Category Archives: Access to care

Nation’s First Medicaid Work Requirement Sheds Thousands From Rolls In Arkansas

Last month, you may recall, I posted an article about Medicaid work requirements in Arkansas from an article in Health Affairs.

Today, Health Affairs posted a follow-up article that reported that thousands are being shed from the Medicaid rolls in Arkansas.

According to the article, the Arkansas Department of Human Services officials announced on Sept. 12 that 4,353 people who were enrolled in the state’s Medicaid expansion program had been locked out of coverage for failing to comply with the work requirement for three months.

The agency has said those people will have until October 5 to apply for a good cause exemption if they were unable to access an online reporting portal because of network server issues that affected it and other agencies.

Source: Nation’s First Medicaid Work Requirement Sheds Thousands From Rolls In Arkansas

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Ex-UN chief Ban Ki-moon says US healthcare system is ‘morally wrong’ | US news | The Guardian

Here is an article from The Guardian newspaper that spells out what is wrong with the American health care system.

We should pay attention to what Secretary General Ban said.

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Exclusive: Former UN secretary general accuses ‘powerful’ health interests in the US of blocking universal healthcare

Source: Ex-UN chief Ban Ki-moon says US healthcare system is ‘morally wrong’ | US news | The Guardian

U.S. Near Bottom, Hong Kong and Singapore at Top of Health Havens – Bloomberg

Want medical care without quickly draining your fortune? Try Singapore or Hong Kong as your healthy havens.

Source: U.S. Near Bottom, Hong Kong and Singapore at Top of Health Havens – Bloomberg

Michigan threatens to repeal Medicaid expansion if work requirements not approved | Healthcare Dive

Note: One more state is attempting to include work requirements for Medicaid recipients, as previously posted in Arkansas Medicaid Work Requirement Failing Out of the Gate.

 

Two JAMA studies bolster critics of work requirements who say most Medicaid recipients who are able to work are already doing so, and tracking compliance will heap more administrative burden onto an already-taxed system.

Source: Michigan threatens to repeal Medicaid expansion if work requirements not approved | Healthcare Dive

Arkansas Medicaid Work Requirement Failing Out of the Gate

Health Affairs blog published an article recently about the early experience of Medicaid recipients in Arkansas after that state implemented a work requirement in June.

Last month, I wrote an article that reported that work requirements for Medicaid worsen health.

The author of the Health Affairs article, Dr. Jessica Greene, is a Professor and the Luciano Chair of Health Care Policy at Baruch College, City University of New York. She conducted in-depth interviews with 18 adult Medicaid recipients in northeast Arkansas in mid-August.

Dr. Greene admits that the interviews are too small a group to provide generalizable results, the interviews do illustrate how the state’s policy is interacting with the day-to-day lives of Medicaid recipients to produce serious potential consequences that have little to do with policy’s stated objectives.

She outlined the results of her interviews as follows:

Lack Of Awareness

Two thirds of the Medicaid recipients (12/18) I interviewed had not heard anything about the new work requirement. “First time I’ve ever heard anything [about it],” a 31-year old man, who had started a vocational training program the day we spoke, said. “You’d think it’d be on the news or something. I ain’t seen it on the news, and I watch Channel 8 news every night.”

At Risk Of Losing Coverage

Of the nine people who, based on their age, should have received a DHS letter letting them know they were subject to the work requirement, four said they had received a letter. Two said the letters indicated they were exempt because they already met the SNAP work requirement.

The other two were at risk for losing Medicaid coverage. One, a 47-year old woman, said she had received her letter about three months earlier; she believed, incorrectly, that she had three months to report her hours. When I asked her if reporting her hours was an obstacle, she said she was struggling with very stressful life issues, including a mentally ill sister, and as a result the work requirement had not received much of her attention. The other person, a 40-year-old woman, described being overwhelmed by receiving the letter: “Basically… I’m like, okay, I’ve got this letter. I file it and I don’t know what to do with it…”

The other five who should have received a work requirement letter were either not sure if the letter arrived or thought it had not. When asked about receiving a DHS letter, a 42-year-old woman said, “I don’t know, I’m going to have to check and make sure [I didn’t receive the letter], because I need my Medicaid card for my sugar pill and my blood pressure pills.” A 46-year-old man, who had recently completed an inpatient drug treatment program, kicking a multi-decade drug addiction, wasn’t sure either. “I may have [received the letter]…I’m horrible about opening mail….I probably throw’d it away.” While the three others did not believe they received the letter, they were all exempt by either working and/or having children in the home, but likely needed to report their hours and exemptions in the portal to maintain Medicaid coverage.

