Tag Archives: health reform

Health insurance can literally be a life-or-death issue

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Health insurance is not health care (and just because health insurance premiums rise does not necessarily mean health care is more expensive), but health insurance is a crucial mechanism that we use to finance and access health care.

And, in some cases, not having health insurance can be the difference between life and death. Just take a look at the results of two studies  published in the August issue of the journal Cancer comparing survival rates for men with two forms of cancer based on insurance status.

From the first study, regarding glioblastoma multiforme, an aggressive type of brain cancer:

Among the 13,665 adult patients in the study cohort, 558 (4.1%) were uninsured, 1516 (11.1%) had Medicaid coverage, and 11,591 (84.8%) had non-Medicaid insurance. Compared with patients who were uninsured, insured patients were more likely to be older, female, white, married, and with a smaller tumor size at diagnosis. Accelerated failure time analysis demonstrated that older age (hazard ratio [HR], 1.04; P<.001), male sex (HR, 1.08; P<.001), large tumor size at the time of diagnosis (HR, 1.26; P<.001), uninsured status (HR, 1.14; P =.018), and Medicaid insurance (HR, 1.10; P =.006) were independent risk factors for shorter survival among patients with GBM, whereas radiotherapy (HR, 0.40; P<.001) and married status (HR, 0.86; P<.001) indicated a better outcome. The authors discovered an overall yearly progressive improvement in survival in patients with non-Medicaid insurance who were diagnosed from 2007 through 2011 (P =.015), but not in uninsured or Medicaid-insured patients.

Rong, X., Yang, W., Garzon-Muvdi, T., Caplan, J. M., Hui, X., Lim, M. and Huang, J. (2016), Influence of insurance status on survival of adults with glioblastoma multiforme: A population-based study. Cancer. doi:10.1002/cncr.30160

Translation: patients with private insurance lived the longest with this form of brain cancer. In terms of surviving glioblastoma multiforme, Medicaid did not seem to make a difference compared to being uninsured.

And the second study, regarding germ cell testicular cancer:

Uninsured patients had an increased risk of metastatic disease at diagnosis (relative risk [RR], 1.26; 95% confidence interval [CI], 1.15-1.38) in comparison with insured patients, as did Medicaid patients (RR, 1.62; 95% CI, 1.51-1.74). Among men with metastatic disease, uninsured and Medicaid patients were more likely to be diagnosed with intermediate/poor-risk disease (RR for uninsured patients, 1.22; 95% CI, 1.04-1.44; RR for Medicaid patients, 1.39; 95% CI, 1.23-1.57) and were less likely to undergo lymph node dissection (RR for uninsured patients, 0.74; 95% CI, 0.57-0.94; RR for Medicaid patients, 0.76; 95% CI, 0.63-0.92) in comparison with insured patients. Men without insurance were more likely to die of their disease (hazard ratio [HR], 1.88; 95% CI, 1.29-2.75) in comparison with insured men, as were those with Medicaid (HR, 1.58; 95% CI, 1.16-2.15).

Markt, S. C., Lago-Hernandez, C. A., Miller, R. E., Mahal, B. A., Bernard, B., Albiges, L., Frazier, L. A., Beard, C. J., Wright, A. A. and Sweeney, C. J. (2016), Insurance status and disparities in disease presentation, treatment, and outcomes for men with germ cell tumors. Cancer. doi:10.1002/cncr.30159

Translation: men who had private insurance were 88 percent more likely to survive germ cell testicular cancer than those who were uninsured, and the men who had Medicaid were 58 percent more likely to survive than those who were uninsured.

In both studies, patients with private insurance tended to be diagnosed earlier on the disease progression than uninsured and Medicaid patients, and this was shown to be important to a patient’s survival.

Arguments for the left and right

There is fodder here for both sides of the political aisle. On the one hand, liberals can point to the 58 percent increase in survival rates among Medicaid patients compared to those who were uninsured. And they can also point to the researchers’ acknowledgement that many of the Medicaid patients were likely to have been uninsured until just after being diagnosed with cancer. Clearly having Medicaid was better for these patients than having no insurance at all.

And yet, on the other side of the aisle, conservatives can point to the results of the first study that, despite all the tax dollars spent on Medicaid, it did not seem to make a difference in survival rates compared to having no insurance at all. Even with the second study, the right can point to the far superior outcomes of patients with private insurance compared to those with Medicaid, even while acknowledging that Medicaid was better for those patients than being uninsured.

Underlying issues

So, what’s an objective observer concerned about health policy supposed to make of these results? I have a few suggestions.

