Tag Archives: ACA

Rural Hospitals to Fail If Medicaid Expansion Ends

In April of 2015, I wrote the following post, Hospital Closures Due to Failure to Expand Medicaid.

This morning, Health Affairs posted a brief, Ending Medicaid Expansion Would Cause Rural Hospitals to Go Under.

As the current regime in Washington, and its allies in Congress slowly dismantle the ACA, rolling back Medicaid expansion will lead to rural hospitals closing, and rural patients being forced to travel long distances to get to a hospital, or to forgo medical at all.

What impact this will have on the entire health care sector is too early to tell, and what this may mean for workers’ comp, is also speculative, but it can’t be good if hospitals in the heartland go out of business.

Some way to make America great again. On the backs of, and on the health of, rural Americans who voted for this clown.

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Number 400

Richard’s Note: The following post was taken from an article posted by Michelle Chaffee a few days ago on LinkedIn. I am re-posting it here so that you can chew on it while you are having your holiday dinner. While you are eating and having a good time with family and friends, look around the table and imagine if one of them was in the same situation Michelle was in. How would you answer the question she poses? And think about this carefully, now that the GOP tax bill has passed and 13 million Americans will lose their healthcare, and millions of children will lose theirs. Then tell me that health care is an entitlement.

Is Healthcare a Right or an Entitlement?

Published on December 12, 2017

Michelle Chaffee

Some of you who have followed my posts over the past few years know that I am a cancer survivor. It’s been almost two years since I was very unexpectedly diagnosed with ovarian cancer. I have shared some of what it’s been like to suddenly find myself in the position of being a patient after spending a career caring for people who are sick, believing I wouldn’t find myself on the other side of this equation. I still struggle with the reality that I have had cancer and that I will have to monitor for it rearing it’s ugly head, for the rest of my life. What I haven’t shared is how the costs of healthcare contributed to my situation, delayed diagnosis and increased my chance for a recurrence. I am sharing it now because as I continue on this journey, I am starting to think the current system is discriminatory and I know it needs to change.

When I was diagnosed with ovarian cancer, I hadn’t been to my doctor for my yearly recommended examination for about 20 months. When I called to make my yearly appointment, I was told I had an outstanding bill I had been unaware of because I had moved and they didn’t have my new address. The bill was a result of “coinsurance” that was from a necessary and fairly routine procedure, still it was substantial enough that I had to set up payments over time because I couldn’t afford to pay it in full. I was told I could not see my doctor until there was a zero balance. I felt fine and had no concerns of any illness so I skipped my routine exam that year. Fast forward almost 2 years later when an unusually potent migraine resulted in a suggestion by my neurologist that I get my hormone levels checked. I contacted a new gynecology group because I couldn’t be seen by my regular ob/gyn because of the balance that still remained. On this routine exam, a very large mass was found on my ovary. So large that even though I was assured it was benign, it needed to be removed. During the surgery, the mass ruptured but the doctor told me not to worry because “It’s not cancer.” She told me the rupture was because it was so large that it made it difficult to remove. She called me about a week later to tell me it was in fact, cancer and the rupture, unfortunately complicated the staging and made recurrence more likely. The fact is, if I had gone to my regular appointment, it would have been discovered when it was much smaller and may not have ruptured. I am not blaming the doctor or the organization where I received care but, it wasn’t discovered because I owed the clinic money and they wouldn’t see me until the bill was paid. I don’t let myself think about that too much, but it’s the truth and it’s the way healthcare works in our current system.

The cost of just the surgery to remove the cancer was over $250,000. This included just one night in the hospital and no chemotherapy or radiation treatment. I had a good insurance plan but even with that, my responsibility was over $30,000. I can safely say most Americans would find it a challenge to add that expense to their yearly budget. The ongoing costs of testing for a possible recurrence are approximately $20,000 every year. That is on top of the nearly $10,000 I pay in premiums each year because I am self employed. I can’t afford this so I stretch out the time between scans and labs further than my doctor recommends.

