Author Archives: danieladougan

Anti-vaccine conspiracy theorists allow measles to come roaring back

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In recent years, there has been a great deal of talk about vaccines causing all sorts of dangerous side effects in children — especially autism. A 1998 study that appeared The Lancet, a prominent peer-reviewed medical journal, raised concerns about this around the world about the MMR (measles, mumps and rubella) vaccine.

But the study was ultimately retracted by The Lancet in 2011 when the publication discovered that the author, Dr. Andrew Wakefield, committed “an elaborate fraud” with this study — deliberately falsifying his research to prove his point. But the damage was still done.

But what about the ACTUAL dangerous side effects of catching the diseases that the vaccines prevent? According to the U.S. Centers for Disease Control and Prevention, measles cases have now reached a 20-year high after being declared eradicated from the United States in 2000. How did it happen?

The current increase in measles cases is being driven by unvaccinated people, primarily U.S. residents, who got measles in other countries, brought the virus back to the United States and spread to others in communities where many people are not vaccinated. — Dr. Anne Schuchat, assistant surgeon general and director of CDC’s National Center for Immunizations and Respiratory Diseases

The reality is that measles is highly contagious and potentially deadly. Even though it was nearly eradicated in the United States, the same cannot be said for many developing countries like the Philippines. But with the uptick in infection rates here in the United States, it’s important to make sure you and your children have been vaccinated even if you don’t plan any trips overseas.

And don’t believe the hype. Vaccines were one of the greatest public health achievements of the 20th century — saving millions and millions of lives.

The Healthy Indiana Plan 2.0 as a form of Medicaid expansion: Part 2 – Policy Analysis

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In a previous post, I provided some background on the politics of Indiana Governor Mike Pence’s proposal to use a modified version of the Healthy Indiana Plan as a substitute for the expansion of traditional Medicaid under the Patient Protection and Affordable Care Act (Obamacare). In this post, I will explore in more detail how the original and modified versions of HIP were designed and the implications of this idea in terms of public policy.

When it comes to the issue of health care, I believe that people in my party need to be solutions conservatives. We must never forget that we’re talking about real people, working people, who deserve a better way. Indiana Governor Mike Pence, address to American Enterprise Institute, 5/16/2014

Nuts and bolts

The gist of the original Healthy Indiana Plan program was a health plan with an $1,100 deductible. Beneficiaries had to make regular financial contributions to a savings account known as a POWER account based on a percentage of their income (between 2% and 5%). State and federal Medicaid funds would fill in the difference between those contributions and the deductible and then finance the traditional coverage after the deductible. Then the beneficiaries spent down that account when they got care — so they were supposed to be more price-sensitive.

At first glance, this would seem like a bad deal for beneficiaries when compared with traditional Medicaid that required no financial contributions at all, but HIP did provide some unique advantages. The most important advantage to beneficiaries was this: HIP provided much better access to physicians than traditional Medicaid due to its higher reimbursement rates.

One problem that Medicaid beneficiaries often face, despite having health coverage, is the ability to actually use that coverage to get access to health care because physicians are reluctant to accept Medicaid patients since it’s often a money-losing proposition for them. So even though they are given the means to pay for medical services, they are still often left with little choice but to go to emergency rooms for non-emergent care — which costs everyone more money.

So, despite conventional wisdom about expanding health coverage, an expansion of traditional Medicaid in Oregon actually increased trips to the emergency room instead of decreasing them, and the beneficiaries did not experience much in the way of improved health. Without a requirement to make any financial contributions, beneficiaries did not feel the pinch of using a higher level of care than they really needed. These results were not lost on Governor Pence when he announced HIP 2.0 as a better way forward.

The low reimbursement rates in traditional Medicaid create very real access problems for beneficiaries, and I’m all for bringing those rates in closer alignment with Medicare and private insurance, but that comes at a cost.

One way the original Healthy Indiana Plan controlled costs to taxpayers in spite of the higher reimbursement rates was to set a numeric cap on enrollment, meaning that people who met the income guidelines could still be turned away if the program was “full,” so people not only needed to be poor, they needed to be fast. And turned away they were: as of December 2012, HIP had 36,500 enrollees and 46,388 eligible people on the waiting list.

