Category Archives: Bad solutions for the uninsured

Fake Medicaid or No Medicaid? Don’t Buy It


Governor Bentley has persisted in failing to offer hope for the uninsured poor in Alabama, through a Medicaid Expansion or otherwise. Behind the scenes, various insiders are passing rumors not to worry—he really will do it… after the primary. Or after the general election. If the rumors are true, the plan is to apply for a “private option” style Medicaid waiver similar to programs in Arkansas and a handful of other states, and he is making people wait for his personal political interests, without regard to their present needs. If the rumors are not true, one can imagine he might benefit from public perception that he is simultaneously accepting and declining the Expansion.

One of the candidates in the Democratic Primary, Parker Griffith, got supporters by promising to expand Medicaid. Now he has revealed his grand idea: private option Medicaid, the same type of program Governor Bentley is/is not planning.

Except it isn’t such a grand idea.

Private option Medicaid is Fake Medicaid. One writer called it “Conservatives’ Awful New Medicaid Ploy”—and it isn’t even conservative. It is just a way to siphon off federal and eventually state money into private pockets, away from providing needed healthcare. Instead of simply directly adding people to the existing state Medicaid program, to be funded mostly by federal money and with generally about 3% overhead, it uses those funds to purchase private insurance at significantly higher overhead and for profit. It’s a skillful bit of flim-flammery to convince conservatives that this is anything but a scam and liberals that it is the only choice—fake Medicaid or none.

These “new” – what scam is ever really new?—programs don’t just eat up healthcare funds.  They have to limit health services to turn a profit. How?

By charging people with no money premiums and/or co-pays, so they will be discouraged from applying at all or seeking care if they do. You may think $35 a month for a household premium isn’t much—if you do, you aren’t likely poor enough to qualify for Medicaid. Even $3 can mean the difference between filling a prescription and skipping it.

By adding “wellness programs” of no proven cost-savings, an additional time charge for workers without sick leave. See page xix of a large analysis on workplace wellness programs by Rand: “[w]e estimate the average annual difference to be $157, but the change is not statistically significant.” This doesn’t mean $157 isn’t significant—it means the $157 “difference” is most likely due to chance instead of a difference and could just as easily be a $157 loss.

By charging a fine for coming to the ER for a non-emergency, instead of making sure all patients have 24-7 access to primary care and developing better ways to triage and redirect patients to appropriate settings. By charging $50 for the crime of being sick enough to be admitted to the hospital.

Already, just a few months in, Arkansas is finding out how much this fake Medicaid is going to cost them.  Are we really looking to follow their footsteps? If you haven’t read Confessions of an Economic Hitman, I highly recommend it. I suspect we are currently the target of the same strategy used to bring developing countries into debt, except this time it is on our own soil.

Both Bentley and Griffith were practicing doctors. I find it hard to believe they are completely unaware of the harm a private option Medicaid could do to patients and our state’s economy. Even so, it may be worth your time to tell them.

For those who have decided the fake option is better than nothing, it might not be so. Once people get their Medicaid cards, they will no longer be able to visit free clinics, get charity care, or apply for patient assistance programs for medicines. I am not sure how to predict whether on balance more people will be better off. I can say with a fair amount of certainty that a good many people will be actively harmed. Sometimes a false front for a good thing is actually far worse than nothing.

Fortunately, there is no reason to believe the choice is between fake Medicaid and nothing. We have more options. We can support candidates who are supporting the real Medicaid Expansion. Democrats could consider taking a look at Kevin Bass in the primary. Those who are determined to support Griffith could put pressure on him to drop the fake Medicaid idea. Republicans could put Bentley on the spot, and decide not to support someone who is/is not doing—hasn’t done— anything specific to address un-insurance and its economic damage to hospitals around the state. You can speak up against wasting funds in a fake program.

In that same vein, there’s no real reason we need to keep putting ourselves in the position of choosing between only two parties, between private insurance and nothing, or between all manner of pretend reforms and nothing. Some of you reading this are donating substantial sums or time to a lose-lose game. Are you getting what you’ve paid for?