In the back of my mind I know this could mean I don’t detect something as soon as I should again and that it can literally mean the difference between life or death.

I also know that if I owe a balance again at the hospital where I get my testing, they can refuse to treat me and I have been down that road before.

So as I write this, I find myself waiting again to find out if something discovered on a diagnostic test done almost 9 months after the doctor ordered it, is something that could take my life. Not only that, I brace myself for the cost of repeated imaging, biopsies and what may follow and I am angry, frustrated and of course, afraid. I know I am not alone and for many, it has been worse. I have worked in healthcare long enough to remember when people were denied insurance coverage because they had an illness like cancer or diabetes or a heart defect. I heard the desperation of new mothers who were grateful their precious newborn had received life saving heart surgery but had already reached their life time insurance maximum and had no idea how they would pay for the ongoing care their child needed to stay alive. The Affordable Care Act changed some of that, at least we aren’t denied coverage but it costs too much and patients can still be denied care if they owe a system money. So we constantly pray we don’t get sick again and try to find the right balance between what we can afford and what will keep us alive.

For those of you out there who say “Healthcare isn’t a right,” I tell you to save your breath unless you have faced a condition that could take your life or the life of someone you love.

To those of you who say patients should forego a smartphone or daily “fancy” coffee drink in order to pay for healthcare I say, what fantasy world do you live in where eliminating those things would make even a miniscule dent in the healthcare costs millions face?

You can also put aside the delusion that someone is sick because they did something wrong. I hate to break it to you but just because you exercise, eat healthy or have no family history of disease doesn’t mean you are magically immune to a life changing diagnosis. It can happen to anyone and I am walking proof of that reality. I ate right, exercised, never smoked, have no family history of cancer and like millions of others in this country I got sick anyway.
I find it especially ironic as I travel to other nations and collaborate with healthcare leaders to improve delivery of care to their citizens that I, a struggle to access the care I need in the United States of America. So I pose the following to ponder:

Should we get the same rights as prisoners?

Shouldn’t we at least get the same rights that criminals in this country get? The supreme court has held that those under government control must have “ Adequate food, clothing, shelter, and medical care as a component of the protections accorded by the Eighth Amendment and that “Deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain,’… proscribed by the Eighth amendment,” equating this pain with cruel and unusual punishment. Does “Cruel and unusual punishment” only apply to prisoners? It seems pretty cruel to make law abiding citizens suffer because they can’t afford medicine or treatment or to force them to choose between food or medical care.

Are we discriminated against if we are sick?

It used to be that healthcare provided through programs like Medicare, Medicaid and CHIP seemed sufficient to mitigate an accusation that there was discrimination based on a citizen’s ability to pay for adequate healthcare. Unfortunately, over time there has been an increasing group of Americans that don’t meet the criteria to receive these supplementary services but also can’t afford the cost of the healthcare available to them. I don’t consider myself poor but I can’t afford $30,000 a year or more for basic healthcare. Do I have the same rights to life and general welfare as anyone else? If treatment to save my life is available, should I be denied it because I don’t have the ability to pay? Did the founders of our country mean to make good health only available to the wealthy? It isn’t just what used to be considered the poor or elderly who can’t afford basic healthcare or medication anymore. Hard working people who have made contributions to their communities and are necessary to our countries security and growth can’t afford necessary care. This is a problem for all of us.

Where do we draw the line?

For those of you who continually argue that the government doesn’t pay for our car insurance or life insurance I will explain the difference. Driving a car isn’t necessary for survival, neither is providing an inheritance for your heirs. These things aren’t the same as access to professional healthcare services that prevent you from dying. Suggesting these things as examples of why healthcare isn’t a right, is a faulty argument and insulting to anyone who is sick. Our founding fathers and leaders were concerned for the health and welfare of our citizens. Franklin D. Roosevelt even tried to enact a “Second bill of rights” that included access to adequate medical care and the opportunity to enjoy good health. They couldn’t have imagined how costly healthcare would become as the model ushered in with the advent of health insurance, has progressed and costs have skyrocketed. I am not even insisting the government cover the cost. Even making it affordable, meaning something I can pay for that doesn’t consume my entire grocery budget for a year is a good place to start. At the very least, insuring people with truly life threatening disease have an opportunity to take advantage of the treatment we can provide seems reasonable to me and maybe it’s time to make it an undeniable right of every American.