Changes in HIP 2.0

Pence’s proposal for HIP 2.0 includes some significant changes from the original version of HIP. Here are the most significant:

  • Removal of the enrollment cap: Now anyone earning up to 138 percent of the federal poverty level can participate without being waitlisted. This is perhaps the most significant change to HIP — making it an entitlement program instead of a block grant program.
  • Employer Benefit Link: For participants who are employed but cannot afford to participate in the plans offered by their employers, there is an option to redirect the HIP funding to help pay for their plan at work.
  • Tiered plans: If participants don’t make regular contributions toward their POWER accounts, they will be shifted from the HIP+ plan to the HIP Basic plan. (They can also opt into the HIP Basic plan if they want to.) In the basic plan, participants will not have to make contributions, but they will have copays when they receive services. Because the required contributions to the POWER account are small and on a sliding scale based on income, the HIP Basic plan could lead to higher out-of-pocket costs for participants.
  • Higher deductible: The deductible is increased from $1,100 to $2,500, but participants in the HIP+ plan will only need to make required contributions based on income…the state still funds the remainder of the POWER account up to the deductible.
  • Workforce development: Anyone who applies for HIP will be connected to employment and job training programs.
  • Dental and vision coverage: HIP 2.0 is designed to include dental and vision coverage in additional to health coverage.

Bending the cost curve?

Reforming traditional Medicaid through this kind of market-based, consumer-driven approach is essential to creating better health outcomes and curbing the dramatic growth in Medicaid spending. Indiana Governor Mike Pence, quoted in The Indianapolis Star, 5/16/2014

Despite Pence’s claims about using contributions from HIP beneficiaries to control costs, Indiana’s state actuary reported that expanding Medicaid via the HIP program would actually cost taxpayers more than expanding traditional Medicaid, presumably because the contributions from beneficiaries would not be enough to offset the much higher reimbursement rates to physicians and hospitals. (Note: The Indiana Family and Social Services Administration disputes that, saying that the actuary determined that HIP will cost less than traditional Medicaid.)

I think it’s a great thing. The only thing I’ve asked this governor to do was provide more health-care coverage. It’s better late than never. Indiana Democratic Representative Ed DeLaney, quoted in The Indianapolis Star, 5/16/2014

Democratic Representative Ed DeLaney, often one of Pence’s harshest critics in the Statehouse, has applauded Pence’s move to expand the Healthy Indiana Plan. And so do I.

As long as the financial contributions from beneficiaries don’t become prohibitively high, it’s good to give them a little skin in the game so that they access care wisely. It’s hard to argue with the fact that traditional Medicaid is severely broken, mostly because it’s so difficult to access physicians and hospitals.

My biggest objection to HIP in the past was the enrollment cap that cruelly excluded tens of thousands of people who met the income guidelines just because they didn’t get in line first. That cap has been eliminated in HIP 2.0 so anyone meeting the income guidelines will get coverage…no more waitlists.

Whether this will benefit Pence in a general election for a possible presidential run in 2016 or 2020 (which is quite likely) or hurt him in a GOP primary remains to be seen.

I’m about the last person who wants to say anything nice about Mike Pence (except maybe Ed DeLaney), but I applaud him for trying to come up with a solution. I hope he and the federal government can work it out for the benefit of Hoosiers below or slightly above the poverty line who so desperately need medical coverage.

The Healthy Indiana Plan 2.0 as a form of Medicaid expansion: Part 1 – Background

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On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (which you might know better as “Obamacare”) into law. Unless you have been in a coma for the past five years, you probably know that this is a controversial law that the GOP has been trying unsuccessfully to repeal ever since that day.

In addition to the legislative attempts to repeal the law, a landmark Supreme Court case (National Federation of Independent Business v. Sebelius) challenged the constitutionality of the law’s mandate that individuals purchase health insurance or pay a penalty.

On June 28, 2012, the Supreme Court ruled on the case, deciding 5-4 in favor of former Secretary of Health and Human Services Kathleen Sebelius, which meant the law would be upheld.

