Progress Notes features doctors and medical students across the country on the frontlines of our health care system. Our views and experiences are diverse, but we share common goals and values. We speak up to move toward a future where everyone can have access to affordable, high-quality health care. Please share our posts, and follow us on Facebook and Twitter!
If you have read some of my previous blog posts, you might think I add WAY too many links to my source material. I am not going to include any links in this piece.
The truth is, I have invested almost 5 years of blood, sweat and tears into ensuring that the Patient Protection and Affordable Care Act was written, passed by both houses of Congress, signed by the President of the United States and survived a Supreme Court Challenge. Now I am spending my time doing my best to see that the law is implemented. As much as anyone, I am terribly frustrated with the deficiencies of the website healthcare.gov. I am more frustrated that a few million Americans may see their health insurance premiums rise as their old policies are cancelled by insurers while making just too much income to qualify for offsetting tax subsidies. These folks, especially if they are healthy, may not feel that there is any benefit to them to purchase a more comprehensive health insurance policy that they rarely use.
But here’s the deal: we are all going to be better off. By expanding the individual health insurance marketplace, we will see health insurance premiums stabilize. This has not been the case for the past 30 years. We have seen double digit premium rate increases, year after year, through many presidential administrations, without any legislation passed to protect consumers. The Affordable Care Act finally protects consumers. The law mandates that insurance companies spend at least 80% of all premium dollars collected on your health care, a needed provision when all of the major insurers’ CEOs get paid tens of millions of dollars every year. The law forbids insurers from continuing the horrible practice of rescission, where policy holders are suddenly dropped once an illness is discovered. The law ensures that your policy is renewable even if you get sick. The law provides consumers access to an affordable policy, one that does not turn them away for having a pre-existing condition as trivial as heartburn or allergies. The law prevents an insurer from cutting off support for medical bills since annual and lifetime benefit caps are no longer.
The law has baked into it pilot projects attempting to revolutionize health care delivery systems. Currently, we have a fragmented system – hospitals, doctors’ offices, pharmacies, and other providers administered care without much coordination. The right hand of the health care system often was not aware of what its left hand was doing. But coordinated care is now the hottest topic in health care thanks to the dialog begun by the Affordable Care Act. The law has allocated funds for these pilot projects, although many coordinated care initiatives are being led by private hospitals, insurers and communities because of its transformative potential. This would not have been so without the national debate begun with the Affordable Care Act.
I must admit, the single greatest driving source inspiring me to advocate for the Affordable Care Act are the innumerable uninsured patients I have cared for in Emergency Rooms, Hospitals, Free Clinics, and my office – beginning in medical school over 17 years ago. I do not ever want to say to a patient, who is desperately asking me “how am I going to afford this,” that I am not sure how we will obtain a test, procedure or life saving medicine. I want to be able to say, “You’re covered.”
The Affordable Care Act has standardized – across Medicare, Medicaid, Tricare and private insurers – that preventive care is to be provided without out of pocket costs (co pay or deductible). My practice experience has made it crystal clear that out of pocket costs shape the decisions of patients. If it is unaffordable, they will delay needed care. Without out of pocket costs for preventive care, it’s not quite as much of a challenge to help patients participate in recommended disease screenings.
Underappreciated by all, The Affordable Care Act is going to encourage providers to focus much more on the costliest element of our health care system: those individuals who require complicated, ongoing, disease management. When chronic care is executed poorly, preventable complications occur in patients with skyrocketing downstream costs. Our sickest patients with the greatest need represent 84% of total health care expenditures – 99% of all Medicare spending. The Affordable Care Act is going to encourage providers to screen for chronic diseases and intervene early while those conditions are still easily manageable using effective and efficient coordinated care. This will allow us to reduce health care spending for all of us – everyone who pays taxes and everyone who pays health insurance premiums.
The mantra of the Affordable Care Act among “insiders” mirrors the mission of the Institute of Healthcare Improvement – better individual care, better population health, at a lower cost for all. This is the so-called “triple aim” drilled into us by Dr. Don Berwick. I strive for this, as I know the 16,000 members of Doctors for America do every day.
You cannot communicate all of this in a sound bite. Even harder is communicating all of the provisions in the law in a discrete period of time (think cable news). I can speak ad nauseum about our $2.3 Trillion dollar health care system – we spend more on health care than the size of the entire national economy of all but 6 other countries. It is remarkable, and discouraging, to know how complex our health care system is and just how complex this law is, meant to attempt to improve just about every aspect of it.