Gallup Poll Says Americans Equally Divided on Single-Payer

Don McCanne, former President of the Physicians for a National Health Plan posted a New York Times article that said that Americans are equally divided over support for single-payer versus private insurance.

The article also said that support for single-payer edged up 10-points from last year, and closed  a 27-point gap since 2010.

This year’s survey, conducted Nov. 2-8, indicated that 48% preferred the private health insurance system and 47% preferred the government-run system.

Here is the breakdown by party:

Favor government-run system
22%  Republicans/Leaners
67%  Democrats/Leaners

Favor system based on private insurance
76%  Republicans/Leaners
29%  Democrats/Leaners

When asked if they had an opinion on “Medicare for All”, the majority said they did not have enough information.
17%  Favor
21%  Oppose
61%  Don’t know enough to say

While private insurance is still favored, if only by a percentage point, time will tell as the GOP’s tax plan takes effect and wipes out the middle class, whether that poll changes in the direction of single-payer.

GOP Tax Reform: Say Goodbye to the Middle Class

As a student of American Social history, I am acutely aware that for much of the 241 years of the Republic, the majority of the American people were not what we today would call “Middle Class.”

In fact, they were cash poor, dirt farmers, tradesmen, owning very little except what they could carry on a horse, mule, or in a wagon as they migrated west in search of better opportunities.

Until the New Deal, the Middle Class as we know it did not exist in such great numbers. True, there was a middle class in the cities and towns of the East Coast and Midwest, but most of them were descendants of immigrants from the 17th and 18th centuries, and rose steadily into the middle class as the nation’s economy shifted from a mercantile to an industrial economy in the first half of the 19th century.

Consider the following quotes from three US presidents regarding the power of money and corporations. You will notice that none of them are wild-eyed radicals in the least.

“I hope we shall crush in its birth the aristocracy of our monied corporations which dare already to challenge our government to a trial by strength, and bid defiance to the laws of our country.”

Thomas Jefferson

“Mischief springs from the power which the moneyed interest derives from a paper currency which they are able to control, from the multitude of corporations with exclusive privileges… which are employed altogether for their benefit.”

Andrew Jackson

“I see in the near future a crisis approaching that unnerves me and causes me to tremble for the safety of my country. Corporations have been enthroned, an era of corruption in high places will follow, and the money-power of the country will endeavor to prolong it’s reign by working upon the prejudices of the people until the wealth is aggregated in a few hands and the Republic is destroyed.”

Abraham Lincoln

So it is no surprise that the Republican Party is ramming down the throats of the American middle class, a tax reform bill that will effectively wipe out the remaining members of the middle class, and redistribute the wealth to those making over $75,000 and those at the very top, the oft-mentioned 1%.

My fellow blogger, and unsuccessful Democratic candidate for County Legislator in upstate New York, Joe Paduda, wrote a very potent analysis of the GOP tax scam legislation. Yes, I did call it a scam, but that is not my word. Others have used it in the past few days in an effort to derail and stop it from passing.

Besides destroying the middle class, it will as Joe points out, bankrupt the health care system. Then we will have to go all the way to a single-payer system just to get the whole thing working again.

Here is Joe’s piece in its entirety:

The tax bill’s impact on healthcare or; If you like your cancer care, you can’t keep it.

        

The GOP “tax reform” bill will directly and significantly affect healthcare. Here’s how.

It removes the individual mandate, but still requires insurers to cover anyone who applies for insurance. So, millions will drop coverage knowing they can sign up if they get sick.

How does that make any sense?

Here’s the high-level impact of the “tax bill that is really a healthcare bill”:

The net – healthcare providers are going to get hammered, and they’re going to look to insured patients to cover their costs.

