Medicaid Growth Could Aggravate Doctor Shortage
By ABBY GOODNOUGH
SAN DIEGO — Dr. Ted Mazer is one of the few ear, nose and throat specialists in this region who treat low-income people on Medicaid, so many of his patients travel long distances to see him.
But now, as California’s Medicaid program is preparing for a major expansion under President Obama’s health care law, Dr. Mazer says he cannot accept additional patients under the government insurance program for a simple reason: It does not pay enough.
“It’s a bad situation that is likely to be made worse,” he said.
His view is shared by many doctors around the country. Medicaid for years has struggled with a shortage of doctors willing to accept its low reimbursement rates and red tape, forcing many patients to wait for care, particularly from specialists like Dr. Mazer.
Yet in just five weeks, millions of additional Americans will be covered by the program, many of them older people with an array of health problems. The Congressional Budget Office predicts that nine million people will gain coverage through Medicaid next year alone. In many of the 26 states expanding the program, the newly eligible have been flocking to sign up.
Community clinics, which typically provide primary but not specialty care, have expanded and hired more medical staff members to meet the anticipated wave of new patients. And managed-care companies are recruiting doctors, nurse practitioners and other professionals into their networks, sometimes offering higher pay if they improve care while keeping costs down. But it is far from clear that the demand can be met, experts say.
In California, with the nation’s largest Medicaid population, many doctors say they are already overwhelmed and are unable to take on more low-income patients. Dr. Hector Flores, a primary care doctor in East Los Angeles whose practice has 26,000 patients, more than a third of whom are on Medicaid, said he could accommodate an additional 1,000 Medicaid patients at most.
“There could easily be 10,000 patients looking for us, and we’re just not going to be able to serve them,” said Dr. Flores, who is also the chairman of the family medicine department at White Memorial Medical Center in Los Angeles.
Obamacare’s Secret Success
By PAUL KRUGMAN
The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the “affordable” bit wasn’t just about subsidizing premiums. It was also supposed to be about “bending the curve” — slowing the seemingly inexorable rise in health costs.
Much of the Beltway establishment scoffed at the promise of cost savings. The prevalent attitude in Washington is that reform isn’t real unless the little people suffer; serious savings are supposed to come from things like raising the Medicare age (which the Congressional Budget Office recently concluded would, in fact, hardly save any money) and throwing millions of Americans off Medicaid. True, a 2011 letter signed by hundreds of health and labor economists pointed out that “the Affordable Care Act contains essentially every cost-containment provision policy analysts have considered effective in reducing the rate of medical spending.” But such expert views were largely ignored.
So, how’s it going? The health exchanges are off to a famously rocky start, but many, though by no means all, of the cost-control measures have already kicked in. Has the curve been bent?
The answer, amazingly, is yes. In fact, the slowdown in health costs has been dramatic.
O.K., the obligatory caveats. First of all, we don’t know how long the good news will last. Health costs in the United States slowed dramatically in the 1990s (although not this dramatically), probably thanks to the rise of health maintenance organizations, but cost growth picked up again after 2000. Second, we don’t know for sure how much of the good news is because of the Affordable Care Act.
Still, the facts are striking. Since 2010, when the act was passed, real health spending per capita — that is, total spending adjusted for overall inflation and population growth — has risen less than a third as rapidly as its long-term average. Real spending per Medicare recipient hasn’t risen at all; real spending per Medicaid beneficiary has actually fallen slightly.
Rooting for Failure
By TIMOTHY EGAN
I just spent 15 minutes on my local health care exchange and realized that I could save a couple hundred dollars a month on my family’s insurance. Of course, I live in Washington State, which has a very competitive market, a superbly functioning website and no Koch-brothers-sponsored saboteurs trying to discourage people from getting health care.
California is just as good. It’s enrolling more than 2,000 people a day. New York is humming as well. And Kentucky, it’s the gold standard now: More than 56,000 people have signed up for new health care coverage -- enough to fill a stadium in Louisville.