Although the case was mostly a victory for Obamacare, part of the Supreme Court’s ruling did weaken one important provision of the law that required states to implement an expansion of Medicaid to adults with incomes up to 133 percent of the federal poverty level. The court ruled that the federal government could not compel states to participate in the Medicaid expansion if the state legislatures and governors did not want to.

What followed was a split along partisan lines — basically the states with Democratic governors and legislatures implemented the Medicaid expansion, and states with Republican governors and legislatures (and states with divided governments) opted out. One of those opt-out states was my home state of Indiana.

In 2008, Indiana (at that time under Governor Mitch Daniels) implemented a Medicaid waiver program called the Healthy Indiana Plan, or HIP. HIP was based on principles of health savings accounts and high-deductible health plans, which are generally favored by conservatives over more comprehensive health coverage requirements. You can read more details about how HIP originally worked here.

The original HIP program did not meet the standards of essential health benefits required under the Affordable Care Act, and it capped enrollment based on a fixed budget rather than allowing anyone who met the income guidelines to enroll, so there was concern that the program would be suspended…it has been temporarily extended through 2014 to allow time for Indiana and the federal government to determine where to go from here.

Now Indiana Governor Mike Pence has proposed using a modified version of the Healthy Indiana Plan (known as HIP 2.0) to substitute for expanding traditional Medicaid under the Affordable Care Act. He has been negotiating with the U.S. Department of Health and Human Services about this for some time now, and it is widely believed that they will be able to reach some sort of compromise.

Pence has received criticism from both the left and the right for his approach. (He has also received bipartisan praise.) But my real question is whether HIP 2.0 is good public policy. I’ll explore in more detail how both version of HIP were designed and the policy implications of that in Part 2.

The U.S. health care system: leading the world in all the wrong ways

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The U.S. health care system: leading the world in all the wrong ways

For as much as the United States spends on health care, you would think that we would have the best care in the world. But we don’t. In fact, the United States health care system leads the world in medical errors, according to a 2005 survey by the Commonwealth Fund.

In fact, medical errors contribute to the deaths of 210,000 to 440,000 U.S. patients each year, making medical errors the third leading causing of death for Americans, behind cancer and heart disease. A more conservative 2010 estimate from the Office of the Inspector General for Health and Human Services put the number at around 180,000.

It’s time to get angry, and it’s time to take action to fix this problem.

Want to save babies? Focus on improving women’s health, not picketing Planned Parenthood

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Family planning is an important part of women’s health. And reproductive health includes access to abortion that I believe should be safe, legal, and rare. I’ve spent a lot of my time trying to bring down the rate of abortions. And it has been my experience that good family planning and good medical care brings down the rate of abortion. Keeping women and men in ignorance and denied the access to services actually increases the rate of abortion. — Secretary of State Hillary Clinton, Testimony before House Foreign Affairs Committee, 2009

It wasn’t too long ago that I stumbled upon an anti-abortion protest outside of a Planned Parenthood clinic that was across the street from my shopping destination. Even though I adamantly disagree with the protesters and doubt that they understand all of the non-abortion services that Planned Parenthood provides, I think their hearts were in the right place. They want to protect fetuses that they consider to be babies.

To further their efforts, pro-life groups have fought to pass anti-abortion laws (which are frequently overturned in court as unconstitutional, most famously in Planned Parenthood v. Casey) and opened crisis pregnancy centers that show ultrasound images to pregnant women (a tactic proven to be ineffective at reducing induced abortions).

I’d like to suggest that if their real goal is to save the lives of babies in the USA — both born and unborn — they might want to focus their energies elsewhere.

Good news/bad news from the USA

First, the good news from the USA. In 2011, induced abortion rates in the United States fell to their lowest since the landmark Roe v. Wade decision. Another good sign is a declining infant mortality rate…reported at 6.05 deaths before the first birthday per 1,000 live births in 2011, which was a 12 percent drop from 2005. So we’re getting a little better at this. The bad news is that better is still not very good by international standards.

