse clicks, Kiva users, say, are able to lend money to a restaurant owner in the Philippines — and to examine her loan proposal and repayment schedule, to read about her and see her photograph.
Charities have long recognized the importance of photographs and narratives in soliciting donations. Watsi’s Web site, too, shows vivid images of its patients, and tells their stories. For example, a 9-year-old girl in Myanmar who needs eye surgery has had to miss a year of school because of her condition.
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