This is terrible news, and cannot be allowed to continue. If there’s even a small chance that, say, half of the 50 million or so Americans currently without heath care might get the same thing that every other advanced country offers its citizens, that would be a disaster.
But not to worry. The failure movement is active and very well funded. You probably know about the creepy Uncle Sam character in ads financed by the Koch brothers. Sicko Sam is seen leering over a woman on her back in a hospital exam room, her legs in stirrups. This same guy is now showing up on college campuses, trying to get young people to opt out of health care. On some campuses, he plies students with free booze and pizza -- swee-eeet!
The Republican Party started a failure campaign earlier this year, but then the strategy got sidetracked in a coercive government shutdown that cost us all $24 billion or so. With the disastrous rollout of the federal exchange, Republicans now smell blood. A recent memo outlined a far-reaching, multilevel assault on the Affordable Care Act. Horror stories -- people losing their lousy health insurance -- will be highlighted, and computer snafus celebrated.
Ron Paul, the nuttier of the two political Pauls, recently suggested to a crowd in Virginia that “nullification” of the health care law might be the best way to kill it. I’m not sure what he meant by that, but it sounds illegal.
Health care website navigators report increased success in Maine
With a deadline looming this weekend, federal officials are cautious to avoid inflating expectations.
WASHINGTON — Groups working to help Mainers navigate the Affordable Care Act are reporting steady improvements on the problem-plagued federal website, but said glitches and error messages still occasionally slow the sign-up process.
That mixed bag is the reality that the Obama administration faces this week as it rushes to meet a self-imposed Saturday deadline for ensuring that the vast majority of site visitors will have success using HealthCare.gov.
But federal officials are also treading carefully to avoid inflating expectations, in part out of fear that a flood of users on Dec. 1 could crash the site and create more political headaches surounding the Affordable Care Act.
“November 30th does not represent a relaunch of HealthCare.gov,” Julie Bataille, spokeswoman for the Centers for Medicare and Medicaid Services, said Wednesday. “It is not a magical date,” and the agency will continue to make improvements “in December and beyond,” Bataille said.
Just 271 Maine residents successfully signed up for health insurance through the online marketplace between Oct. 1 and Nov. 2. Nationwide, 106,185 people selected health insurance plans during the first 33 days, well shy of the 500,000 that administration officials had projected would enroll at first. The majority of those signed up through state-run websites, however, not the federally run website used by residents of Maine and 35 other states.
Contract is signed with conservative Medicaid consultant. Maine should get its money’s worth
osted Nov. 29, 2013, at 10:18 a.m.
There’s cause for concern in several aspects of a recent announcement that Maine’s health and human services department is paying an outside firm $925,000 to undertake a comprehensive review of the state’s Medicaid and public welfare programs.
Democratic skeptics have focused on the conservative credentials of the firm’s head and said the final product will simply back up Gov. Paul LePage’s past, critical rhetoric on Medicaid and welfare. Gary Alexander led Rhode Island’s Executive Office of Health and Human Services under Republican former Gov. Donald Carcieri before serving as secretary of Pennsylvania’s Department of Public Welfare in Republican Gov. Tom Corbett’s administration.
We don’t approve of the LePage administration awarding the contract to the Alexander Group without first publishing a request for proposals and then selecting the most competitive bid. And the cost of the study has rightly raised eyebrows.
But Democrats should also agree with Republicans and the LePage administration that Maine’s $2.5 billion Medicaid program is in need of reform and could benefit from an outside review. And with the contract already signed, lawmakers should focus on making sure Maine gets its money’s worth from Alexander.
The LePage administration considers Alexander to have unique expertise to help it plan and carry out an overhaul of the Department of Health and Human Services and the programs it administers. In Rhode Island, Alexander successfully obtained a “global waiver” from the federal government that allowed the state additional flexibility in designing its Medicaid program. Maine Health and Human Services Commissioner Mary Mayhew and LePage have often spoken about a need for additional flexibility and a “global waiver” from the federal government to administer Medicaid largely as they see fit.