The Affordable Care Act will improve our health care system so long as it is allowed to work and provided some help in properly achieving implementation. I am privileged in my career to have been witness to the most affluent and high tech care in the Duke Medical Center Intensive Care Units and the most impoverished care on the trauma surgery service at the District of Columbia’s General Hospital. After taking care of thousands of patients in my lifetime, and immersing myself in health policy in the last 5 years, I want to see the Affordable Care Act succeed.
Success will depend on advocates like Doctors for America sticking with this effort – learning about loopholes and problems and applying the proper fixes to the law. This has a long tradition in our great nation. After Medicare’s passage in 1965, there have been both major and minor changes to the program every year to make it better. The Affordable Care Act has the same potential to improve year-after-year.
The Affordable Care Act is here to stay, but without better public education and understanding, the effectiveness of the law is in jeopardy. It would be foolish to abandon this critical law simply because a website is temporarily not functioning. A website can be fixed.
We need to meet the Americans who are losing their previous insurance policy and make too much to qualify for a subsidy. These folks are angry, and understandably so. I hope with good information, they will see that they will benefit in the long run. I hope they never have to learn of the protections of their new policies due to a devastating illness, but I am glad if they get sick they will avoid bankruptcy.
Every victory for this law brings new challenges, and that’s OK by me. The law was never going to be perfect and fix everything. It’s a start. I have a feeling that I and my colleagues at Doctors for America will need to continue to work to improve our healthcare system for quite some time to come. We plan to see this through.
All day today, the EPA is holding a public hearing for comments regarding proposals to cut carbon emissions from existing power plants. Here is what I plan to say during my speaking slot tonight:
Existing power plants create 38 percent of the carbon pollution in the United States, making them the largest single source of carbon in our environment. They also create 32 percent of the total greenhouse gases produced in this nation. I applaud the EPA’s efforts to regulate the toxins, acid gases, heavy metals, and smog-forming and soot-forming emissions from newly built power plants, but there should be standards for existing power plants as well.
I see the results of carbon pollution in my practice, especially during the summer months. I can predict which of my patients will come to see me on hot and humid days. My patients with asthma, who normally can live a healthy life with the help of maintenance inhalers, will come see me on those days. I take care of a 21 year old female, who is normally full of life. She was a cheerleader in high school and now is pursuing her college education. Her smile brightens everyone’s day around her. But on a hot and humid day in my home state of Virginia, I know she will call. She will come in to my office, gasping for air, with wheezing I don’t need a stethoscope to hear. She does not smile on these days. I know she is coming in on the hot and humid days because the soot (a.k.a. fine particulate air pollution) that is produced by coal fired power plants will enter into her airway and cause intense inflammation that even her usual asthma inhalers cannot control. I think the American Lung Association has said it best - the inflammation caused in the small airways from soot is like a sunburn inside your lungs. Now, since I do not have asthma, that sunburn is survivable for me. But for someone with asthma, emphysema or other lung disease, that sunburn can lead to lost days of school, work, doctor’s visits, ER visits, or death.
Conservative estimates show that regulation carbon pollution will lead to 20,000 fewer hospital and ER visits for those with lung disease, 3,000 fewer heart attacks and 30,000 fewer deaths annually. Reducing carbon emissions will cut asthma exacerbations by 1.4 million cases per year, and prevent 2.4 million missed days of work and school. This is a health imperative, and an economic imperative as I likely don’t need to inform you of the costs of health care considering our recent public debates.
As recently as 2 days ago, it was reported in the New York Times that an 8 year old in China was diagnosed with lung cancer. 8 years old. Her physician attributed her lung cancer to air pollution since she lived in close proximity to busy roads. The province where she lives has been shrouded in a haze of smog in the last month. How many more children need to get lung cancer before we act? Lung cancer is the #1 cause of cancer in China, fastest growing in individuals between the ages of 3 up to 50 regardless of their smoking status. This 8 year old girl was not a cigarette smoker, but rather a victim of her environment. In fact, the World Health Organization estimates that air pollution is responsible for 40% of premature deaths worldwide. The National Academy of Sciences has estimated that air pollution has shortened the lifespan of Chinese citizens by 5 years.
