It's called the National Health Service Corps. Since 1972 it has provided medical education loan repayment for young medical professionals who provide primary care services in medically underserved areas of the U.S. NHSC provides scholarships to medical, osteopathic, dental and behavioral health students or loan repayment after they graduate in exchange for their service to needy populations in health professional shortage areas -- see map below.
Now, here's some good news. This past week the U.S. Health Resources and Services Administration (HRSA), the federal agency that runs the NHSC, reported that 8,900 health professionals are now NHSC providers serving about 9.3 million Americans. That's more than double the number of Corps providers as recently as 2008. How come?
You probably guessed -- the Affordable Care Act provided an additional $284 million to expand the Corps, thanks to the advocacy of Vermont Senator Bernie Sanders.
Here is some more good news. HRSA Administrator Dr. Mary K. Wakefield reports that "More than 85 percent of National Health Service Corps providers continue to serve in high need areas two years after their service commitment is met."
Click here to read the stories of 40 current NHSC clinicians. Here's a bit about Roberto Beltran, a nurse practitioner and immigrant from Peru who is fulfilling his NHSC obligation at the Uphams Corner Health Center in Dorchester:
"Upham's clinic in urban Dorchester serves a diverse population and on any given day, Roberto finds himself switching between Spanish, English, and the Portuguese-based Creole he's learning from the Cape Verde immigrants who make up one-third of the clinic's patients. Some of his time is spent seeing walk-in patients in the urgent care department, and Roberto is proud of his work to improve work flow systems to enable patients being seen quicker. 'We would like to maximize the capability for walk-in care and want people to come to their community health centers and not the ER.'
"But, most of Roberto's time is spent in geriatric care, which includes home visits for some patients. As clinical coordinator for the geriatrics program, Roberto oversees a staff of six and works with the clinic's primary care providers to deliver interdisciplinary and integrated care to patients."
The National Health Service Corps -- something else to like about the ACA.
So, the healthcare.gov website is getting better, much better. That's good news. And stories of Americans finding better and affordable care through the Affordable Care Act are starting to proliferate. Soon, we can expect the media to start ignoring the ACA, until the next reason for panic erupts.
Here's something for which I am thankful:
Thank goodness the rollout of the new coverage/subsidies/website was scheduled for 2013 and not 2011 or 2012!
Over the past three and one half years, many have asked me: why was the fall of 2013/early 2014 the time for implementation as opposed to 2011, 2012, or the fall of 2014. Reasonable question. And here's my answer:
Fall of 2011 -- way too early, too much work to be done, no chance states would be ready to launch their own health insurance exchanges.
Fall of 2012 -- when the ACA was signed in March 2010, 2012 seemed a long time away, and the logical year for implementation. There were concerns about how long it would take states to go through their legislative processes to set up their own exchanges (we believed nearly all states would choose to do so). But two other concerns weighed heavily:
First, the need to keep the total net cost of the ACA -- over ten years -- to under one trillion dollars, something easier to do if there were no expansion in federal fiscal years 2010, 2011, 2012, and 2013; and
Second, the need to avoid potential political flak if the coverage expansion rollout had mishaps, say, on a scale similar to the rollout of the Medicare "Part D" prescription drug program in 2005-06.
So, the rollout was set for 2013. And thank goodness! Can you imagine the political freakout that would have occurred if the rollout debacle were happening in the fall of 2012 or 2014???
I am thankful that Team Obama is getting the infrastructure of the ACA right, however long it takes to get all the way. I am even more thankful this is happening now rather than 12 months before or after now.
Health care justice for Americans is winning.
Many of you have seen or heard about the new Commonwealth Fund report: "Access, Affordability, and Insurance Complexity Are Often Worse in the United States Compared to 10 Other Countries." It's a familiar song we've been hearing for years, and, according to the Fund, it's not getting better:
"A 2013 survey conducted in 11 countries finds that U.S. adults are significantly more likely than their counterparts to forgo health care because of the cost, to have difficulty paying for care even when they have insurance, and to deal with time-consuming insurance issues."
Here is one chart I find compelling and want to consider in light of another study that came out this past week:
That's the premise of a blog posted today by former Beth Israel Deaconess Medical Center's CEO Paul Levy, which he himself describes at "so outrageous it might actually have merit." Read for yourself Paul's "Modest Proposal" at his "Not Running a Hospital" blog.
The question of Steward Health Care's long-term game plan has been on people's minds ever since the Archdiocese of Boston sold the former Caritas Christi network to the private equity firm, Cerberus, in 2010. I wrote to Paul and asked why on earth Cerberus would find it in their self-interest to do this. He wrote back:
"They have extracted millions in cash already. They haven't invested anything of their own money. They just used retained earnings. This would avoid the losses of actually having to run a system going forward."
I would not hold my breath. But Paul's questioning does raise the question of the fate of this important hospital and health care system. Guessing Cerberus' long-term intentions has been a favorite parlor game for Massachusetts health system watchers since their arrival. Something will happen -- private equity is not made to sit still.
It's only a question of when...