While Alexander’s qualifications would seem to fit the bill, it’s worth noting that he has generated his share of controversy.
Statins by Numbers
By JASON KARLAWISH
PHILADELPHIA — MEDICINE is having its moneyball moment.
In his book “Moneyball,” Michael Lewis chronicled how the Oakland A’s, in order to identify the best predictors of a winning baseball team, used a highly formulaic, statistics-driven approach in place of the traditional assessments of coaches and managers. This month, in a similar spirit, the American Heart Association and the American College of Cardiology issued new, numerically driven guidelines for the treatment of cardiovascular disease.
These guidelines recommend that doctors no longer use a patient’s LDL cholesterol level to decide whether to prescribe a cholesterol-lowering statin, and instead rely on the results of a web-based “risk calculator” — the Omnibus Risk Estimator — that determines a person’s chances of suffering atherosclerotic cardiovascular disease in 10 years.
Into the Omnibus Risk Estimator you enter nine variables, including age, sex, total cholesterol and systolic blood pressure, and the estimator returns your 10-year and lifetime risks of stroke, heart attack or death from cardiovascular disease. With these data, you and your doctor decide whether to invest in a lifetime of daily therapy with a statin pill.
This is a revolutionary shift. Once upon a time, medicine was a discipline based on the nuanced diagnosis and treatment of sick patients. Now, Big Data, networked computers and a culture obsessed with knowing its numbers have moved medicine from the bedside to the desktop (or laptop). The art of medicine is becoming the science of an insurance actuary.
It is also becoming big business. The developers of the World Health Organization’s FRAX calculator, which calculates your 10-year risk of major osteoporotic fracture, licensed it to General Electric, a manufacturer of bone-density measurement devices.
What is the problem with grounding medical practice in the cold logic of numbers? In theory, nothing. But in practice, as decades of work in fields like behavioral economics have shown, people — patients and doctors alike — often have a hard time making sense of quantified risks. Douglas B. White, a researcher at the University of Pittsburgh, has shown that the family members of seriously ill patients, when presented with dire prognoses, typically offer quite variable understandings not only of qualitative terms such as “extremely likely” but also of quantitative terms such as “5 percent.” We like our numbers, but despite our desire for better information and an ethic of “informed consent,” we don’t know how to use them.
Why Health Care Isn't Just About Insurance
Wednesday, 27 November 2013 10:47By Maya Schenwar, Truthout | Opinion
In the past year, I spent approximately $5,128 to suppress my neurons from spontaneously firing at odd angles across my left temporal lobe, setting off waves of ethereal light and frantic convulsions, delivering a shadowy vision of my own death or a long-buried memory from childhood, knocking me to the ground in the midst of a workday and profoundly disrupting my life.
I live with epilepsy, a disorder that takes as many lives as breast cancer every year and increases one's chances of sudden death by 24 times, compared with the general US population. Fortunately, I also live with decent insurance.
Had I lacked that coverage, my last year of treatment would've cost me tens of thousands of dollars. For a person with more severe epilepsy, that number could skyrocket into the hundreds of thousands, greatly exceeding most Americans' range of affordability. The Affordable Care Act doesn't eliminate the problem: Because 26 states have rejected Medicaid expansion, many of thepoorest people are left in the lurch - or the emergency rooms, where they're usually treated in a hurry, without follow-up. A post-seizure ER check-in simply won't do the trick for epilepsy patients, who need a consistent, monitored regimen that will prevent them from having seizures in the future.
Moreover, plenty of folks who have insurance still miss the epilepsy treatment boat. Paying $5,128 is rough on my bank account. But for many, that sum - steep copays plus high-priced brand-name drugs - could mean forgoing adequate treatment, endangering their health and their survival.