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Filed under Alabama Politics, Bad solutions for the uninsured, Medicaid

New Rules– Critical Update on Pre-existing Conditions


Note:  this post has been edited:  please see  https://pippaabston.wordpress.com/2012/11/21/new-rules-on-pre-existing-conditions-take-two/ for the edited version. Very quick, unpolished post today, because I have to leave for rounds in a few minutes and just found out about this late last night.  Will be with family on Thanksgiving and no time to get to it, but you might want to send in your comment to Health and Human Services, and it looks like there is a 30 day deadline.

HHS has issued their proposed rule for how the changes on pre-existing conditions will take place in 2014.  Please read it, at least the beginning, because I need help figuring it out.  A couple of terms:  “grandfathered” means a plan that was around before 2010 so doesn’t have to meet many of the new rules in the ACA.  It is now very hard to get ungrandfathered—an employer can switch insurance companies completely and as long as the new policy is similar to the old one, it is not new—it is still grandfathered.  I’ll call these plans “old.”

A non-grandfathered plan is a “new” plan that has to meet the ACA requirements all around, like preventive care without co-pays.

So the original ACA said that in 2014, insurers had to accept people with pre-existing conditions without discrimination, except for “old” individual plans.  Here is then language that  means, to me, that “old” group plans have to play by those rules also, in Section 1251: “The provisions of section 2704 (related to pre-existing condition exclusions) of the Public Health Service Act (as added by this title) shall apply to grandfathered health plans that are group plans for plan years beginning with the first plan year to which such provisions otherwise apply.”  Clear as mud, but section 2704 is the part that says insurers can’t exclude people.  I don’t think I’m the only person who interpreted it this way—here is BCBS of Al describing the incoming changes, and they list the pre-existing condition rules in both columns (page 2).  Of course, the info in the link may change if they apply the new HHS wording.

The new proposed rule, just issued, appears to completely ignore the ACA here.  It says: “Proposed §147.104 would require issuers offering non-grandfathered health insurance
coverage to accept every individual or employer who applies for coverage in the individual or
group market, as applicable, subject to certain exceptions (for example, limits on network
capacity).” In translation, only “new” insurance plans have to play by the pre-existing condition rules.

That is HUGE.  Why?  Because if you work or get hired by an employer who only offers grandfathered plans (like my boss), you will not get the new coverage of pre-existing conditions.  You might get the insurance, but it might not cover, say, your asthma, if you haven’t had continuous large employer coverage.  And that could be the case indefinitely, because HHS keeps adjusting the criteria for becoming “new” so that it is very easy to stay old, forever.  They call it “keeping the plan you have.”

I have re-read the requirements for insurers to participate in the coming Exchanges, and I can’t find any requirement that the plans offered must be “new”.  So people with pre-existing conditions may or may not be able to find a plan on the Exchange or outside of it, in the individual market.  If they can’t, they would be stuck with the high cost high risk pool run by the states.

There are already enough loopholes built into the ACA without HHS blatantly undoing it.  This is Obama’s appointee doing it, so if you don’t like it, better speak up now.  If I have misinterpreted these proposed rules or the ACA, please let me know—it is entirely possible!  The thing is a mess and hard to wrangle with.  Please help me out here—what do you think?

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Filed under Bad solutions for the uninsured, Healthcare reform, HHS rules on ACA

The Myth of the Free ER


 

Instead of writing my blog last week, I found myself in a local ER. I’m there sometimes to see a patient being admitted or occasionally with a family member, but not usually for myself. The last time, in fact, was 24 years ago in medical school when I broke my neck in a car crash. Since then, I’ve managed to steer clear, until last week.

Tuesday started like any ordinary day. I ate some old-fashioned oatmeal with a sliced banana, a handful of almonds and a few cherries. About 30 to 45 minutes later, I suddenly had some abdominal pain I attributed to gas. I’m not prone to it, with my high-fiber diet, but that’s what it felt like. I went to work and tried to ignore it as it steadily worsened and began to radiate into my right shoulder, but shortly after lunch when I could no longer stand up straight and nausea set in, I decided with some embarrassment to tell my partners I needed to go home—because of gas! My husband came to pick me up but took me to the ER instead of home.