The real net – The folks most hurt by this are those in deep-red areas where there is little choice in healthcare plans, lots of struggling rural hospitals, and no other safety net.  Alaskans, Nebraskans, Iowans, Wyoming residents are among those who are going to lose access to healthcare – and lose health care providers.

Here are the details.

According to the Commonwealth Fund, “repeal would save the federal government $338 billion between 2018 and 2027, resulting from lower federal costs for premium tax credits and Medicaid. By 2027, 13 million fewer people will have health insurance, either because they decide against buying coverage or can no longer afford it.”

Most of those who drop coverage will be healthier than average, forcing insurers in the individual market to raise prices to cover care for a sicker population. This is how “death spirals” start, an event we’ve seen dozens of times in state markets, and one that is inevitable without a mandate and subsidies.

For example, older Americans would see higher increases than younger folks. Here’s how much your premiums would increase if you are in the individual marketplace.

So, what’s the impact on you?

Those 13 million who drop insurance, which include older, poorer, sicker people, will need coverage – and they’ll get it from at most expensive and least effective place – your local ER. Which you will pay for in part due to cost-shifting.

ACA provided a huge increase in funding for emergency care services – folks who didn’t have coverage before were able to get insurance from Medicaid or private insurers, insurance that paid for their emergency care.

From The Hill:

[after ACA passage] there were 41 percent fewer uninsured drug overdoses, 25 percent fewer uninsured heart attacks, and over 32 percent fewer uninsured appendectomies in 2015 compared to 2013. The total percent reduction in inpatient uninsured hospitalizations across all conditions was 28 percent lower in 2015 than in 2013. Between 2013 and 2015, Arizona saw a 25 percent reduction in state uninsured hospitalizations, Nevada a 75 percent reduction, Tennessee a 17 percent drop, and West Virginia an 86 percent decline.

If the GOP “tax bill” passes, hospital and health system charges to insureds (yes, you work comp payer) are going to increase – and/or those hospitals and health systems will go bankrupt.

What does this mean?

It means we of the middle class had a very good run, but the ruling class has spoken, and they want us to disappear, or at least shrink to the point that we become unimportant to their pursuit of greater wealth. Why else would the donor class of the Republican Party, the Koch Brothers, the Mercer family, Sheldon Adelson, and the rest of their donors threaten members of Congress with no more funds for their re-election if they fail to pass this bill?

There is a word for that, it’s called Extortion. And we are the sacrificial lambs.

No Paradox

Sometimes, the solution to a problem is staring you right in the face, but you refuse to see it because you are blinded by your perceptions, your beliefs, or the distortions others have placed in your mind by lies and falsehoods spread about the real benefits of the solution, or the downsides.

Case in point, the question of single-payer health care in the US. The health insurance industry and their lobbyists and defenders in Congress have done a great job poisoning the minds of many Americans against the idea of single-payer, whether on ideological or economic grounds.

Yet, many of these same Americans are getting some form of government-sponsored health care, either Medicare, Medicaid, Tricare, or health care through the Veterans Administration. So, it was striking that before the enactment of the ACA, many Tea Party protesters shouted or carried signs that read, “Keep your hands off of MY Medicare!”

What they did not know or realize, was that it wasn’t THEIR Medicare, but the government’s Medicare. They were ones receiving the benefits.

So, it struck me this morning when I read an article by Tom Lynch of the Lynch Ryan blog, Workers’ Comp Insider.com.

The article, The American Health Care Paradox: A Lot Of Money For Poor Results, compares the US health care system with the health care systems of the OECD nations (Organization for Economic Cooperation and Development).

The OECD has 35 members, of which the US is one, and was formed in Paris in 1961. They promote policies that will improve the economic and social well-being of people around the world. It also performs annual comparative analyses of issues affecting its members.

Health care is one such issue, as is life expectancy, infant mortality, obesity, and death rates from cancer, among other health care-related topics.

But regarding health care, as Tom reports, on a per capita basis, we spend 41% more on health care than our wealthy nation peers in the OECD, and 81% more than the entire OECD average.

