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Posts tagged as “Obamacare”

Medicaid expansion’s uncounted benefit


When I served on the Governor’s first workgroup that studied and recommended Medicaid Expansion for the State of Idaho, I sat on the panel next to a former director of the Idaho Department of Corrections. I had previous experience working as a physician in the Idaho prisons and we had discussed this in the past.

After one long day of presentations from experts with graphs, tables, numbers and projections as we were getting up from our chairs to go he bent over and whispered to me, “I hate that Obamacare, but this Medicaid expansion would sure be a benefit for my guys.”

I nodded, but after he left I wondered if he meant by “my guys” the recently incarcerated and released, or the guards who work at the prison. Knowing the low pay for prison staff, he may have meant both.

The next day when the summary was being provided about the costs and benefits of Medicaid expansion, I asked the expert if they had figured in any savings from criminal justice costs. They said, no, such calculations would just be too hard to do. I argue they would be substantial. You can’t count what you don’t see.

People in custody (county jail or state prison) are not eligible for Medicaid health insurance to pay for their health care. That cost comes right out of the Idaho general fund. Right now, the charge for folks in prison is over $16/day, almost $6000 per prisoner per year; a total of $48M dollars a year we can’t spend on schools or roads.

My short time working as a doctor in the Idaho prison taught me a lot. I was expecting to see lots of healthy young men with a history of behavioral and substance issues. I was surprised how many middle aged and older inmates there were with chronic disease. Over 65% of the inmates were on chronic medications; many were on psychiatric meds. Imagine what happens to these folks when they are released to the community with no access to health care and a $6000/year health care habit. We are being stupid about how we treat people. Idaho pays 100% of their health care costs in prison, then because they are not eligible for health insurance in Idaho, we pay 0% when they are released. If we expanded Medicaid eligibility we would pay 10% of the costs. Seems a good investment to me.

Right now, the legislatures Justice Reinvestment Oversight Committee (JROC) is hearing testimony from “experts” as to why we need to spend $500M to build a new prison here in Idaho. That’s what the Board of Corrections has recommended. Prosecutors are saying, “It’s not our fault our prison population is exploding. We are just enforcing the laws you legislators write.”

The easiest, cheapest recommendation the JROC could make to the legislature and the governor, easier than sentencing reform, cheaper than building a new prison, would be to say what the former director said to me: “We hate that Obamacare, but expanding Medicaid would sure be a good thing for our people.”

Unintended consequences


The true heart of the Affordable Care Act, sometimes referred to as “Obamacare” but termed here as simply the ACA, is the structure it provides for the maintenance of adequate, portable, comprehensive and reliable private health insurance to all of us and our families.

For most of us the impact of this law and the changes it wrought have been invisible. For the healthy among us, who were happy to remain in the same employment with already adequate insurance, who did not encounter disastrous illness or injury, and who were without disabled children, the advent of the ACA brought nary a ripple.

One sizable bunch did see an immediate benefit. The self-employed, such as small-firm professionals and the like, who might have been paying for health coverage at very high individual private insurance rates, and the part time or low wage employee who did not receive insurance from their employment and could not otherwise afford private policies, both suddenly found adequate health insurance available through state exchanges at rates equivalent to that charged large employers and groups, and with significant federal subsidies for the lower rungs of qualified individuals.

While there were many process problems getting the bugs worked out of the exchange machinery, there have been few complaints over the products that popped out, or to the ultimate cost of it to the qualified participants. These participants have joined the majority in enjoying adequate, non-cancellable, portable, comprehensive and reliable private health insurance at an affordable cost.

Not so much is heard of any of the essential changes brought about by the new law, for the simple reason that they appear to be working exactly as designed. For the first time ever, most of us no longer worry about a catastrophic illness or injury blowing through the ceiling of our health insurance, or having a company cancel coverage in the middle of difficult times, or of being chained to ill-fitting employment because of the risk of being trapped by a preexisting condition clause, or of having a recommended treatment denied by bureaucratic action with no recourse to have the matter reviewed or reconsidered, or of keeping adequate coverage for a child all the way through college.

These matters do not affect most of us, but for the millions and millions who have been affected by any one of these elements in their lives or the lives of their loved ones dependent upon them, the saving provisions of the ACA have provided immeasurable relief and peace of mind.

The only foghorn clamoring away, usually from the right, has been connected to the fact that premiums have gone up. But the ACA doesn’t touch premiums; it is based on private insurance, which requires private payment of premiums, which is connected to actual costs. From the beginning it was made clear that health care costs would be going up, and premiums were going to rise. The major omission the critics make is in failing mention that premiums have not increased as fast or far as was predicted without the adoption of the ACA. The rate of growth of health care costs has flattened, and the increases that are coming are not as great as once feared.