In triage, the nurse asked me to rate the pain, on a scale of 1 to 10, with 10 being the worst. I’ve asked a lot of patients that same question, but for some reason I was completely baffled by it. It hurt enough that I couldn’t really think. I didn’t want to have to explain that, because talking made it worse, so I just guessed a number—6. Which meant we had to sit a long time in the waiting room! There aren’t any couches in waiting rooms to lie down on. Since I couldn’t sit upright, I draped myself over my husband’s knees and hid my face so I didn’t have to fake-smile (if you’re a Southern girl, you know what I’m talking about).

After awhile, maybe an hour, I started wondering if I should send my husband back to give them an updated number—7? 8? But what if it was just gas, and I wound up in front of someone with something real? I couldn’t figure it out, so I kept quiet.

Finally, a room, followed by questions, an exam, labs, ultrasound, morphine, nausea medicine and CT scan. And lots of hot blankets, because I was shivering so hard my teeth chattered. Nothing conclusive—labs showed my pancreas seemed mildly ticked off, meaning possibly gallstones, but my esteemed gallbladder playfully hid from the ultrasound (one must speak respectfully of gallbladders). No diagnosis, but not much more pain either, so I was sent home. When I got up to dress, the pain started to return. I asked the nurse just to bring me some ibuprofen for the road—by that time I realized nothing had burst open inside of me and I was probably not dying. I felt silly later, having forgotten ER ibuprofen is pricey.

A couple of days later, with milder but recurring pain, I saw my own doctor. I made my case for a duodenal ulcer instead of gallstones, partly based on the lack of cutting involved and partly on the better melodrama potential in an ulcer. After all, I could say “this new EMR system is giving me an ulcer”, but no one would believe it had given me gallstones. I only have 4 of the 5 F’s—fair, female, over forty, and fertile. Besides, it’s becoming downright quaint to keep one’s gallbladder anymore, which appeals to my nonconformist nature. Both organs can refer pain to the right shoulder, and both can annoy the pancreas. And the only spot that hurts when poked is exactly over my duodenum.

So we shall see. My doctor agreed to let me try out ulcer, with a backup plan. No more ibuprofen. I have said a blessing over the little bottle of Protonix. So far it doesn’t hurt much anymore except at about 2 am. If God has a sense of humor, She would definitely let me have something cured by a proton pump inhibitor, after all the ranting I’ve done about the overuse of same.

I wish I could say that I paid more attention to everyone else in the waiting room that day. All I know is that there were a LOT of people waiting, mostly without complaining. I imagine some of them didn’t have insurance, or at least not good coverage. I have pretty good insurance and still had to pay $70 before leaving— the famous “wallet biopsy.” One of the common conservative responses to un-insurance is to say “oh, but they can get free care at the ER.” This is untrue on so many levels.

The ER isn’t free—uninsured patients will be billed, and if they can’t pay, wages can be garnished, cars taken, credit ruined. Whatever money the hospital can’t recoup will get passed on to the rest of us in higher charges or reduced services. It also isn’t definitive care, nor is it intended to be. I did not leave the ER with a diagnosis and didn’t expect one—all the ER needed to do was be reasonably sure I wouldn’t die or be permanently maimed if they sent me home. A real diagnosis can take weeks sometimes. I didn’t get any preventive care there, and they didn’t check my thyroid to be sure I was on the right dose of hormone replacement. They didn’t offer me a flu shot. They didn’t ask if I was eating my vegetables or getting regular exercise and sleep. We didn’t chat about my family history or my philosophical diagnosis preferences, and I wasn’t in chatting mode anyway.

I can only get those parts of my medical care with my regular doctor. We can’t solve un-insurance with ER’s, even if we had more of them and even if they were actually free. We need more primary care doctors—internists, family medicine doctors and pediatricians—and we need everyone here to have that care covered reliably. I couldn’t give an accurate pain level last week, but I can tell you my level of fed-up-ness with our current healthcare financing system—11 out of 10. Let’s fix this mess—Medicare for All.

