Rep. Raul Labrador (R-ID) speaks with members of the media at Trump Tower December 12, 2016 in New York. / AFP / KENA BETANCUR (Photo credit should read KENA BETANCUR/AFP/Getty Images)
Back in May, an angry constituent asked Congressmen Raul Labrador why he voted for the Republican House Healthcare Bill, that the constituent claimed would cause people to die for lack of Medicaid funding. The Freedom Caucus member shot back with a now infamous retort: “Nobody dies because they don’t have access to healthcare.” Amidst backlash over what he now describes as an inelegant statement, Labrador tried to clarify his remarks: “I was trying to explain that all hospitals are required by law to treat patients in need of emergency care regardless of their ability to pay, and that the Republican plan does not change that.”
But Labrador forgot to mention that, although hospitals are required to treat emergently ill patients regardless of ability to pay, they are also allowed to bill those patients for that care. That means people without insurance often find themselves either avoiding emergency rooms altogether, or driving long distances to hospitals known for being more forgiving of medical debt. Labrador overlooked the life-threatening risks that financially strapped people take to keep out of medical debt.
Insurance sometimes saves lives by enabling people to get emergency care close to home, without fear of financial insolvency.
This travel-and-die phenomenon is not what most insurance enthusiasts think about when they say insurance improves health. Instead, they talk about how insurance makes people more likely to receive the primary care that prevents life threatening illnesses – mammograms and colonoscopies; blood pressure pills and flu shots. They point out that patients with insurance are more likely to see doctors when they start developing worrisome symptoms. With insurance, the cost of a cardiology appointment no longer stands in the way of getting that “heartburn” checked out. In short, insurance improves health and saves lives by being the difference between whether or not people receive lifesaving medical care.
(To read the rest of this story, please visit Forbes.)
My son was underperforming at school, and I was gently encouraging him to try harder (if gesticulating like an over caffeinated Italian qualifies as gentle encouragement). He could not understand why I was upset: “Dad, most of my friends are doing drugs and engaging in unprotected sex. You should be rewarding me for being such a good kid.”
“Reward you for not being bad?!?,” I replied incredulously. That made no sense to me. “When you go above and beyond – when you exert exceptional effort to achieve important goals – then we can talk about what reward you have earned.”
The folks running South Carolina’s Medicaid program don’t appear to agree with my parenting philosophy. A couple years ago, they contracted with a private insurer, the Centene Corporation, to manage its Medicaid population. Part of the company’s approach involved rewarding Medicaid enrollees for receiving recommended preventive care.
This rewards program flips medical payment on its head. Normally, when people go to the family medicine doctor for an annual checkup, they are charged a modest copay for the visit. But through its CentAccount program, the folks at Centene pay patients for receiving such care. You got that right – they aren’t charged for the visit; they are rewarded for it!
When a Medicaid enrollee brings her infant in for a Well Child visit, she receives $10. If she makes all six visits for the year, she will get $25 in that final appointment, adding up to a $75 reward from taxpayers for bringing her child to appointments that the rest of us brought our kids to at our own expense.
In fact, here’s a list of some of the healthcare services CentAccount rewards its customers for receiving:
- Annual Adult Well Care Visit
- Well Child Visit
- Infant Well Child Visits
- Childhood Immunizations
- Health Risk Screening
- Annual Cervical Cancer
- Annual Breast Cancer Screening
- Annual Diabetes Screening – HbA1c Tests, Eye Exams, Kidney Screening, and LDL-cholesterol Screening
- Flu Shot
- Prenatal Visits
- Postpartum Visit
At first glance, it might seem obvious that such rewards are unfair. For the same reason it seems wrong to reward my teenager for not doing drugs, why should we reward a parent for vaccinating a child – for doing what any good parent ought to do?
On the other hand, it is also not fair that many Medicaid enrollees are poor enough to qualify for the program despite working full time. It is also not fair that many lose out on their hourly earnings when they take time from work to bring their children to pediatricians.
(To read the rest of this article, please visit Forbes.)
This picture, from the Kaiser Family Foundation, shows that many people who lack health insurance in the United States right now are actually eligible for either Medicaid or federally subsidized private insurance.
Most conservatives agree that Medicaid costs are too high. Most liberals agree that Medicaid patients should receive necessary medical care for free. And both conservatives and liberals agree that we should embrace ways to encourage Medicaid patients to obtain important preventive care services, in hopes that such services will lower healthcare costs by promoting public health.
But does anyone agree with the idea of paying Medicaid patients to receive such services?