All of this means that for most of us, we have grown complacent; the ACA is working just fine, thank you, and we would not like to see any of it lost. The few of us who are complaining about the cost would complain anyway – with or without the ACA. Notwithstanding the campaign rhetoric coming from the parade of Republican beseechers, we all know there is no realistic political chance that the country is going to reverse course on health care now. Too many of the core provisions are proving to be too valuable and too popular for anyone to seriously suggest a complete repeal. Even the wannabees, when pressed on details, hide behind promises to save the best provisions of the act which, when one tracks down and adds up all the promises, turns out to include it all.

There is this nagging problem. Through the willful act of several of the states, including Idaho, the ACA is not being permitted to fully engage the entirety of the health insurance coverage that was expected. The individuals left at risk are among the very poor and helpless – those without clout or means, and who are now being ignored for the very worst of reasons – spiteful politics.

Under the ACA, everyone who is gainfully employed or occupied is supposed to be guaranteed access to affordable health coverage, either through their employer or through a state exchange. The exchange is available to anyone who is employed but does not receive insurance through employment or who is self-employed. The coverage is still private coverage by private insurers, although the premiums may be subsidized for qualified individuals. The purpose of the exchange is two-fold: (1) to make insurance available at what amounts to group rates, rather than individual rates, and (2) to establish subsidies where needed. To make this work, it is required by the act that a participating individual have some level of income, measured at a percentage of the poverty level established for the state, in order to qualify for private health insurance through the exchange.

The requirement for a floor level of income to participate through an exchange meant that those individuals who earned less than the required percentage to qualify for insurance through the exchange, but who, for any of a variety of reasons, might not qualify for standard Medicaid – would remain uninsured. In Idaho, for example, this gap consists of approximately 78,000 individuals, all uninsured.

The solution under the ACA was to provide that the states would increase the eligibility level of Medicaid to include by definition all individuals in this gap. This expansion of Medicaid is fully funded under the ACA, with all revenue measures in place. There will be no cost to the states at all for the first 10 years of the ACA; after that, the federal government will pay 90% of the increased benefit cost, with the states paying 10%.

No one anticipated what actually happened. The Supreme Court struck the mandatory provision for expansion of Medicaid. And, despite the fact that it is integral to providing seamless coverage to the poorest, despite the fact that it is fully funded for ten years so comes at no cost to the states, and despite the fact that by not buying into the Medicaid expansion, the states gives up hundreds of millions of dollars in federal grants – 26 states declined to expand, and continue to decline to expand their Medicaid programs.

One of those states is Idaho. The governor and the legislature refuse to even consider the expansion bill. A bill for the expansion has been introduced every year, but has yet to be mentioned by the Governor in his state of the state message, or to see the floor of either house for a vote.

If Medicaid were so extended, the ACA would provide a seamless blanket of coverage available to essentially everyone. In Idaho, the expansion of Medicaid could replace almost the entirety of several state and county programs for indigent care and catastrophic care, currently running state and counties approximately $63 million per year. The benefits, which might have been paid to medical providers in Idaho on behalf of this group for the current years, have been estimated to be in the range of $73 million per year. If one adds these resources together, Idaho has already watched close to $272 million slip through its fingers by not expanding Medicaid originally, and the state is losing somewhere in the range of an additional $136 million per year for every year it does not act.

This is not all. We, or at least some of us, are paying those specific federal taxes created within the ACA for funding the expansion of Medicaid nationwide. No credit exists or refunds for those states that have not gone along. Our money derived from these tax sources within Idaho is not being returned to our state, and must be added to the losses sustained by Idaho for not approving the expansion.

As Idaho heads into the third legislative session since the rollout of the ACA, the subject will come up again. Every single outside interest group that has looked into this has recommended expansion. Other alternatives to expansion are woefully inadequate and there is no valid, logical reason for continuing to withhold. Perhaps the wisest of the group who will be assembling here next week will see at last that there is no U-turn on the horizon for the ACA and that money is money is money.

Pry the thing out of committee and pass the damn bill.

Governor and the working poor


The Governor’s proposed plan to avoid recognizing the Affordable Care Act remedy for Idaho’s working poor, as revealed in last Saturday’s Statesman, is just plain dumb.

He cannot seriously expect anybody to believe in it. Further, as stories of needless deaths and suffering from lack of affordable health care continue to mount, the Governor’s continued obstinacy to expanding Medicaid is just plain cruel.

The problem is how to provide adequate health coverage for a defined class of Idaho’s working poor, meaning those who do not receive health care through their employment, do not earn enough to qualify for subsidized private insurance from the state exchange, cannot depend upon a parent or spouse for health care coverage, and who earn too much to qualify for Medicaid under existing eligibility requirements. In Idaho there are approximately 78,000 individuals who fall into this category and have therefore remained uninsured. Two solutions are on the horizon.