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The Competition Conundrum


The meme of competition underlies every conservative healthcare reform proposal, so much so that it has taken on a sacred nature. I notice that many progressives tend to side-step this one—yes, they argue outcomes, but not necessarily the fundamental concept that competition is the root of all good, in every transactional system. Maybe that’s because it’s just hard to fight a meme like this. When it comes to varieties of flat-earthers, facts can be beside the point.

I had a comment on my last post that I was ignoring basic economics by not understanding that the laws of supply and demand, with enough competition, would by necessity result in lower prices and higher quality. So I thought it would be worth a try to look at a few factors in health insurance that are different from the basic market principles for things like pizza or haircuts. Remember I’m not an economist, so I’m going to stick to the easy stuff—the basics.

First of all, when someone is trying to sell us pizzas, the goal is to balance the price and quality to maximize the chance most of us will come back. If organic tomatoes, at a higher price, don’t affect our desire for more, they won’t be in the sauce. The sellers also need us to eat as much pizza as possible. In contrast, a smart health insurance company wants us to buy their product but not to actually use it. That is the only way they can make the increasing profits shareholders demand. Remember we aren’t their only customers—shareholders count too. This is really an unusual economic setup, when you think about it, so it would be simplistic to think “basic” economics would work.

So how can they entice us to buy a product but not use it? You might think they would try to keep us healthy, but other tactics are far quicker and more lucrative. First, they use tricky wording to hide the fact that they don’t cover certain services we might assume would be covered. Some diagnoses, unless we are medically trained, would be completely unfamiliar to us. So we might see an illness in the contract under excluded conditions and have no idea this mattered. Then they throw multiple layers of roadblocks in our way. Provider networks and formularies keep their costs low partly because some customers will decide to pay a higher price out of pocket for a better doctor or medicine. Denying claims or authorizations initially and then “realizing” there was an error if challenged lets insurers cheat customers who never catch the error. Even those long, convoluted phone trees to get prior authorization or protest a claim denial (“press one if you want to bite someone”) make some patients give up in frustration. I could go on and on about these tactics but have discussed many in previous posts.

Now let’s look at haircuts. Same thing as pizzas, in that my barber (yes, I have a barber and think she is awesome) is motivated to give me a haircut that makes me want to come back, and also hopes I’ll tell my friends about her. But the price of a haircut, if you ask any woman, does not depend only or maybe even primarily on quality. It depends instead on the cache of the salon—the area of town, the type of clientele (helps if some big-wigs go there, pun intended), the décor. I’ve seen plenty of women walk out of trendy salons with very ordinary hair. If they were bad cuts, of course people wouldn’t go back—but ordinary turns into glamorous if you get to share hairdressers with the women who buy $500 shoes. Or maybe with John Edwards. This same principle holds true with pricey wines. Tasters who drink wine poured from a fancy bottle give much higher ratings than they do to the same wine poured from a bottle labeled Mad Dog.

So competition does not always result in the best quality, even in non-insurance products—there are too many factors other than quality that play into demand. Insurers borrow this principle in their Medicare Advantage plans, marketing products that have great names or have cool perks like health club membership discounts but fail to offer quality coverage for serious illnesses. I’ve seen a recent insurance commercial talking up the friendly nurse a new cancer patient can call to get treatment options (I guess instead of talking to the oncologist). Never mind that this nurse has an interest in keeping your care cheaper for his company. The company doesn’t care if the sickies leave and don’t come back—it works just fine to keep only the customers who don’t have to use their product. Apparently negative feedback does not lower insurance market value much. Maybe the dissatisfied customers are too sick or too dead to make noise.

Risk pool size also makes competition an ineffective way to lower prices. If we had a very competitive market with lots of insurers, and no large companies dominated, each risk pool would be smaller and more vulnerable to effects of a few unlucky customers with expensive illnesses. Premiums would have to increase to compensate in those pools, and healthy customers without pre-existing conditions would migrate to another pool at lower cost. Using the pizza analogy again, customers who didn’t eat the pizza would try to find pizza places where no one else ate it either. If someone did eat it, the others would be better off if that person got food poisoning and never came back. Eventually we’d wind up with sick people in plans they couldn’t afford anymore. Of course, free market proponents would remove all the new health insurance reform features, including protection for pre-existing conditions and price controls, in the service of the god Competition.