The Clean Air Act has led to longer life expectancies for Americans since it was passed. All of us have something to gain from reducing carbon emissions:
fewer cases of lung cancer and heart disease for non-smokers
fewer ER visits and hospital stays for those with lung disease, reducing our health care costs
fewer missed days of school and work for those with asthma and other lung diseases, leading to a more productive society
I took the time to drive here tonight from my home about an hour away in Fredericksburg, Virginia to advocate for my patients, to advocate for our strained and expensive health system, and most of all, to advocate for my 3 year old son who I do not want to end up like that poor 8 year old in China.
EPA Public Hearing
November 7, 2013
Christopher Lillis, MD, FACP
Member, Board of Directors, Doctors for America www.drsforamerica.org/
Member, Health and Public Policy Committee, Virginia Chapter American College of Physicians
Columnist, Free Lance Star Newspaper, Fredericksburg, VA
I posed the following questions to a few trusted sources, and pasted below are the responses back I have so far. If I get more responses, I will follow again with another post.
1) Is it safe to assume that the worst case scenario will be about 5 million people will fall into the "gap" of getting their old insurance dropped AND having an income too high to obtain a tax subsidy?
2) Can we do some "real" calculations for these folks? How much will these folks save when they no longer need to pay out-of-pocket for preventive care? Can we quantify the savings for someone who has a catastrophic illness who will now have the benefit of an out-of-pocket maximum?
3) What would the impact be on the insurance market as a whole if insurers were permitted to write policies that DO NOT cover pregnancy for individuals over the age of 50? It seems this element of the minimum benefits package is especially onerous for those who do not qualify for subsidies and have higher premiums.
Daniel Polsky, Executive Director, Leonard Davis Institute of Health Economics at UPenn replied:
“There are good questions. I don't know the answer to any of them except that I can't imagine coverage for pregnancy for women over 50 having any relationship to the final premium.
I would frame question 2 differently. The folks getting the letters were clearly very price sensitive when they purchased their last policy, but were they "rational" in the sense that they understood the benefits and chose a lower cost policy as their optimal plan? I think the administration's point of view is that these individuals did not make a rational purchase in that they would have regretted their choice in hind site after getting sick because they would have only then realized that they did not really purchase a product that offered the type of protection from loss that they had originally thought. If the individual market was a failed market because of the information problems then the paternal minimum benefits will improve welfare. But if the market was working, eliminating these plans will create some real losers in the trade, particularly among those who don't get compensated with a subsidy. But as I said to my friend who will have to pay $300 more a month, what you are buying is real insurance. If, God forbid, something happened to someone in your family your insurance may cover you until the end of the policy year, but you'd have a tough time getting a policy for that same price (if at all) the following year. So that extra $300 is buying you real insurance for the first time….in my mind, the most important added value will be the guaranteed issue and renewability at premium rates that are not determined by health status. Much of the focus has been the added value within the given plan year, but the real value only gets discovered when the healthy folks get sick and would have found themselves with few options within the individual market. ”
Henry Aaron, Bruce and Virginia MacLaury Senior Fellow, The Brookings Institution responded:
“3. I would be amazed if the impact of covering pregnancies for women over 50 were more than .01 percent. But this coverage strikes me as particularly important for pre-menopausal women over 50, as their pregnancies, rare though they surely are, are extremely high risk. That is the sort of thing we have insurance for. And once one starts saying that particular groups will not be covered for selective conditions that they cannot or are unlikely to have, one is on the road to de-pooling and risk selection.”
This piece does a masterful job of concisely showing, through video evidence, of why the ACA has had a no good, very bad day.
As an advocate for the ACA, I too am guilty of repeating the phrase, “if you like your plan, you can keep it.” However, as several journalists wrote about yesterday, turns out that ignored the reality that many health insurance plans individuals purchased on the open market prior to the ACA would not exist after implementation of the ACA.
Data existed in 2010 showing that health insurance policies bought by individuals prior to enactment of the ACA would not comply with the minimum benefits standards of the ACA. That data led experts to predict that anywhere from 50-75% of those policies - purchased by individuals - would not comply with the ACA. Prior to the ACA, roughly 14 million Americans bought their own insurance representing 4.5% of the population. Using worst case scenario numbers, as many as 10 million Americans may get a cancellation notice from their insurer prior to January 1, when their insurers will then need to comply with the minimum benefits packages. Turns out the slogan, “If you like your plan, you can keep it,” applied to those on Medicare, Medicaid, Tricare, the Veterans Administration, Department of Defense, Employer based insurance and of course, the uninsured - roughly 95% of the American people – but not the small percentage of Americans that already purchased an individual policy.