Option A is to expand Medicaid to cover this defined class. This obvious solution is the intended implementation of the ACA. Federal funds to cover ten years of expanded Medicaid benefits are already built into the Act, so the cost to the state to accomplish and maintain the expansion is exactly zero. The estimated return in federal health benefits paid on behalf of the working poor recipients would be approximately $70 million per year. All that is required to fully implement the Act is state approval.

Option B is to continue the status quo with the addition of the Governor’s proposed care plan. This plan would cover some doctor’s visits for preventive care only, but would not provide coverage for labs, diagnostics, hospital care, prescription coverage, or follow up. Emergency care would still be under county indigency programs. Non-emergency hospitalization and surgery is not covered; there is no coverage for acute outpatient, non-emergency diagnostics, nor any follow-up care.

This means for example, that most cancer, cardiac and diabetic care would not be covered except for emergency flare-ups. To get any kind of follow up care, the circumstances have to qualify as a catastrophic disease or condition. The young woman who died in Idaho Falls from untreated asthma would still be uninsured under the Governor’s status quo plan. Everyone, even the Republicans who were recently quoted, acknowledged that the addition of the new plan to the existing hodge-podge of the status quo would be inadequate.

The cost of this new plan would be at least $30 million per year. In addition, the cost to the counties for indigent emergency care is over $30 million per year, and the cost to the state for catastrophic health care is over $35 million per year. Since the Medicaid expansion would essentially replace all of these status quo resources, these costs to the state and counties, approaching $100 million every year, could be almost completely eliminated.

On the pure numbers, Idaho has already lost in excess of $250 million over the initial two years of the ACA in state and county costs that could have been avoided and federal benefits that would have been paid if Medicaid had been expanded when the ACA was first implemented. Unnecessary deaths sustained by reason of inadequate health care in Idaho – which now are centered upon the 78,000 uninsured – have been estimated at 124 deaths per year.

It is pure sophistry to argue that there is some advantage to turning away close to $70 million per year in federally funded health care benefits for the poorest among us, plus wasting a combined $100 million per year of our own taxpayer money that could be saved, just to maintain a half-baked patchwork of admittedly inadequate state based programs. When the unnecessary death toll is measured against amounts of money we are flushing down the toilet every year, the right wing’s political objections to expanding Medicaid become the height of Luddite ignorance.

Even if the Republicans pull all their rabbits out of all their hats nationally in the elections of 2016, no thinking politician expects the ACA to be repealed outright; too much of it has become too ingrained in too many lives to imagine a U-turn now. With expanded Medicaid under the ACA now in place in 30 of our 50 states, there is no political chance that it could be abandoned in 2017. As even the tightest fisted Republican must acknowledge, adequate coverage for the very poorest among us is a legitimate government function that will be retained.

Given all of this, and whether one is a flaming liberal Democrat, a rock ribbed Libertarian or a teapot Conservative, money is money is money. Approving the Medicaid expansion will solve the problem with Idaho’s working poor, eliminate the wretched consequences of inadequate health coverage, and bring about a potential return to the state, in terms of immediate cost avoidance, potential cost reductions and fund savings at the state and county level, together with inflow of federal dollars for benefits paid to the working poor, of close to $165 million per year.

What can the Guv possibly be thinking?

First take

As the debate continues (and of course will this next week with the Republican presidential debate) about the Affordable Care Act, ah, Obamacare, some actual review of results so far would seem to be in prder. A good one has just been released, by the Kaiser Family Foundation, which has been tracking results year by year and with special depth in California, which is where the new report is situated. California is just one marketplace, but since it includes a fifth of the national population, it's a pretty good marker. Here is some of what it says:

After two rounds of open enrollment under the Affordable Care Act, 68 percent of Californians who were uninsured prior to the first open enrollment period now report that they have health insurance, referred to in this report as the “recently insured.” This share is up from 58 percent after the first open enrollment period in the spring of 2014. The largest share of California’s previously uninsured, a third (34 percent), say they have coverage thought the state’s Medicaid program, Medi-Cal, up from 25 percent after the first open enrollment period. In addition, 14 percent say they are insured through an employer, 12 percent say they have a plan through Covered California, the state’s health insurance marketplace where people can shop for and compare health insurance plans and access federal subsidies for coverage, and another 7 percent say they have other non-group coverage or insurance through some other source. About a third (32 percent) report being currently uninsured, referred to in this report as the “remaining uninsured.” Because the same group of previously uninsured people has been followed over time, the survey is also able to explore the dynamics of health insurance and track how many people have moved in to or back out of coverage since the baseline survey in 2013.

Shorter: It's working, it's making improvements, but there's still a lot of room for improvement. Which is more or less what a lot of people have been thinking.