Do folks really want the natural outcome of competition in health insurance—products the sellers don’t want them to be able to use? Do they value a principle like competition, whether it works or not, more than coverage when they are sick? Are they ready to constantly scramble from risk pool to risk pool when prices rise? And to pay through the nose when they get sick and the well folks run away, along with their premiums?

All this reasoning has limitations. I know from experience in medicine that things don’t always work the way it seems they should. We used to think babies were safer sleeping on their stomachs, until we looked at the data and found out they were 10 times more likely to die. So if you want to ignore everything I just said, fine—look at what happens in the real world. We have plenty of examples of states with multiple competing products and states like Alabama with one heavily dominating company. And insurance is expensive everywhere.

We might not be able to overcome the religion of competition. Maybe we’ll just have to borrow it for our own purposes. If we had a national health insurance, an improved Medicare for all of us, we could access it for preventive medical care or early treatment. Paying well for this type of care, and maybe even treatment for obesity and nicotine addiction, would become the best way to lower overall costs. We wouldn’t have to pay part of our premiums for advertising brochures and commercials, customer service people who get paid to confuse us, high-salary executives or shareholder profits. We could have the largest risk pool possible, making our individual payments the cheapest. Because of this, our pizza businesses, hair salons and automobile makers could save money, by not having to fund private insurance and by having healthy, productive employees. They could—guess what? Compete!

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Faith-based health cost sharing


I saw a very interesting program by Dan Rather last week, with one feature on faith-based healthcare cost sharing plans.  Under PPACA, people can opt for these plans and be exempt from the private insurer mandate.  Members pay a small fee monthly, but instead of paying to the plan itself, they are instructed to send their checks directly to another member who has incurred costs.  A central computerized system keeps track of where money is supposed to go.

Dan pointed out several concerning points about these plans.  They are not actually insurance plans backed by any sort of contract guarantee– if the total pot runs dry, members have no recourse to get payment.  Payment rates to hospitals and providers aren’t negotiated, so members would have to pay the full price for services.  If you’ve ever had a procedure done in a hospital, you know the huge discrepancy between the initial hospital charge and the final payment after insurance write-offs.  Important services like mental illness treatment, addiction treatment,   preventive care, chronic condition medication and contraception are not covered at all.  And there are lengthy waiting periods for pre-existing condition coverage (for example, 7 years after treatment for cancer).  Members have to promise not to smoke, use addictive substances or break religious rules about sex.

The natural result would be that membership would  be skewed towards healthy people– another example of cherry picking.  People who need care will have to get private insurance and will shift our overall risk pool towards higher cost enrollees.  If these entities really take off,  the rest of us will have to pay higher premiums.  Even though I dislike PPACA and the mandate to pay private corporations for shoddy products, if we are going to have the mandate there should not be loopholes like this.

I was interested that during all the smug talk from members about how they were more responsible with their healthy lifestyles, the camera zoned in on the handfuls of cookies they were holding during meetings!  And every one of the members shown was overweight if not obese.  I mention this NOT to blame obesity on moral choices, since I think the evidence is powerful that fat gain doesn’t result from poor self-discipline, but just to show the hypocrisy involved.  Although Dan didn’t comment verbally, the videographer was not very subtle.

As a Christian, the whole thing was depressing to me on a deeper level.  One of these groups calls itself  “Samaritan Ministries.”  If you haven’t read the Good Samaritan parable in a while, go check it out.  What a gross misuse of the story!  Yes, members are sharing resources as early Christian groups are said to have done, described in another part of the Bible.  But their behavior is exactly the opposite of what Jesus was teaching in the Good Samaritan parable.  The parable was about our duty to treat strangers, even those far outside our social circles, as neighbors deserving of care.  It is not in any way a virtue for members of the health plan to share with people they approve of, especially knowing they may benefit themselves.  By excluding non-Christians, they are behaving  just like those who saw the injured man in the parable and passed him by.   I know all of us fall short of perfect neighborliness, but generally we ought to have the sense to be embarrassed about it.  At least we shouldn’t boast about our selfishness on national television.