This has caused a great deal of anger and a great deal of fodder for opponents of the ACA. Some reasonable conservative writers are taking a more measured approach. As an advocate of the ACA, I must admit, these are not the Americans I was fighting for to get the ACA passed. The general impression of the individual market, all true, was that policies were too expensive, inaccessible to those with pre-existing conditions, and flimsy to the point of barely covering medical expenses incurred. Many in health policy circles refer to the prior policies purchased on the individual market appropriately as “junk insurance.” Deductibles in those policies were climbing, prescriptions may not have been covered, and one medical catastrophe would lead to bankruptcy despite having “health insurance.”
I was fighting for those I care for in the Free Clinics of Virginia. The 30 million people who have the potential of gaining access to health insurance if the ACA is completely implemented as designed (I’m looking at you, Governors unwilling to expand Medicaid). I was, and still fight, for those who were denied insurance due to pre-existing conditions or reached their annual or lifetime coverage caps only be told they are on their own with their medical bills.
But the fact remains that change is jarring. Kitchen table economics are very different from Washington, DC economics. Those 10 million people who may see their policy cancelled are looking at the sticker price of the new proposed policy and see often that it is higher. They remember those words, “if you like your plan you can keep it” and feel betrayed.
There is reason to hope, though. Those same individuals, in large numbers, will qualify for tax subsidies to afford their insurance. All of those individuals will be protected by more robust insurance, free from the threat of rescission, free from annual or lifetime caps, making preventive care free from out of pocket cost and ensuring that for-profit health insurers spend 80% of your premiums dollars on your health care. Looking at one of the most prominent media stories about this controversy is a Florida woman who will lose her $50 a month insurance policy. However, there is ample evidence she will be better off. You don’t have to take my word for it, just look at individuals who have done their own math.
But the media narrative will be focused on those who understandably feel betrayed who are receiving cancellation notices. Many will qualify for subsidies. All will be protected from bankruptcy if a serious illness occurs. All will have preventive care without out-of-pocket costs which saves lives. But there is going to be a population who will experience the broken promise of “if you like your plan you can keep it.” Those individuals will be middle class, making more than 400% of the federal poverty limit ($46K for an individual, $94K for a family of four) thereby missing the cut off for federal income tax subsidies. They will be among the 10 million Americans with a cancellation notice for their previous individual policy that does not comply with the minimum benefits standard of the ACA. I do not know how many Americans will fall into this trap of losing their prior policy and making too much money for a subsidy. Maybe some health economists can figure this out, but I suspect those calculations will be very difficult. We, as the advocacy community for the ACA, need to acknowledge this population and make an appeal akin to this pitch perfect piece from my favorite health care journalist Jonathan Cohn. The big picture is that our country’s health care system will be much more stable and much better off in the long run, but how much a consolation this is for those who make too much for a subsidy and lose their prior coverage is hard to predict. The most direct benefit may not be felt by those who remain healthy – they will never face the specter of financial ruin for a catastrophic illness.
With all sincerity, I apologize to those who have heard over and over again, including from me, that “if you like your plan, you can keep it” if you are among those that experiences a different reality. It remains my belief that we will be better off as a nation with the Affordable Care Act and even those who do not qualify for subsidies will directly and indirectly benefit in the years to come.
While the Affordable Care Act ends the era of denying people with pre-existing conditions access to health care, it allows insurance companies to charge tobacco users up to 50% more for their monthly premiums. Tobacco use for this purpose is defined as any self-reported tobacco use four or more times a week within the past six months. There are excellent intentions behind this policy – smoking is the number one preventable cause of death and smokers disproportionately incur health care costs due to the debilitating diseases that result from the habit. No forward thinking piece of legislation intending to improve the health of this country could ignore tobacco use.
However, this smoking surcharge makes the crucial assumption that continuing to smoke is a choice. Charging a higher premium for established smokers will either at best encourage people to stop smoking immediately in order to access health insurance or at worst deter smokers from signing up for health insurance in the first place. Nicotine is one of the most addictive substances known to man and counseling a patient to quit smoking is one of the most impactful services a doctor can provide. Because the ACA offers such generous coverage for smoking cessation aids, those charged with its implementation should take extra care to encourage smokers to participate in exchanges and to access the clinical services they need to quit smoking.
The stubborn presence of tobacco use is frustrating considering the plethora of studies that link it to so many debilitating diseases. Last month, I rotated in the Bronx at a federally qualified health center. There, I saw firsthand the incredibly high rate of smoking in a population that was mostly hidden from me in my everyday life. Though I still occasionally meet someone who smokes, the behavior has mostly retreated from populations of higher socioeconomic status and has burrowed itself and its destruction in low income families. Furthermore, since most people who smoke are of lower income, this results in an additional barrier to coverage when they have to pay an extra premium to receive coverage.