In 2008, the United States ranked 27th in infant mortality rate among Organization for Economic Cooperation and Development countries, and a previous report linked the United States’ relatively unfavorable infant mortality ranking to its higher percentage of preterm births. Despite the recent infant mortality decline, comparing the 2011 U.S. infant mortality rate with the 2008 international rankings would still have the United States ranked 27th. — U.S. Centers for Disease Control and prevention, NCHS Data Brief, April 2013 (emphasis added)

 

Not getting much value

US not getting much value

Despite spending more than any other nation on earth for health care per capita, the United States (depicted on the far righthand side of the chart) still lags behind many other countries in terms of infant mortality and abortion rates. Although the United States is not the worst performer on the list in terms of abortion and infant mortality, countries like Mexico and Estonia spend far less on health care per person. Please note that lower numbers for all variables always indicate better performance in this chart.

But is more health spending the answer? A quick glance at the data would suggest not, since the United States has the highest health care spending on earth, both in real dollars and as a percentage of gross domestic product.

In terms of the unborn, even though the U.S. abortion rate is dropping, it’s still too high. In 2008, the United States reported a rate of 20 induced abortions per 1,000 women ages 15-44. Germany, the top performing country, reported only 7.

What’s interesting is the inverse correlation between restrictive abortion laws and the number of abortions…especially the number of unsafe abortions. That is, the more restrictive a country’s abortion laws are, the more abortions occur. And they are of the unsafe, back-alley variety that endangers women’s lives.

Although the legal status of abortion and risk associated with the procedure are not perfectly correlated, it is well documented that morbidity and mortality resulting from abortion tend to be high in countries and regions characterized by restrictive abortion laws, and is very low when these are liberal…We found that the proportion of women living under liberal abortion laws is inversely associated with the abortion rate in the subregions of the world. — Sedgh, G. et al. “Induced abortion: incidence and trends worldwide from 1995 to 2008,” from The Lancet, 2012

It’s worth pointing out that the study classifies the U.S. as having liberal abortion laws, but obviously the people picketing outside of Planned Parenthood are hoping to change that.

So what’s a country to do?

Just because the United States spends more on health care by far than any other nation in the world doesn’t mean we’ve been spending the money very wisely. Indeed 31 percent of U.S. healthcare spending is on administrative costs.

But Sedgh, G. and colleagues offer an idea.

Other studies have found that abortion incidence is inversely associated with the level of contraceptive use, especially where fertility rates are holding steady, and there is a positive correlation between unmet need for contraception and abortion levels. — Sedgh, G. et al. “Induced abortion: incidence and trends worldwide from 1995 to 2008,” from The Lancet, 2012

And if you don’t believe that, there’s this:

The United Nations Population Fund (UNFPA) has calculated that funding which provides modern contraceptive services in developing countries ($7.1 billion in 2003) prevents 187 million unintended pregnancies, 60 million unplanned births, 105 million induced abortions, 22 million spontaneous abortions, and 215,000 pregnancy-related deaths each year. — John Lomoy, Organization for Economic Cooperation and Development

Fortunately, the Patient Protection and Affordable Care Act (that is, Obamacare) goes a long way in improving access to contraception and other women’s preventive health programs that can also reduce infant mortality rates.

Cutting through the clutter

Unfortunately for a lot of born and unborn babies, the pro-life crowd has spread a lot of misinformation about the impact of the Affordable Care Act’s women’s preventive health provisions.

To be clear, Obamacare does not provide any funding for abortions, nor does any other federal program due to the Hyde Amendment. Even the Medicaid funds that Planned Parenthood receives are specifically for the non-abortion services it provides…just like any other health provider that provides these services.

The Supreme Court recently heard arguments in the Sebelius v. Hobby Lobby Inc. case in which Hobby Lobby argued that the law’s required coverage of emergency contraception (Plan B and Ella) violated their religious beliefs, and they should not be required to include it in their employees’ insurance plans. Pro-life groups have inaccurately referred to Plan B and Ella as abortifacients, probably for political reasons. In reality, even traditional birth control pills can prevent implantation in the uterus (not just conception), so the distinction is totally made up.