Here is a table from Kaiser Health News showing what South Carolina plans to offer Medicaid enrollees, depending on which services they receive. There aren’t any huge rewards here, but when you think about the large number of people who are eligible for Medicaid in South Carolina, the cost of these rewards could be substantial:
When I first learned of this reward program, I was reminded of a conversation I had with my teenage son. He had underperformed in school, obtaining grades incommensurate with his ability. I was expressing my disappointment with his lack of effort, but he had a rejoinder: “Dad, you should be rewarding me, for not doing drugs, or drinking and driving like all my friends.”
The percent of Americans without health insurance has dropped precipitously in the last few years, thanks in large part to the Affordable Care Act, a.k.a. Obamacare. This is especially true in those states that, in accordance with the law, expanded Medicaid eligibility. Here is a picture of some recent data:
This is really good news, and the figures are likely to continue improving over the next few years. But they will improve a lot more if holdout states agree to expand Medicaid.
I’m not holding my breath.
We have an outlier problem when it comes to healthcare spending. Sure, there are some services we provide far too often for far too many people. And in the United States, at least, most of the healthcare services we provide for patients are far too expensive. But a closer look at healthcare spending data reveal that a huge part of our healthcare spending problem comes from a tiny portion of patients. Take for example this picture, courtesy of Charles Ornstein, illustrating how we spend money for Medicaid patients. Medicaid is a state/federal program to offer health insurance primarily to low income people. As this picture shows, almost half of Medicaid spending is concentrated on just 5% of the Medicaid population. You heard me right – 5%!
To control healthcare expenditures, we need to pay close attention to the small sliver of patients that account for a huge chunk of our healthcare spending.
When I think of the federal government, “efficiency” is rarely the first thing on my mind. But when it comes to controlling healthcare costs, we need to consider the possibility that the federal government is better at this job than anyone else. Consider the fact that the United States dwarfs other countries in healthcare spending, despite having a more robust private insurance market than most of our peer countries. Consider this picture, from a recent Kaiser Family Foundation study. It shows a significant rise in private health spending over recent years, especially compared to growth in Medicare and Medicaid:
There’s a lot behind these numbers, much more than I’m going to cover in this short post. But I thought many of you would find these figures interesting.
A while ago, I wrote a post on how hard it can be for Medicaid recipients to get medical appointments, because so many physicians limit the number of Medicaid patients they see. They limit the number because Medicaid reimbursement is often, well, crappy! Here is a picture from a recent NEJM piece showing just how crappy reimbursement is in different states:
The outlier – Tennessee. Congrats to that state for paying doctors a fair fee for caring for these needy people.
My home state of North Carolina is one of a number of states that refused to expand Medicaid, even though the Affordable Care Act stipulates that the federal government will cover the majority of expenses associated with such expansion. Here is an excellent story in the Fayetteville Observer laying out the issues:
Denise Johnson works six days a week in the laundry room of a hotel on U.S. 301. The 58-year-old Fayetteville resident doesn’t work enough hours to be considered full-time and doesn’t receive health benefits.
Johnson applied for Medicaid at the Department of Social Services, but she was ineligible because she made too much money. Then she tried signing up for subsidized health insurance coverage under Obamacare. Turns out she doesn’t make enough money to qualify for subsidies.
“I’m like, ‘What affordable care?'” she said, referring to the actual name of the health insurance program, the Affordable Care Act.
Johnson falls into a gap in the health insurance program created by the writers of the law, a Supreme Court decision and North Carolina’s Republican-controlled legislature.
When the Supreme Court ruled that Obamacare was constitutional, it also said that the federal government could not make it mandatory for states to accept one part of the law – an expansion of Medicaid benefits to people at 138 percent of the federal poverty level.
When North Carolina’s legislature rejected that expansion, approximately 500,000 state residents were stuck. They earn too much to qualify for Medicaid under the state’s eligibility guidelines. But under the law, they don’t make enough money to qualify for financial assistance to pay for private insurance.
That leaves Johnson, who has a liver disease and eye problems, unable to afford health care.
To read the rest of this story, please visit fayobserver.com.
The always informative Jonathan Cohn at the New Republic recently wrote about an opinion poll that seems to show significant support for at least one part of The Affordable Care Act. It showed a majority not only of Democrats and independents, but also Republicans, supporting Medicaid expansion:
Only one problem with that finding. Ask the same question while mentioning that this policy is encouraged by the Affordable Care Act, and now only about a third of Republicans support the idea:
So much for objective thinking!