As the fight against tobacco continues to evolve, so should our policy ideas. The tobacco industry needs 5,000 new smokers every day to stay afloat. 88% of smokers began smoking before age 18. Though smoking is often seen as an adult issue, we should continue to support the many excellent anti-smoking campaigns and participate in research that helps us understand how to encourage adolescents that have started smoking to kick some butt.
Earlier this week the CDC reported that obesity levels have plateaued over the past few years. In 2012, about 34.9% of the people in this country were obese as compared to 35.7% in 2010. While some may take solace or even rejoice in this news, I can’t help but be cynical in thinking this is really not something to celebrate. This is sobering reminder that we're not seeing a change in adult obesity. The fact remains that nearly one third of U.S. children and about two thirds of U.S. adults are overweight or obese and therefore at increased risk for hypertension, diabetes, and musculoskeletal disease. Despite new campaign efforts, increased awareness among health care providers, and increased attention in the media, we are unable to budge the bulge and obesity remains a massive problem (pun intended on both counts).
Whether or not obesity itself is, in fact, its own disease entity is a topic for another day, but the fact that it increases the risk of numerous chronic illnesses is indisputable. And the fact that the health care system is in no way optimally equipped to manage obese patients is also indisputable. Tackling obesity requires engagement with the social, economic, and psychological determinants of health in each and every patient. Instead we take a piece meal approach in bandaging the chronic sequelae of obesity with medications and surgery.
Of course, given the multitude of factors at work in the obesity epidemic, there is no one group on whom to place the blame. With regard to health care providers, there are multiple financial forces and time pressures working against coordinated care and counseling for the obese patient. Not only is it more profitable to prescribe a pill or do a tummy tuck, but it is much easier both time-wise and emotionally than motivating someone towards weight loss. Behavior change is the holy grail of health care in the 21st century and given the circumstances of health care today, it remains largely elusive. It is not a fix that the doctor can prescribe, but rather it relies on the willingness and compliance of the patient—a surrender of control than many who desire to heal have difficulty accepting and attempting. However, most doctors are truly caring people with a desire to help their patients towards health and wellness. One major problem is that they lack the skills and practice to do just this.
Medical education is entirely outdated in that it does not teach how to best manage the lion’s share of today’s health burden—obesity and related chronic illnesses—that are crippling our nation’s physical and fiscal health. By and large, physicians lack the necessary skill set to motivate, encourage, and act as health coaches in partnership with patients. In a perspective published in the New England Journal of Medicine last week, researchers argue that part of the blame for the obesity epidemic lies with the way physicians are trained (1). Weight, specifically overweight, is not a topic breached in medical school, and therefore it is not on our radar as a crucial vital sign. A 2005 study of doctors-in-training found that only a small percentage even noted obesity in heavy patients’ medical histories, indicating that weight was not a priority in assessing their health (2). And while many of us can recognize overweight when we see it, probing the root causes of that overweight is akin to opening Pandora’s box…
“Information overload! Find quick fix and abort mission.”
Now finished with the preclinical portion of my medical education, I can speak to this. In total, I received approximately two hours of training in nutrition. And when I say nutrition, I mean research nutrition—a bombardment of results from studies that focus on one micronutrient and forget the rest of the food and the people who consume it. Unhelpful to say the least. I filled out a few online modules (that I could repeat over and over again until I received a passing score) and then moved on with my life, feeling completely inept at addressing dietary and weight management concerns with future patients. And this is coming from someone who has already invested countless hours reading about the latest trends and evidence in nutrition and fitness. I feel particularly bad for many of my classmates who will get questions from patients wanting to lose weight, and will have no idea how to address these concerns. And exercise prescriptions? The American College of Sports Medicine exercise recommendations (3) are nowhere to be found in our curriculum, nor are they asked on National Board Exams, so why would we bother learning them? There are already enough esoteric minutia to memorize, so I certainly cannot blame my classmates for turning a blind eye to lifestyle factors, even though they have greater relevance to the diseases and comorbidities they will encounter in practice.