ACA Enrollment numbers and other statistics for October 2013 were released this afternoon by officials from the U.S. Department of Health & Human Services. Right away, interpretations are out. The New York Times sums it up the: Health Law Enrollment Figures Far Short of Initial Estimates.
1,509,883 -- Individuals who have applied for coverage
396,261 -- Individuals determined eligible for Medicaid or Children's Coverage
106,185 -- Individuals who have selected a private health insurance plan
Of the 106,185 sign-ups, 76,391 enrolled through state marketplaces, while 26,794 enrolled through the federal exchange. Given all the problems with the website and the hurricane of publicity, I'm surprised 26,794 were able to close the deal.
So is this terrible and is the ACA heading for disaster? Honestly, I do not believe so. As the Broadway show tune goes: "It's not where you start, it's where you finish." The media's continuing hyperventilation about how the law's implementation is doing, minute by minute, fits their needs, not the realities of implementing this complex law and program.
On the other hand, the Republicans' hammering on implementation failures -- it's a good thing, and a turning point:
“By the time we reach the critical month of December, actual enrollment could lag projections by over one million people,” Representative Dave Camp, Republican of Michigan and chairman of the House Ways and Means Committee, wrote in a letter this month, accompanying a subpoena for detailed enrollment data. In an interview, he said the enrollment figures were only one part of the story. “It’s not just about the top-line number,” he said. “What I want to know is the mix of these people. What kind of insurance are they getting, what age are they?”
Are you listening? No more repeal, no more defund -- let's talk about the details, say the Republicans. Let's spin them in the most negative way possible, for sure. But let's change the subject.
By the way, the "projection" of 7 million enrollees by March 2014 -- that was the estimate of the Congressional Budget Office based on their calculation of how many enrollees would sign up. It was not a statement of how many "had to" sign up or else the law would fail. It was the CBO's good faith projection of how many they thought likely to sign up. I have huge respect and appreciation for CBO's estimate, and recognition that CBO's numbers are usually wrong.
In the first month of open enrollment for coverage under the ACA, despite all the website issues and the horrible media coverage, more than 1.5 million Americans applied for new insurance coverage under the law.
We're winning. Keep calm and carry on.
Last Friday, I heard a presentation on leadership by Dr. Linda Hill from the Harvard Business School. Of many noteworthy thoughts, one struck me as spot-on in relation to our current dilemma with the Affordable Care Act. Dr. Hill presented this handy equation:
Character + Competence = Trust
So we have two dimensions to trust -- that you try to do the right thing and that you know how to do the right thing. It plays into President Obama's current challenges in a compelling way.
First, on the matter of individual health insurance policy holders who will not be able to "keep the coverage you have if you like it," the question is whether Obama said that -- repeatedly -- knowing it was not true. That gets to character.
Second, on the matter of the dysfunctional health insurance exchange websites, the question is whether Obama and his team know how to do it right. That gets to competence.
Both trigger a trust challenge -- and that's why the current double dilemma sticks and matters beyond the ramifications for the ACA.
I've been hearing this charge since 2006. U.S. health reform is going to cause a huge shortage of physicians, and Massachusetts is Exhibit A that this will happen -- case closed.
First, I'll address some unrecognized issues about the Massachusetts physician shortage. Second, I'll discuss the U.S. shortage.
First, Massachusetts, egged on by the annual physician satisfaction survey conducted by the Massachusetts Medical Society. Here is their own description of their most recent results from the survey this past September:
"The Medical Society's 2013 analysis found four specialties to be in critical or severe shortage: family medicine, internal medicine, neurology, and gastroenterology. The primary care specialties of family medicine and internal medicine were recorded with shortages for the eighth consecutive year. A trend analysis over the last five years (2009-2013) shows that seven specialties have been in short supply in at least three of those five years: family medicine, internal medicine, psychiatry, dermatology, general surgery, neurology, and urology."
Full disclosure: I have many friends in the MA Medical Society and am a big admirer of their work. But, regarding their study, which gets avidly reported all over the country as evidence of terrible physician shortages in Massachusetts, consider this from the report's methodology section on page 9:
"A survey was mailed to 7,212 practicing physicians in January 2013. The survey was mailed to those physicians licensed through the Commonwealth of Massachusetts Board of Registration in Medicine who have a full and active license and a primary business address in Massachusetts. The survey mailing included both MMS members and nonmembers who were randomly selected from 18 specialties (anesthesiology, cardiology, dermatology, emergency medicine, gastroenterology, general surgery, internal medicine and family medicine (primary care), neurology, neurosurgery, OB/GYN, oncology, orthopedics, pediatrics, psychiatry, radiology, urology and vascular surgery). Each survey was sent with a cover letter and a postage-paid return envelope. The surveys were serial numbered, and a second follow-up mailing to non-responders occurred in late January 2013. Of the surveys that were mailed out, 748 were completed and returned for a response rate of 10.4%."
So, 9 out of 10 physicians surveyed did not respond. Residents and Fellows were also surveyed and their response rate was 3.25%. And this is Exhibit A for national media stories about the physician workforce debacle in Massachusetts.