The following graph indicates amount of public versus private funding of health care among the OECD nations, as well as the OECD average. The light blue bars indicate private funding; the dark blue bars indicate public funding.

OECD Health Care Funding — 2015

According to Tom, while our public funding (Medicare, Medicaid, etc.) is comparable to many of the other countries in the OECD, private funding in the US is more than 100% greater tham Switzerland, and 300% greater than the OECD average.

Life expectancy:            US: 78.8 years (76.3 men, 81.2 women)
UK: 81 years (79.2 men; 82.8 women)
Japan: 83.9 years (80.8 men; 87.1 women)

Infant mortality:          US: 6.1% (per 1000 live births) 45% higher than UK at 4.2%, and 265%                                                higher than Japan’s at 2.3%.

Obesity and overweight rate is exceeded only by New Zealand. Finally, the rate of death from cancer per 100,000 people is 188, Mexico’s is 115, Japan’s is 177. But we lead the world in smoking cessation (whoopee!). So, I guess we can all breathe easier now than the rest of the world, especially the third world where so many start smoking at a very young age.

Into this discussion, Tom throws the current Republican tax plan, which he rightly says will throw 13 million people off of health care, and see $25 billion cut from Medicare.

Tom says that fixing health care will take time and a lot more money, and he is skeptical that the GOP tax scam will do that.

Duh! Of course it won’t. That’s the whole point of the tax scam and the umpteenth attempts to scuttle the ACA. They don’t believe in health care as a right for all Americans. It is in their DNA as Libertarian Conservatives. They are not Republicans, at least not like the two Republican presidents who tried to get health care passed, Theodore Roosevelt and Richard Nixon.

No, they want the money for their fat cat donors. They even said so publicly and bragged about it. And if all those votes to repeal and replace ACA didn’t convince you that they are fundamentally opposed to any government-sponsored health care, except their own, then you are blind.

The solution is staring you in the face on the above chart, Every other OECD member nation spends more publicly for health care than we do privately, and we are getting bad outcomes. Why is that? It is because health care is not like other consumer goods, and therefore should not be funded or marketed by private companies.

It is long past the time we should follow suit and do what every other OECD country has done, create a single-payer, improved Medicare for All system and stop fooling ourselves that the private market works. It does not, and the proof is in the metrics on cost, life expectancy, infant mortality, obesity and cancer deaths, etc.

Foreign Patients Get Liver Transplants in US Hospitals First

ProPublica, those lovely folks who published several articles some time back on workers’ comp, are at it again.

This time, they are focusing their ire on how foreign patients are getting liver transplants at some US hospitals ahead of Americans waiting for such transplants.

The story, published yesterday, was co-published with a local Fox station in New Orleans.

From 2013 to 2016, New York-Presbyterian Hospital gave 20 livers to foreign nationals who came to the US solely for a transplant, essentially exporting the organs and removing them from the pool of available livers to New Yorkers.

Dr. Herbert Pardes (I was familiar with his name from living in NY), wrote that, “Patients in equal need of a liver transplant should not have to wait and suffer differently because of the U.S. state where they reside.”

Dr, Pardes was the former chief executive, and is now the executive vice president of the board at New York-Presbyterian.

Yet, according to the story, Dr. Pardes left out NY-P’s contribution to the shortage, as stated above from 2013 to 2016.

These 20 livers represent 5.2 percent of the hospital’s liver transplants during that time, which was one of the highest ratios in the country.

ProPublica reported that unknown to the public, or to sick patients and their families, organs donated domestically are sometimes given to patients flying in from other countries, who often pay a premium. Some hospitals even seek them out.

A company from Saudi Arabia said it signed an agreement with Ochsner Medical Center in New Orleans in 2015.

The practice is legal, according to the story, and foreign nationals must wait their turn in the same way as domestic patients. The transplant centers justify this on medical and humanitarian grounds, but at a time when we have an Administration touting “America First”, this may run counter to the national mood.

The  director of the transplant institute at the Mount Sinai Hospital in New York, Dr. Sander Florman, said he struggles with “in essence, selling the organs we do have to foreign nationals with bushels of money.”