Despite my persistent frustrations, there are glimmers of hope and the tide is beginning to turn. More medical education programs are incorporating what’s called motivational interviewing techniques into their curricula. This strategy helps doctors ask more effective questions to elicit meaningful answers from patients about what factors are contributing to their lifestyle choices, their attitudes towards change, and next steps towards progress. At the University of California San Francisco School of Medicine, first year students are encouraged to educate elementary and high school students about nutrition and physical activity, and the health consequences of obesity. In real-life clinical settings, students hone their interviewing and relationship skills in discussing the delicate issue of weight with patients. Finally, sessions on cultural competence and diversity in many medical schools are providing a deeper understanding of the social contributors to health, including socioeconomic and ethnic influences, which are powerful factors in diseases like obesity.
Yet as we layer on more and more elements to medical training, we must not forget that more work does not always translate to more skill and better outcomes. Indeed, the workaholic culture of medicine is often antithetical to health itself as evidenced by the high rates of physician burnout. Numerous studies have shown that “soft skills” like compassion, empathy, and communication—those exact skills needed to encourage behavior change—have been shown to diminish over the course of medical training (4,5). Hence, a core component of preclinical medical education should be empowering students to achieve balance in order to preserve their own sense of “humanness” in what is a humane calling. Pursuing balance and practicing wellness, which encompasses anything from exercise and cooking to spiritual practice and the arts, sharpens the relevance of health promotion for our patients. Doctors can be models the behaviors we desire in our patients. The physician who leads a fulfilled and balanced life is more likely bring a more preventative and integrative approach to patient care. Perhaps then we can shift the gears of that drive obesity from neutral into reverse.
1. Colbert JA, Jangi S. Training physicians to manage obesity--back to the drawing board. N Engl J Med. 2013 Oct 10;369(15):1389-91.
2. Ruser CB, Sanders L, Brescia GR, Talbot M, Hartman K, Vivieros K, Bravata DM. Identification and management of overweight and obesity by internal medicine residents. J Gen Intern Med. 2005 Dec;20(12):1139-41
3. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP; American College of Sports Medicine. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334-59
4. Chopra SS, Sotile WM, Sotile MO. Physician burnout. J Am Med Assoc 2004;291(5):633
5. Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Med Educ 2004;38(9):934-941
Great fleas have little fleas upon their back to bite 'em
And little fleas have lesser fleas, and so ad infinitum
Who knew? This famous couplet, which the mathematician Augustus DeMorgan apparently expropriated from the poet and social critic Jonathan Swift, comes from a book whose title originally (and now again) captures the essence of complex interdependency, a “budget of paradoxes”. The lines came to mind unbidden during the recent government shutdown, when I learned that in DC, where I teach and practice, hospitals were surviving on reserve funds the city tapped to pay bills normally covered by the federal government under Medicaid. By the early part of last week, those funds were nearly tapped out.
Republicans in Congress seem inclined to treat those depend upon the federal government to pay its debts as no more than pesky fleas. But for DC hospitals that provide care to a large Medicaid population, the threatened interruption of reimbursement was of great concern. Our local hospital system is already under enormous stress. With a shortage of beds, patients are “boarding” in emergency departments, sleeping on stretchers or in recliners in hallways for days on end. At my own hospital, our once beautifully appointed space now resembles a train station waiting room, with nurses, physicians, and social workers clacking away at keyboards and pleading on telephones to find places for weary patients-in-waiting. From the halls of congress to the hallways of the emergency department is a very short step, at least in this city.
Many municipal hospitals operate on a slim economic margin. If the government had defaulted on its obligations, hospitals would not have been able to pay their staff or suppliers on time. Like the bigger and lesser fleas, this process would have transferred the economic burden inexorably down a line that begins with businesses and professionals and lands squarely on the backs of patients. Delay in reimbursement would have meant more beds would close, and the people now crammed into hospital hallways would have been sleeping, or dying, in homes, attics and on subway grates.
The infinite regression of suffering that would follow from a governmental failure to pay its debts, like the bites of fleas, is something none of us, but especially those of us involved in healthcare, can ignore.
As in the rest of states using the federal government’s healthcare.gov portal to the Affordable Care Act’s marketplaces, Utahns have experienced their share of difficulties signing up for insurance. Inability to get beyond the home page or being bumped off prematurely seems to be a common complaint.
Despite the not unexpected bugs in a new and complicated information technology system, residents of the Beehive State are finding bargains and access to health insurance that was previously unobtainable. One of the most spectacular success stories is that of Phil Sherburne and his family.