  • Private insurance probably improves access to care because reimbursement rates for physicians and hospitals are much higher than Medicaid. Many physicians will not accept Medicaid patients due to the very low reimbursement rates. Medicaid can also have issues with the timeliness of reimbursement, depending how much funding is left in a given state’s Medicaid budget. Even the physicians who do accept Medicaid might be less inclined to proceed with aggressive cancer treatments for their Medicaid patients than they would be for their patients with private insurance. The germ cell study found that Medicaid and uninsured patients did have a different treatment path from patients with private insurance, but this might be because they were also diagnosed later.
  • Medicaid isn’t as good as private insurance, but it’s better than nothing. Particularly for the germ cell cancers, Medicaid patients had much better outcomes than uninsured patients even though they did not fare as well as the patients with private insurance. Medicaid certainly has its administrative and funding/reimbursement challenges as a government bureaucracy reliant in part on state government sources, but does anyone seriously believe this is causing the cancer patients in their population to die in such large numbers? I’m all for innovations to make Medicaid as efficient as possible so that it can serve these populations as effectively and cost effectively as possible, but the idea that is it a hindrance to care for people who can’t afford private insurance is simply not borne out by the evidence. One learning point from these studies for Medicaid plans is to do more to encourage their populations to get cancer screenings so that these cancers can be caught earlier, but that doesn’t fully explain the insurance disparities.
  • These comparisons don’t represent realistic policy choices. I don’t know of anyone on either side of the aisle who has proposed putting the Medicaid population on private health insurance plans like the ones employers offer to their employees. Republicans would balk at the high cost to taxpayers, and Democrats would balk at the high levels of cost sharing for poor people who can’t afford it as well as the involvement of private insurance companies in general. Sure, some private health insurers have contracts with state governments to administer managed Medicaid plans, but those plans still don’t reimburse physicians and hospitals the way private plans do. They’re not equivalent. Even the private health insurance plans that are available on the exchanges for people a little higher up the economic ladder than Medicaid patients tend to have lower physician and hospital reimbursement rates than most employer-sponsored or individual plans outside of the exchanges. Considering how many Medicaid patients are covered by managed Medicaid plans operated by private insurance companies, one would think these private insurers would be able to close the gap between their regular insured and their Medicaid patients. Given the very real policy implications being debated in state legislatures today, it would be interesting to learn if there are real disparities between managed Medicaid and traditional Medicaid patients, but so far that research is lacking.
  • Medicaid is not Medicare, and it’s especially not single payer. Some on the left, like Senator and former presidential candidate Bernie Sanders, have been calling for a single-payer system that would essentially be “Medicare for all.” Medicare’s reimbursement rates are lower than private insurance but higher than Medicaid, and Medicare have the same payment timeliness issues that Medicaid does because it’s funded entirely by the federal government without involvement of state governments. Unlike Medicaid, physician participation in Medicare is already nearly universal (although I don’t know of too many pediatricians who take Medicare patients today because most Medicare beneficiaries are over 65). Eliminating private health insurance and moving to a “Medicare for all” system regardless of age would bring those pediatricians and the few outliers from other specialties into the Medicare fold because there would literally be no other source of income for them if they intended to continue practicing medicine at all.
  • Achieving equally bad outcomes would be a pyrrhic victory. I’ve seen bumper stickers from conservatives that read, “Liberals want misery spread equally.” It’s a concern worth addressing. If we address these disparities by merely reducing the survival rates of people who currently have private insurance, things will be equal, but no one will be better off. For germ cell testicular cancer, the research tells us that taxpayer dollars spent on Medicaid are quite literally saving lives for people who would otherwise be uninsured. But it’s very important that we understand the complex reasons why the Medicaid population is experiencing these disparities compared to the population with private insurance and address them. My health economics professor from graduate school would say that we need to build a better model.

John Oliver buys – and forgives – $15 million in medical debt

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John Oliver, host of Last Week Tonight on HBO, did something truly incredible recently. He purchased nearly $15 million in medical debt…and then forgave it all.

As wonderful as that act of generosity was, it was barely a drop in the bucket for the gigantic problem of medical debt in the USA.

Disclaimer: It only cost John Oliver $60,000 to buy this debt, but that’s still hugely generous.

Link

Ever since the Patient Protection and Affordable Care Act (aka Obamacare) became law in 2010, Republicans have been talking non-stop about repealing it and replacing it with a health care plan of their own. But they can’t even agree on what that plan should be in broad terms or if there should be a replacement plan at all.

Some replacement plans have been proposed by Republicans to give the impression that they care about the problem. And yet a lot of hard-core conservatives just don’t think the government should even be trying to expand access to health coverage at all. They just want to repeal Obamacare but not replace it with anything…perhaps their replacement plan should be called Wedon’tcare?

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.

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.

Why YOU should care about health policy

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First of all, I’d like to welcome you to my new blog site devoted solely to health policy. I’m currently a graduate student in health administration, and I’ve also spent years working in the health care industry in areas ranging from revenue cycle management to health insurance to my current job in the public health / information technology world. There are a lot of people out there who know more than I do about these things, and a lot has been written over the years. But I’ve picked up a thing or two myself, and I’d like to share.

But isn’t this topic something that should be left in the halls of academia instead of subjecting poor, unsuspecting readers like you to jargon like “Quality-Adjusted Life Years” and “Adverse Selection Death Spiral?”

I mean, why should academics and graduate students be the only ones who have to be bored by this? I say, “Share the misery.”

But seriously. I’m writing about this topic because I sincerely believe you need to read about it. And it doesn’t really matter who YOU are. Because no matter what we study in school, no matter what we do for a living, we’re all a part of this system. We all will receive health care at some point in our lives. Plus, some of us vote, and there’s no more contentious political issue today than reforming our health care system.