What’s the real story?

It is hard to say precisely what is prompting the pro-life movement to back policies that are so counterproductive to reducing the number of abortions, infant mortality and deaths among pregnant women. I have a few hypotheses:

  1. An overly simplistic view of policy. If you tell someone that something they abhor is legal, the intuitive response would be to say, “We should try to change that law” because they don’t want it to happen anymore. Of course, sometimes reality is counterintuitive. When abortion is not legal, desperate women still get abortions…it’s just that they are of the unsafe, back-alley variety. Conservatives who oppose gun control measures should understand this line of reasoning: if you make performing an abortion a crime, then only criminals will perform abortions.
  2. Unspoken motivations. Access to contraception and abortion has been a major step forward for the rights of women, and conservatives tend to be uncomfortable with that. Sure, the early feminists like Elizabeth Cady Stanton and Susan B. Anthony opposed abortion, but the abortions they opposed were unsafe and coerced by men. They had no concept of abortion in the way we think of it today as a safe medical procedure initiated by the woman.
  3. Political wedge issues. Politics is a very ugly business sometimes, and if you can portray your opponents are murderers, that’s pretty effective. That’s precisely what the GOP has done with the abortion issue, and religious conservatives have overwhelmingly rewarded them for it, often voting against their economic interests to vote for pro-life candidates.

Don’t fall for it. The data shows overwhelmingly the pro-life crowd is (perhaps unintentionally) harming the babies they claim to cherish.

Never underestimate procrastination

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With only a few days left to go before the March 31 deadline, there was real cause for concern that enrollment on the health insurance exchanges would not come anywhere close to the goal of 7 million enrollees. After all, between October 1 and March 21, fewer than 6 million Americans had enrolled. Some had revised the goals down to 6 million…a major blow. But more than 1 million Americans jumped on, as they often do, at the last minute, enabling the exchanges to exceed the original goal of 7 million. It just goes to show that it’s human nature to procrastinate.

The adverse selection death spiral

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Earlier I wrote about how the Obamacare exchanges have failed to attract many young, healthy people — and how the early technical glitches have made the problem worse.

Of course, the older and sicker people who really needed health insurance coverage would have enrolled by hook or by crook — but in order to make all of this work economically, we need as many young, healthy adults as possible in order to prevent the adverse selection death spiral from making the exchanges unworkable.

In order to explain the problem of adverse selection in health insurance, it may be useful to use a different, simpler kind of insurance: homeowner’s insurance.

Suppose you haven’t had homeowner’s insurance for a number of years. Then all of a sudden your house catches on fire, and you have $100,000 in damage. If you walk into an insurance agent’s office the day after the fire and try to buy a policy that will pay for the repairs to your property after they have already occurred the agent will probably have a good laugh and explain why the insurance company would never, ever want to do that.

If there were a law, however, that said homeowner’s insurance companies have to accept all new applications, regardless of the condition of the home at the time of the application, restore the home to its original condition and charge these people the same premiums as everyone else, what do you suppose people might do?

Well, first of all, people whose homes were in good condition would naturally drop their insurance coverage since there would be no incentive whatsoever to keep paying premiums. If the insurer were required by law to accept any application, then people would wait until their houses caught on fire and then apply right after calling the fire department. Why not? And, of course, in order for the homeowner’s insurance company to stay afloat, the premiums would go up — dramatically.

Even if this were somehow workable, which it isn’t, if the fire damage were too extensive, the homeowner’s insurance company could declare the house a total loss and write the policyholder a check to buy a new house.

We sort of inherently understand and accept this in homeowner’s insurance because our home (or our car, boat, motorcycle, etc.) is a piece of property that has a dollar value on it and can be replaced. Plus, a fire at your home is largely an unpredictable event — the kind of event where an insurance market can function well. (Of course, there are some cases where people try to turn unpredictable events like fires into predictable events by deliberately causing them in order to cash in on a claim payout, but this can land them in prison for insurance fraud.)

Pre-existing conditions

But now let’s adapt that analogy back to health insurance. (Disclaimer: I’ve said for a long time that insurance is a really inappropriate paradigm for financing health care…but it’s the one we have in the United States.)