Sherburne, the owner of small retail shop, could not afford health insurance for himself, his wife, and three children, for several years. After suffering a rotator cuff injury it was difficult to even find a plan that would cover him at all. He paid cash for all his families’ health care needs, including a $3000 bill his wife received after an ER visit for a gallbladder attack.
He had a heck of time accessing the marketplace. On October 1st he couldn’t get past the home page. On October 3rd he tried several times throughout the day and evening, got past the homepage, but then was bumped off. He called the 1-800 number but gave up after being placed on hold for over 10 minutes. But on October 5th he was finally successful. He found 38 available plans and found out that he and his family were eligible for a sizeable subsidy via tax credits. He considered a high deductible plan that would have cost him a mere $5 per month but eventually purchased a silver plan that, with the tax credits, will cost him $123 a month. The plan retails at $850 per month.
Once he got into the site, Shelburne was really impressed with the layout, pop-up links, and ease in comparing costs and benefit packages of the various plans. Each of the five family members required about a page of information “but once I got on to the site it took about an hour, start to finish.” He was even able to make sure his son’s pediatrician was in the plan’s network. “It was really slick,” he summarized. “Once they get the bugs worked out, it will work well and bring peace of mind to a lot of people.”
Although there has been lots of attempted and actual visits to healthcare.gov, it is difficult to determine exactly how many individuals in Utah, and in other states, have actually successfully signed up for insurance. But even if that number is currently low, there is still lots of time left for success with open enrollment available until March 31 of 2014. And as was noted in a recent opinion peace in the New York Times, folks will likely do lots of shopping before they actually buy. There were an average of 18 inquiries on the 2006-era Massachusetts Health Connector website before a person signed up for coverage.
Many have been surprised that the balky marketplace website, although generating many complaints and much frustration, has not produced much anger and recrimination. Folks have been quite patient and reasonable as they queue up to hunt for insurance. But those surprised by such forbearance fundamentally misunderstand the plight of the uninsured. Although experiencing several hours of computer bugs is frustrating, it pales in comparison to the frustration and anxiety one feels for oneself and their family when they endure years without health insurance coverage. Human beings by nature will placidly overcome multiple hurdles to improve their own and their families’ safety and security.
The official opening of the online marketplaces created under the ACA was highly anticipated- and not without its glitches, in the best sort of way. After months of foreboding press about how 80% of the uninsured didn’t even know about the healthcare exchanges, let alone whether they would sign up for coverage, websites and call centers were inundated across the country. 4.7 million unique visitors went to healthcare.gov, the portal for individuals and small business owners to find out their options under the new insurance program. For some, this resulted in long wait times or spurious website access. For others, it highlighted institutional gaps that exist for at least 15% of American adults- lack of regular internet access.
My day began with trying to sign my father up for an account on the federal exchange, as he lives in a state that has chosen not to run its own. The first challenge we encountered, on the first page we went to: him sitting in silent confusion for a moment then saying “What’s an email address?” It was then I realized that this might take a while. And here’s the thing- that’s ok. October 1st was just the beginning of a 6 month enrollment period, of the first year, of what will become a program integral to the fabric of our social structure, just like Medicare and Medicaid. These programs (among others) have become interwoven into our concept of what we as a society value and think deserves protection from the unpredictabilities and vicissitudes of both economic downturns and political volatility. The Affordable Care Act is just beginning the social and symbolic work it will do- both over the next year and the next decade.
And Americans understand this- and can be a patient people, which might surprise some of the commentators and pundits who edged toward forecasting failure after technical challenges in the roll outs. But sites were overwhelmed by a pent up demand for affordable health care coverage, a desire by millions across the country to provide financial and emotional security for themselves and their families for the time when (not if) they next find themselves in need of medical care. A narrative emerged from a panoply of community centers and doctor’s offices that people trying to sign up were eager, and while disappointed with some of the wait times, willing to wait. For the savings, and sense of security, some were willing to wait all day. Or perfectly willing to come back next week. Or the week after. Plans don’t kick in until January, and for people who may have been waiting for coverage for years- a few weeks more, after which they will have the same coverage the rest of us can enjoy, feels pretty reasonable. As one official said, this is not a sprint, it’s a marathon. But for the 5700 people enrolled as of today, it’s a marathon they’ve already won.
Utah’s Medicaid Expansion Community Workgroup has completed its work and given Utah Governor Gary Herbert several options that would expand insurance coverage for Utah’s 123,000 low-income uninsured. Unfortunately, the governor will not make a final decision about expanding Medicaid until January. Thus, the state will lose out starting January 1st on millions of dollars of available federal funds. Even more concerning, the state’s uninsured, ineligible for or unable to afford insurance in the Affordable Care Act’s (ACA) Health Insurance Marketplaces, will continue to suffer.