Between 2013 and 2016, 252 foreigners came to the US purely to receive livers at American hospitals. In 2016, the most recent year for which there is data, the majority of foreign recipients were from countries in the Middle East, including Saudi Arabia, Kuwait, Israel and the UAE. Another 100 foreigners staying in the US as non-residents also received livers.

At the same time, more than 14,000 people, nearly all Americans, are waiting for livers, a figure that has remained very high for decades, they report. By comparison, fewer than 8,000 liver transplants were performed last year in the US, an all-time high. National median wait time is more than 14 months, and in NY, the time is longer.

In 2016. more than 2.600 patients were removed from waiting lists nationally, either because they died or were too sick to receive a liver transplant.

All this is happening at a time when the party in power is seeking to take health care away from those who recently received care for the first time in a long time from the ACA, and at a time when the medical travel industry is focused not on transplant surgeries, but on boutique treatments and surgeries for wealthy or upper middle class Americans to go abroad for bariatric, plastic or reconstructive surgery, knee surgery, dental care, etc.

And yet, when the very idea of medical travel is broached in the medical community, it is disparaged and discouraged by physicians and others as unsafe, impractical, and not worth the effort, Obviously, it is well worth the effort on the part of foreign patients to come here and take organs meant for Americans, so why not allow Americans to take their organs?

Is it because the hospitals that supply these organs to foreign patients are making huge sums of money, and the poor schnook American with liver disease (or kidney disease, as in the case of yours truly) must die so that an American hospital can improve its bottom line?

It is high time to cut the crap and promote medical travel the right way and for the right reasons, not only for those who can afford it, but those who need transplants and can’t get them here.

That is the true nature of the globalization of healthcare…a two-way street.

 

CMS Proposes to Allow States to Define Health Benefits

A connection of mine today posted a link to a CMS Fact Sheet in which they propose to allow states to define essential health benefits beginning January 1, 2019.

According to the fact sheet, this rule is intended to increase flexibility in the individual market, improve program integrity, and reduce regulatory burdens associated with the PPACA in the individual and small group markets. (See my post, “Regulation Strangulation“)

The rule also includes proposals that would provide states with more options in how the essential health benefits (EHBs) are defined for their state, it would also enhance the role of states related to qualified health plan (QHP) certification, and to provide states with additional flexibility in the operation and establishment of Exchanges, particularly the Small Business Health Options Program (SHOP) Exchanges.

Finally, they propose to permit states to reduce the magnitude of risk adjustment transfers in the small group market to minimize unnecessary burden, and proposes other changes that would streamline the Exchange consumer experience and the individual and small group markets.

What does this really mean?

Anytime the federal government attempts to allow the individual states to determine or define certain social benefits, we end up with a hodgepodge of rules, regulations, costs of impairment, etc.

We know that in certain states, the loss of a body part in one state has an impairment value different from the same body part in another state, according to the ProPublica report .

So when I see that CMS wants to allow states to define what essential health benefits are,  we have to ask ourselves, what do they mean by essential, and is one state’s essential health benefits, another state’s burden?

I understand that certain states, particularly so-called “Red” states with conservative governors and legislatures, will be free to decide that certain treatments and procedures are just too expensive for them to cover, or that they violate the ethical or moral sentiments of the community in the state, i.e., abortion, birth control, sexual reassignment surgery, etc.

Allowing states to define and decide what is essential and what is not, may be harmful to the health of many of their citizens, even if it saves the state money.

And I am rather leery of CMS’s desire to “strengthen” the individual or small group markets, because who decides what constitutes strengthening, and who makes those decisions and under what circumstances.

Rather than allowing legislators and governors to decide what medical care their citizens can receive in their state, rather than trying to shore up a market, whether it is the individual market or the group market, we should move to provide all Americans with the same health care and the same medical benefits, coast to coast, under a Medicare for All plan.

Anything less would be worse than what we have now, and would be more costly and more complex and confusing. This rule should be scraped.