Policy Not Sparking Work-Related Changes

Of the nine participants who were likely subject to the policy, only two were not meeting the 80 hour work-related activity requirement and did not seem to qualify for an exemption. Both told me that they were actively seeking work, and that the work requirement had not at all impacted their job seeking. In addition, those I interviewed between the ages of 19-29, who will be subject to the policy in 2019, either worked, went to school, and/or had children under 18 years old in the home. No one I spoke with reported that the policy had or would spark them to change their work-related activities.

Online Portal Challenging For Many

Participants described a very wide range of computer and online skills and access. Approximately a third said that reporting hours on the online portal would not be possible for them: “I can’t do that. I don’t have a phone. I don’t have a computer.”

Several, who were confident of their own skills, mentioned family members who would struggle. “Half my family probably doesn’t have a smart phone….A lot of people here don’t have internet still,” a 19-year old woman explained.

Mixed Attitudes About Linking Medicaid And Work-Related Activities

Almost all the participants believed that people who could work should be working. “I believe if you are able to work and you want the extra help that Medicaid gives, then you should work,” said a 28-year old woman who was currently working and has young children. But several expressed concern about those who had mental or physical conditions that would prevent them from meeting the requirement. One man raised questions about people who were “borderline” who were not officially considered disabled but still had serious health conditions. A 42-year-old woman, who works with people with disabilities said, “I think it’ll do more harm than good…. What they supposed to do, just get cut off Medicaid because they can’t meet those requirements?”

Others raised concerns about transportation needed to get to work and volunteering. “Some people don’t have vehicles, and sometimes it’s not necessarily their fault. Sometimes something happens and they lose their money… It’s not fair,” said a 21-year old recipient who is a college student. When I asked a woman who was looking for work whether she had tried to get help from the Department of Workforce Services, she said that she couldn’t get there because it was 30 miles away and there is no public transportation.

Not Going To Lift People Out Of Poverty

Participants were very skeptical about the Governor’s claim that the work requirement policy would help them out of poverty, as many were already working and still struggling financially.

One participant argued that the policy was not about getting people to work at all, but about reducing the number of Medicaid recipients: “It seems like a ploy for the state to save money. That’s all it is. It’s nothing about trying to get people back to work…”

Summing Up

Of the people I interviewed who were at risk of losing Medicaid coverage as a result of the work requirement, most were at risk because they lacked awareness of the policy or were overwhelmed by it, rather than because they were not meeting the 80 hours a month of work-related activities or the terms of an exemption. If this is true more broadly, the state will be ending people’s health coverage for the wrong reasons, adding credence to those who argue this policy is about reducing the rolls, rather than supporting people to get employment.

A 38-year-old woman who recently had to quit her job to get her niece, who she mothers, a birth certificate and other paperwork to start school argued that the policy does not take into account the complex lives of low-income people. “You are saying this should be possible, but you don’t know my circumstances. You haven’t been here,” she explained.

Given this limited, but anecdotal survey of the experience of 18 Medicaid recipients, it is clear that this idea is not rooted in any realistic and scientific study of how work requirements will affect Medicaid recipients, but rather is another way of getting people off the roles and moving towards eliminating Medicaid altogether, which is precisely what the Republican Party has been trying to do for decades. The war on the poor continues.

 

Growing General Surgeon Shortage

On the heels of my recent post, Free Medical School Tuition Could Solve Physician Shortage, comes a new article about the shortage of general surgeons.

Friday, Reuters Health reported about a new study in the US that projected that the shortage of general surgeons in the US will get worse as the number of doctors entering the workforce fails to keep pace with population growth.

The study’s researchers predicted shortages based on their estimates of population growth by 2050, and by the number of medical schools and hospital-sponsored general surgery trainee positions.

  • By 2050, there will be a deficit of 7,047 general surgeons nationwide
  • That is higher than the shortage of 6,000 they predicted a decade ago based on the pace of population growth and new surgeons entering the job market at that time.

The lead study author, Dr. E. Christopher Ellison of Ohio State University, was quoted as saying, “Leaders in surgery have predicted a pending shortage in the general surgery workforce for more than 10 years.”

Dr. Ellison also said that, “the impact of the general surgeon shortages on patients is measured in the timeliness of care and the consequences of delays in care.”

The study was published in the journal Surgery, and the researchers noted that there should be about 7.5 general surgeons for every 100,000 people, to maintain acceptable access to surgical care.

According to the study, the number of general surgery resident positions and the number of residents completing their training has been rising in the US, but these increases have been insufficient to maintain the ideal number of surgeons for the population.