The week that was


In one week. The Affordable Care Act is upheld by the nation’s highest court - in the process assuring more frantic right wing attacks to end its life-saving existence. The same court then cast aside unconstitutional - and poorly argued - barriers to universal marriage. And the Confederate flag - long regarded as a defining symbol for 13 states in our nation - is suddenly being swept into the dust bin of history as an icon of slavery.

In a week!

It would be hard to find a single period in the last 100 or so years in which so much of the basic societal tapestry of this country was so drastically altered. In one week!

Then the inspirational coda: America’s first Black president, in the pulpit of a Black church that had been tragically assaulted, summing up those days - and that deadly assault - in 35-minutes of classic oratory, climaxed by his breaking into song and leading the congregation - and much of the nation - in the classic hymn “Amazing Grace.”

Others, with a better grasp of the English language than mine, are struggling to recap the historic political, legal, social and racial meaning(s) of all this. I wish them well. The after-effects will linger for a long, long time as they reflect and attempt to define.

One of the facets of all this capturing my attention has been watching reactions to both those whose causes have been vindicated or upheld and those who’ve seen their opposition to all this overridden legally and morally.

In a general sense, the vindicated have been happy, ecstatic, joyful, prayerful and - above all - gracious. Those in the first person, who’ve had their lives and social conditions changed for the better, have generally not been angry or expressed vindictiveness or scorn for either the process or for those who forced them into our courts for relief.

The same cannot be said for many of those who found little support for their views in our highest court. Among our Republican presidential aspirants, for example, Bush and Rubio came closest to a civilized response, expressing anger and disappointment while admitting laws of the land had been changed in proper and accepted ways; the nation needs to adjust and move on.

But Mike Huckabee - the only ordained minister and “man of God” among the GOP presidential contenders - spoke for many of his supporters and those of other candidates in a totally unfounded way regarding the gay marriage ruling. Said the “pastor:” “This flawed, failed decision is an out-of-control act of unconstitutional judicial tyranny.” Vindictive. Angry. Scorn-filled. Wrong.

Time was, you took your issue to the courts, argued your best case, presented your best evidence and placed that issue in the hands of a judge or judges. The outcome, whatever it was, was the outcome. You either accepted it and went on your way or you regrouped and began your judicial journey again, hoping for a different verdict. You did not reject the decision and you did not insult those who decided it. Now, we have elected officials urging people to “ignore” or “pick-and-chose” which laws/decisions to obey and which to disregard. Wrong headed. Dangerous. No nation - no society - can exist when laws become “suggestions” or are ignored because someone doesn’t agree.

In a most basic way, the U.S. Supreme Court exists for a single purpose: to measure issues before it to the justices’ interpretation of the U.S. Constitution. Justices aren’t tyrants. They aren’t “out-of-control.” Their decisions - whether you agree or not - are not failures despite whether your argument prevailed or lost. Those decisions are deemed to be the legal application of the Constitution by the court and are not “unconstitutional” unless subsequently proven so in another case.

Huckabee is not the problem. But he certainly is symptomatic of the way things political have been conducted in this country for too long. One group - usually Democrat - trying to do something which the other group - usually Republican - has attempted to stop the issue under discussion. In the case of the Affordable Care Act - most of which has been upheld twice now by SCOTUS and victorious over more than 50 failed legislative challenges - Republicans have not offered a version of their own. Not one. But Speaker Boehner says the efforts to eradicate ACA laws will continue. So much for acceptance.

As for the gay marriage decision, many GOP governors are telling state officials to either ignore the SCOTUS finding or not honor it by not issuing licenses until new state laws (doomed to ultimately fail) can be written and enacted. One governor even says he’ll introduce legislation to stop ALL marriages in his state. Acceptance? Gracious? Scorn!

Republicans nationally are slipping into a posture of irrelevance in politics. The courts - the demographics - the country - are changing. Foot dragging, obstinance, unrestrained opposition, angry epithets, unsubstantiated challenges to our legal system, futile efforts to swim against the tide of public opinion of reasonable gun laws, immigration and other issues will assure reduced GOP influence on this country’s direction. All of that is confirmed by overwhelming evidence.

Quietly looking back, that presidential coda to the week’s nation-changing events seemed to have even more relevance far beyond the walls of a South Carolina church than a local eulogy for a local pastor. In an often plain-spoken way - in an often soaring use of the English language - the President tied all these events of joy, anger, sorrow and tragedy into a tapestry of acceptance and hope this country has rarely seen.

Whatever your politics - whatever your personal beliefs - whatever your religion - whatever your ethnicity or race - if you haven’t heard the President’s words - all the President’s words - please search the I-net for the Pinckney eulogy. Set aside your worldly joys and concerns for 35 minutes. Watch. Listen.

The massive change our society has undergone in recent days is reason enough to take the time. Trying to understand what all this change means for the future makes it absolutely essential.