At the August 1st workgroup meeting, testimony and a white paper were received from Sven E. Wilson, PhD, a Professor of Public Policy in the Departments of Political Science and Economics at Brigham Young University. Dr. Wilson is also a Research Economist at the National Bureau of Economic Research and a Senior Consultant in the Utah Department of Health.
Wilson prefaced his remarks by describing himself as a “conservative economist” who believes in individual responsibility and that free market and private sector approaches to solving problems of resource distribution are nearly always preferential to government intervention. Nevertheless, he recommended that the state of Utah take advantage of the ACA’s option to expand Medicaid.
Wilson’s testimony and paper made these points. Economic analysis does more than just analyze dollars spent but must factor in a broader perspective “that includes the things that affect human welfare and happiness---things like health, suffering, life expectancy, family relations, leisure time, and quality of life.” The responsible economic analysis provides policymakers with a broad view of on-budget and off-budget costs and benefits from which they can choose. But ultimately, the policy choice is made not purely on the basis of costs and benefits but on questions of values: “what is the proper role of government and what kind of society do the citizens of the state want to have?”
On-budget impacts to the state, based on data from Public Consulting Group’s (PCG) 2013 report, are minimal when compared to the cost of health insurance in the private market and the overall impact on the state’s budget. The 10 year average cost to the state to fully expand Medicaid is $158 per patient per year with the federal government picking up the additional $3,040 per patient per year. This cost compares very favorably with the average cost of private health insurance for an individual in Utah at $4,257 and family of $11,869. After figuring that the average state budget would increase by 0.26% annually he concluded that “looking at the state budgetary costs alone, Medicaid expansion seems like a very good bargain.” And this does not even take into account the new tax revenues generated from the influx of new federal money.
He then went on to describe the off-budget benefits of the Medicaid expansion. Direct benefits to the newly insured are the most important and will be discussed below. Reduction in uncompensated care to Utah providers will save the state’s insured citizens $815 million in costs currently shifted to them. It will also likely produce efficiencies in health care as service in expensive emergency department settings moves to the outpatient arena. The $3.12 billion in new revenues to the health care industry and $2.91 billion in economic impact over 10 years, even if significantly overestimated by PCG (and Wilson goes into great detail how such estimates are problematic and must be looked at with great skepticism), will more than compensate for the estimated 10 year cost to the state of $158 million for the full Medicaid expansion. The ease in financial and emotional strain to families of the newly insured is immeasurable but certainly “exceeds the state’s budgetary costs many times over.”
Wilson also discussed possible off-budget cost of the expansion. These negative impacts may include potential disruptions of insurance markets, denial or delay of medical services to all populations of patients, increases in the price of medical services to the non-Medicaid population, and diversion of scare state resources from the needs of education and law enforcement. These negative impacts disproportionately impact the poor more than the affluent.
Next in his paper is a discussion of the concept of “consumer surplus,” which Wilson considers to be the strongest economic argument for Medicaid expansion. Consumer surplus is “the amount of money that consumers would be willing to spend on a good or service beyond what the market requires them to pay.” Consumer surplus associated with health care and health insurance is very high. As prices rise, consumer demand for health services changes little and displays the economic concept of price-inelastic demand. Even the poor are willing to pay a lot for health care; studies have shown that even those on Medicaid are willing to spend on average an additional $1,900 a year for health care services. If 100,000 poor Utahns are willing to spend $1,900 dollars a year for ten years, that is $1.9 billion of consumer surplus. So how much is insurance worth to the poor if they were not insured? Quite a lot ---and much more than the budgetary cost to the state.
Wilson argues that “if we put all the relevant costs and benefits on the table—meaning everyone’s benefits and everyone’s cost are given equal standing--the benefits to Utahns of using federal dollars over the next decade vastly out way the costs.”
He was, however, very sympathetic to concerns by many of the conservative members of the study group who are convinced that federal support of the expansion is unsustainable in light of the federal government’s looming budget deficits. Wilson views federal deficit spending as an existential threat to the continued survival of the country, “but standing up valiantly against the excess of the federal government does little to protect the state economically disadvantaged citizens.” “It’s a good war” summarized Wilson in his testimony to the committee “but I don’t know that [Medicaid expansion]’s the right battle.”