The authors stated, that if anything, the projected shortage is an underestimate.

Dr. Ellison: “We have not considered the impact of the aging population on the surgeon’s workload…Patients 65 years and older are more likely to need general surgery services, and as that segment of the population increases, there will be a corresponding increase in the demands for general surgeons.”

Ellison also added, that because most general surgeons practice in metropolitan areas, the impact of the shortage will be more keenly felt by rural communities.

The researchers assumed, in calculating the projected shortage, that some young trainees would choose subspecialties like vascular or transplant surgery, instead of general surgery. They assumed, also, that general surgeons would work for 30 years before retiring.

Two possibilities can be reached from the findings of the study: one, it is possible that the researchers have over- or under-estimated how many general surgeons will enter the profession each year and how many years they will remain on the job; and two, it is also possible that population growth estimates might change again, altering the shortage projections.

Dr. Anupam Jena, a Harvard Medical School researcher and a physician at Massachusetts General Hospital said the following: “Because there are fixed high costs to developing a general surgical practice in a more remotely populated area, we observe fewer practices in these areas. I wouldn’t call this a shortage per se, but I do think it’s a problem that as a society we need to figure out solutions to.”

Dr. Jena was not part of the study. Two solutions offered by Dr. Jena, however, were identifying ways for rural patients who need surgical care to be promptly evaluated and treated at medical centers several hours away, or it might involve encouraging graduates of both American and foreign medical training programs to work in remote parts of the country.

I’ve discussed the projected shortage of physicians in the past, but this is the first time, a specific specialty of physicians has been studied for a projected shortage specifically. And as in the past, I have suggested that medical travel could alleviate the shortage, especially in workers’ compensation.

Either we follow the suggestions of Dr. Jena and others, or we consider looking abroad for the solution to a growing problem — a shortage of general surgeons.

 

Medicaid Work Requirements Worsen Health

Back in May, I posted a link to a Health Affairs blog article, Social Determinants Of Health: A Public Health Concept In Conflict in which it was reported that the current regime was seeking to impose work requirements for people on Medicaid.

As reported then, and on Monday in a follow-up article, CMS approved the first waiver to implement a work requirement for Medicaid beneficiaries in Kentucky on January 12th.

The article stated that a couple of weeks ago, a district court found the approval of these work requirements to be “arbitrary and capricious”, and in direct violation of the Administrative Procedures Act of 1996.

According to the article, CMS failed to consider whether the waiver’s estimated removal of 95,000 Kentuckians was in line with the program’s goals of furnishing medical assistance, and the judge ordered the waiver to be returned to CMS.

It was the government’s argument, the article states, that new research into the social determinants of health demonstrate that income and employment are associated with improved health, and so a work requirement thereby fits within the goals of the program.

The case in Kentucky hinged on the fact that work requirements worsened financial assistance, which the judge pointed out is a main tenet of the program.

The author then writes that if CMS wants to use research within the social determinants of health, then he will analyze Medicaid work requirements through this lens. A recent post in Health Affairs focused on the perversion of social determinants of health as a concept, and the current post builds off that one, to demonstrate that this regime’s justification for Medicaid work requirements is misguided at best.

To illustrate this, he follows a theoretical low-income worker, a 50-year-old from Louisville, who could no longer work in his job as a longshoreman due to cardiovascular disease and suffered chest pain whenever he exerted himself. He is uninsured, has a wife and three adult children. And is also trying to find a job.

The author continues by examining the following issues: Unemployment and Health, Medicaid Improves Health, Medicaid Work Requirements Harm Those With Jobs, and concludes by stating that Medicaid Work Requirements Worsen Health.

The theoretical case of the 50-year-old longshoreman is not so theoretical, as each of the 16 Kentucky plaintiffs in the case demonstrated. One is a graduating student with endometriosis, another is a mother of four with congenital hip dysplasia, and another is a partly blind mortician (no jokes, please) with chronic lung disease. All would have risked losing their coverage as a result of work requirements.

And to make the case more clearly, your humble blogger, while not currently on Medicaid, but eventually will be, has end-stage renal disease, and does peritoneal dialysis every night at home, and goes to the clinic twice a month for blood work and to see the nephrologist. In addition, every two weeks on a Monday, as will happen this coming Monday, I have to be home to receive my supplies, and this Friday must call in another order. Working a full-time job, if one were available that matched my experience, would prevent me from doing so.

This is another reason why our health care system is broken and needs to be replaced by a single payer system that does not separate out older beneficiaries, as Medicare does, poorer ones as Medicaid does, and children and military personnel, as the other programs do.

One system for all Americans.