In health care, there are certainly unpredictable events like an accidental injury from playing basketball, but there are also a lot of predictable events. And these are the ones that can really add up like the house fire. If you’re recently diagnosed with cancer, you know in advance that you’re going to need a lot of expensive treatment in the near future. And if you’ve gone without insurance for a while, you might suddenly start to rethink that decision.

But for the insurance company, they don’t want anything to do with you at that point just like the homeowner’s insurance company doesn’t want anything to do with you after you’ve had a massive fire that needs to be repaired. So, just like the homeowner’s insurance agent denying the applicant whose house caught fire, the health insurer would deny that application on the basis of pre-existing conditions.

I wrote earlier that we understand and accept this in terms of homeowner’s insurance, but we feel quite differently when it comes to our health. Obviously for the person with cancer, financing their treatment could be a matter of life and death — and there’s no way to declare a person to be a total loss and just cash out their bodies. (At least not yet.)

On the surface, it may seem like the health insurer is just being greedy by denying this person’s application, but in reality the health insurer is trying to keep its premium rates down for all of the healthy people it has in the pool. If health insurers no longer had this option, then you would see the same kind of dramatic premium increases that you would see if homeowner’s insurance companies had to accept everyone who applied, even if their house had burned.

Finding a counterweight

And yet, we still don’t accept this from an ethical point of view. I know I don’t.

So if we require health insurers to accept everyone at the same premium rate regardless of health status — even someone just diagnosed with cancer — then we need a counterweight to make sure people don’t game the system and buy insurance even when they don’t need it. Along with the requirements for guaranteed issue (no denials for pre-existing conditions) and community rating (no rate increases based on pre-existing conditions), the Affordable Care Act has three counterweights.

First is the individual mandate. This is the part of the law that everybody hates because it’s basically the part of the law where we pay the price for all of the things we want — there is no free lunch. The second, and related counterweight, is an open enrollment deadline — the deadline for this year to avoid the tax penalty is March 31. Finally, there is 3:1 age banding that allows insurers to charge older people up to three times as much for premiums as younger people. (Insurers might prefer something closer to 10:1 age banding, but 3:1 is a lot less of a market distortion than no age banding at all.)

Check HealthCare.gov or your state exchange (where applicable) for yourself. If you compare the price of an unsubsidized health insurance policy with the tax penalty — especially this year — you will see that the penalty is much cheaper. Of course the price of a health insurance policy offered on the exchanges could be reduced dramatically if you qualify for income-based subsidies, but even then the penalty amount for not buying insurance is still relatively small. So many young, healthy people will opt to take their chances and pay the penalty instead of purchasing a policy…if they even realize that they have to make this decision.

If enrollment in the exchanges continues to skew older and sicker, then next year the premiums will inevitably rise higher…maybe much higher whereas the penalties are prescribed in the law without accounting for these actuarial changes. This may even accelerate the death spiral and render the law totally unworkable.

How this all plays out still remains to be seen, but if you’re a young, healthy adult without insurance, I’d like to ask you to at least shop around and see what you qualify for. You may be pleasantly surprised.

Obamacare exchanges: The number of people who enroll is less important than who enrolls

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An underwhelming five million Americans have signed up for coverage in the new health insurance exchanges so far. That’s far short of the Obama administration’s goal of seven million enrollments by the March 31 deadline. It’s human nature to wait until the last possible minute, so there’s a good chance that the number will rise significantly in the remaining 10 days. In fact, the Congressional Budget Office projects another one million enrollments before the deadline.

But six million is still one million short of the goal. That gap is disappointing, and Republicans are almost certain to pounce on it as another failure of the Affordable Care Act.

When the exchanges first opened on October 1, 2013, the federal exchange site (www.healthcare.gov) was beseeched with glitches that made it nearly impossible for anyone to sign up. To make matters worse, these hassles disproportionately dissuaded younger, healthier people from enrolling. After all, younger adults tend to be more technically savvy as a group than older adults and have less patience for more traditional forms of enrollment like paper or telephone.