We all have a stake in what happens, and the more we know, the better off we’ll all  be. So let’s get started.

Still think we can solve health care with free-market principles? Just go to the ER.

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I’m going to share a Fox News story that has its roots in the federal government’s intrusion in health care and how it led to a man’s death because he had to wait too long to see a doctor.

But it’s not the government intrusion into health care you’re probably thinking of. What really killed John Verrier was not the Patient Protection and Affordable Care Act of 2009 (commonly dubbed Obamacare, but I’ll shorten it to PPACA), but the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA).

You see, this is a story about how the government intruding in health care led to the tragic death of 30-year-old ER patient John Verrier. Verrier died in the waiting room at St. Barnabas Hospital in the Bronx  more than eight hours after he checked in. Apparently the hospital did not have a policy in place to check on people in the waiting room at the ER to make sure they were still present or alive — even after they called his name to be seen and he did not answer.

A little background: EMTALA requires all hospitals that participate in Medicare (which is essentially all hospitals period) to evaluate and stabilize any patient who comes to the emergency room, regardless of ability to pay. Sounds like a good idea, right? I mean, who wants hospitals to turn people with emergency ailments away or dump them onto county hospitals without being stabilized just because they can’t pay the bill? Sadly, the law had to be written because that’s exactly what was happening in the 1980s at an alarming rate. People died. There have even been plenty of cases post-EMTALA where hospitals have dumped patients due to the inability to pay.

Why would hospitals continue to dump patients after EMTALA said they couldn’t? Because, as Avik Roy of Forbes wrote, EMTALA is “one of the great unfunded mandates in American history.”

So what does this have to do with John Verrier’s death? According to a report on the case in the New York Post, a hospital employee said, “He died because [there’s] not enough staff to take care of the number of patients we see each day. We need more staff at Saint Barnabas.”

It makes sense, doesn’t it? If the federal government requires hospitals to accept all patients regardless of their ability to pay, then you can expect two outcomes:

1) A lot of people will get care and not pay for it. In fact, according to the Centers for Medicare and Medicaid Services, 55 percent of emergency room care goes uncompensated.

2) A lot of those people who need care but cannot pay for it will end up in the emergency room because, unlike at a traditional physician practice or an urgent care, the ER has to evaluate and stabilize them BY LAW even if they can’t pay. So a lot of people who end up in the ER have non-emergent conditions and would be better off if treated at a lower level of care…that is, if the primary care or urgent care practice would actually treat them since they don’t have to. A study in Health Affairs revealed that:

Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. (emphasis added) Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7–27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately $4.4 billion annually.

So, here’s the perfect storm that led to the death of John Verrier. The unfunded mandate of EMTALA has led to a lot of  uncompensated care at hospitals, so it’s not surprising that hospitals like St. Barnabas don’t dedicate enough staff to the ER — it’s a loss center for them.

From my years of graduate-level study in health administration, I have my suspicions that management best practices are to staff the ER just enough to not violate EMTALA…walk right up to the line, but don’t cross it. Here in Indianapolis, we have a county safety-net hospital called Eskenazi Health. The previous facility was called Wishard Memorial Hospital.

And, according to one of my professors who would be in a position to have firsthand knowledge, there was a common saying among staff and management at private hospitals in the area: “Tube ’em to the Wish,” which meant that the hospital’s policy was to evaluate and stabilize an indigent patient just enough to not violate EMTALA and then dump the patient at the county hospital.

So, back to the understaffed ER at St. Barnabas and John Verrier’s deadly wait, it’s certainly worth considering that EMTALA played a role in his death. He was complaining of a rash, which on its surface would not seem like a life-threatening medical condition, but he was waiting for hours and hours just to be evaluated.

But, of course, I’m not suggesting that we stop requiring hospital emergency rooms to treat everyone without regard to their ability to pay — I’m suggesting that if we mandate something, we need to pay for it. After all, I’m not sure whether John Verrier was insured or not…so simply repealing EMTALA might have killed him too.

And that’s where the other federal law in this story — PPACA — can make a real difference. By passing EMTALA in 1986, we as a country established the idea that health care is a right and not a privilege and not a commodity that can be allocated by Adam Smith’s invisible hand. We just refused to acknowledge the price of this belief because we didn’t want to pay it. But of course there is always a price — there is no free lunch. It comes up in higher hospital bills and higher health insurance premiums for the rest of us. It comes up in hospitals being declared tax exempt because of the amount of charity care they provide to indigent patients.

By addressing the problem of millions of Americans being uninsured, we can reduce the problem of uncompensated care for hospitals that leads to understaffing AND we can give people with non-emergent conditions more appropriate care alternatives where payment will not be a barrier to treatment. PPACA is certainly not a complete answer to the problem, but it’s a big step. Maybe if Ronald Reagan had extended insurance coverage to all Americans back in 1986 instead of just mandating that hospitals see everyone in the ER without regard to ability to pay, then John Verrier and so many others in his situation might have lived.