Maybe the rest of us can form a new religion with a simple statement of faith — “Everybody in, Nobody out.”  This faith organization would allow members to be part of any other faith simultaneously or be atheist.  Instead of forming a faith-based health plan, however, members would naturally want to support legislation enacting  “Improved Medicare for All”, an actual insurance, with no body part excluded.   We would send our contributions through taxes and ask the government to manage distribution of payments to private doctors and hospitals.   Under our plan, insurance would cover believers and non-believers alike.  Anybody want to sign up?  Go to www.pnhp.org— all are welcome.

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Big excitement over September 23? Not really


Yesterday a wave of changes scheduled under the Patient Protection and Affordable Care Act went into effect.  Lots of people seem excited, but unfortunately I’m afraid they don’t realize the changes won’t apply to most of us.  For example, insurers won’t be allowed to turn away or deny claims for those under 19 with pre-existing conditions– but this only applies to new plans.  So if you already have insurance, the rules won’t change for your children– and several large insurers have announced that they will no longer issue new individual policies for children.  They say the law just encourages families to wait until their children are sick to get insurance so it will be too expensive to cover them.

The same “grandfather effect” rules for the lifetime dollar limits for children, coverage for preventive services, and even new rights to appeal claims denials.

There is now a ban on rescinding coverage for people for frivolous reasons– if you make an honest mistake on your insurance application, they can’t cancel your policy when you get an expensive illness.  BUT– this was always the case, and it never stopped that kind of thing.  Maybe it will help that now people know it is illegal, but most likely they will still wind up bogged down in court trying to appeal these cancellations.

The only improvement I see that isn’t ruined by the grandfather effect is that people can stay on their parents’ policies until they are 26.  But if they’ve developed a pre-existing condition during the time they were off, and it isn’t a new policy, then they are still out of luck.  I’m sure we will see all sorts of ways to keep plans grandfathered as long as possible– and I suspect there will be some creative ways private insurers will deal with the 19 to 25 year olds too.

As provisions of PPACA come into play, this will give us more opportunities to witness the misbehaviors of insurance companies as they scramble to get around every loophole they can find.  Maybe this will ultimately help people realize that we don’t need them at all– we can fund our own healthcare without these middlemen in the way.  Advocate for publicly funded, privately delivered healthcare– a new, improved version of Medicare for all of us.

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Why not fix just the broken parts?


I’m at the spring meeting of the Alabama Chapter of the American Academy of Pediatrics for the next few days, so I won’t have time to pore through the legislative text, most likely, until I get back.  But I’m going to try and do some brief posts on some common questions we get.

Both conservatives and liberals alike often ask why we don’t just fix the broken parts of our healthcare system and preserve the parts that are working well.  The popular PNHP answer is that this would be like giving aspirin to a cancer patient (instead of chemotherapy).  I’ve also come up with an analogy to putting a bandaid on a patient with multiple trauma injuries.

But here’s another way to look at it.  We actually can agree with this– the improved, expanded Medicare for All plan is very conservative of our present system.  It removes, surgically, the “broken” part– private insurers– and preserves the privately run physician offices and hospitals!  Because the idea is so straightforward, there is no need for the multiple layers of regulation embedded in the current legislation or even in the system we had before this.  When people complain about our government not being able to “do anything right”, I have many examples to the contrary; but I do have to say government does better at distributing funds (what we’re asking it to do) than it does regulating the behavior of other entities.

Now, for those who think more in our healthcare system is broken than private insurers, you may be right also.  There is much that could be improved upon in terms of quality medical care, fair physician payment, physician distribution and supply, etc.  But there will always be things we can improve upon– that’s the nature of any human system.  And those other items can be addressed individually.  There is no reason they have to be attached to legislation dealing strictly with finance and access.  Which is part of why HR 676, the single payer bill, is so short and easy to read!

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