Epilepsy's socioeconomic disparities aren't confined to the issue of health insurance. Even poor people who have insurance are likelier than higher-income people to have epilepsy, and their seizures are more likely to go uncontrolled. Recent research indicates that African-Americans with epilepsy are also at higher risk. Although high-quality medical treatment for all would mark an immense step toward epilepsy progress, drugs, doctor's appointments and surgeries clearly aren't the only variables in the recovery equation.
This reality hit home for me in December 2012. In the wake of a car accident, my seizures re-erupted, rendering me neurologically scrambled, headache-ridden and barely able to leave the house. Although I underwent a flurry of tests resulting in a boosted prescription (which I was able to fill thanks to my aforementioned decent insurance), it became clear that I also needed to re-evaluate the way I led my life. At this point, I was sleeping about three and a half hours per night, and spending most of the remaining 20.5 hours biting my nails over a vast inventory of problems, both real and imagined. Stress and intense worrying can trigger seizures, especially when the worrier is beset with fatigue. Consequently, after some inward squabbling, I took a several-weeks-long medical leave from work.
During that leave, I was able to retain my benefits and was guaranteed a job upon my return. Meanwhile, I adjusted to my new medication regimen, confronted my seizure triggers head-on, modified my diet, and slept, and slept, and slept. Gradually, my flare-ups eased.
For stress-related conditions like epilepsy, true recovery requires mental and physical space. This is especially true for people living in poverty, for whom severe psychological strain tends to be the norm. (An author of a recent Princeton study on the topic told The Washington Post, "Picture yourself after an all-nighter. Being poor is like that every day.") Structural racism, too, has been widely shown to take a palpable physiological and psychological toll. In a recent, highly publicized study in Sociological Inquiry, five times more black participants as white participants experienced emotional stress, and six times as many experienced physical stress.
Health Care Site Rushing to Make Fixes by Sunday
By SHARON LaFRANIERE, ERIC LIPTON and IAN AUSTEN
As the Obama administration’s weekend deadline for a smoothly functioning online marketplace for health insurance arrives, more than a month of frantic repair work is paying off with fewer crashes and error messages and speedier loading of pages, according to government officials, groups that help people enroll and experts involved in the project.
But specialists said weeks of additional work lie ahead, including a major reconfiguration of the computer hardware, if the $630 million site, Healthcare.gov, is to accommodate the expected flood of people seeking to buy health insurance. Without the additional changes, experts predict, the website may continue to crash during periods of peak use.
Beyond the prospect of potential delays for consumers, insurers warn that problems remain in the invisible “back end” that transmits enrollment information to them. That data has been plagued by inaccuracies, insurers say. Administration officials have been unwilling to disclose the error rate.
As late as Wednesday, the site still continued to slow down when 30,000 users tried to log on simultaneously, according to project specialists. A batch of hardware upgrades and software fixes scheduled for this weekend, administration officials say, will allow the site to handle 50,000 simultaneous users, as promised, by Dec. 1, which is Sunday.
The Health and Human Services Department announced that the site would be shut down for 11 hours on Friday night to put those upgrades into place, on top of the usual four-hour timeout for maintenance on Saturday night.
Although the administration has postponed a December marketing campaign, fearful that the site would collapse under a surge in traffic, five weeks of repair work have clearly made the exchange better. From last Sunday to Tuesday, nearly 20,000 users managed to enroll in insurance plans, the most for a three-day period, according to people familiar with the project. By comparison, fewer than 27,000 users picked an insurance plan on the federal site in the entire month of October.
And pages that once took an average of eight seconds to load now show up in a fraction of a second. The rate at which a user sees an error message has also dropped from about 6 percent to 0.75 percent.
But the pace of enrollment must pick up drastically if the administration is to meet its target of signing up seven million people by the end of March, the number that insurers say they need to spread risks and keep prices down. While some states that built their own sites are making better progress enrolling people, applicants in 36 states, with two-thirds of the nation’s population, depend on the federal site.
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