Give ... me ... a ... break.FULL ENTRY
I was prepared to be unimpressed listening this afternoon to President Barack Obama talk in Boston's Faneuil Hall about the Affordable Care Act and the problems it is facing: i.e. the website ordeal, the individual health insurance policy cancellations affecting policy holders in the individual market, and more.
Instead, I came away impressed. Despite breath-taking Republican and media determination to turn every negative development into health reform Armageddon, implementation of the ACA is working and has already made life-saving and life-improving differences for many Americans. Here are some worthy things I heard the President emphasize:
"the strongest consumer protections this country has ever known"
"no more discriminating against kids with pre-existing conditions"
"no more dropping your policy when you need it most"
"no more life time or annual limits"
"full coverage of clinical preventive services"
"young adults stay on their parents plan until age 26"
"insurance companies ... can't use your medical history to charge you more"
"tax credits that will bring the cost down even further"
And that's just for starters.FULL ENTRY
I have not written about the ACA website fiasco because ... what do I know? I hope Team Obama can fix it soon.
Now that the shutdown/debt ceiling crisis is over, critics are going after the Obama Administration for the problems plaguing the federal health insurance exchange website. One of the most persistent critics has been the Washington Post's Ezra Klein, otherwise an ardent supporter of the ACA.
Today, though, Ezra took the gloves off with the anti-ACA crowd who are crying crocodile tears about the inability of federal Exchange website applicants to get their insurance coverage applications through the process. All I can say is -- wish I had written that:
The classic definition of chutzpah is the child who kills his parents and then asks for leniency because he's an orphan. But in recent weeks, we've begun to see the Washington definition: A party that does everything possible to sabotage a law and then professes fury when the law's launch is rocky.
On Tuesday, Rep. Paul Ryan became the latest Republicans to call for HHS Secretary Kathleen Sebelius to step down because of the Affordable Care Act's troubled launch. "I do believe people should be held accountable," he said.
How about House Republicans who refused to appropriate the money the Department of Health and Human Services said it needed to properly implement Obamacare?
How about Senate Republicans who tried to intimidate Sebelius out of using existing HHS funds to implement Obamacare? 'Would you describe the authority under which you believe you have the ability to conduct such transfers?' Sen. Orrin Hatch demanded at one hearing. It's difficult to imagine the size of the disaster if Sebelius hadn't moved those funds.
How about congressional Republicans who refuse to permit the packages of technical fixes and tweaks that laws of this size routinely require?
How about Republican governors who told the Obama administration they absolutely had to be left to build their own health-care exchanges -- you'll remember that the House Democrats' health-care plan included a single, national exchange -- and then refused to build, leaving the construction of 34 insurance marketplaces up to HHS?
How about the coordinated Republican effort to get the law declared unconstitutional -- an effort that ultimately failed, but that stalled implementation as government and industry waited for the uncertainty to resolve?
How about the dozens of Republican governors who refused to take federal dollars to expand Medicaid, leaving about 5.5 million low-income people who'd be eligible for free, federally-funded government insurance to slip through the cracks?
The GOP's strategy hasn't just tried to win elections and repeal Obamacare. They've actively sought to sabotage the implementation of the law. They intimidated the people who were implementing the law. They made clear that problems would be exploited rather than fixed. A few weeks ago, they literally shut down the government because they refused to pass a funding bill that contained money for Obamacare.
The Obama administration deserves all the criticism it's getting for the poor start of health law and more. Their job was to implement the law effectively -- even if Republicans were standing in their way. So far, it's clear that they weren't able to smoothly surmount both the complexities of the law and the political roadblocks thrown in their path. Who President Obama will ultimately hold accountable -- if anyone -- for the failed launch is an interesting question.
But the GOP's complaints that their plan to undermine the law worked too well and someone has to pay border on the comic. If Republicans believe Sebelius is truly to blame for the law's poor launch, they should be pinning a medal on her.
And there's more...
Now that the shutdown insanity is in a locked ward, we should expect a fevered level of attention to return immediately to the progress of the Affordable Care Act expansions. We can predict a frantic desire to know one thing:
How many have signed up for coverage in the last three minutes?
Two models come to mind for reporting this information. Model A is the New York Stock Exchange and minute-by-minute tallies and updates. Model B is the monthly unemployment statistics, out the first Friday of every month (except when there's a federal government shutdown -- d'oh!).
In Massachusetts, we had intense interest in the progress of enrollment in the early days of health reform in 2006 and 2007, and we followed Model B. Once a month, at the board meeting of the Health Connector, everyone would learn what happened the month before. That makes sense.
To my friends in the media, I have one message: please take a chill pill. You won't see 7 million enrollees for a while, and that's not failure, that's real world.
Here's the actual data on initial enrollment in Commonwealth Choice -- the unsubsidized part of MA health reform:
|Choice1 - Monthly Enrollment|
Worth noting -- July 2007 was the first month of actual coverage. Enrollment in the months leading up to July was a trickle. You can see the biggest jump in December 2007 because that is the month when the individual mandate penalty became effective -- even though it was only a $95 hit on state taxes for 2007.
Here's the actual data on initial enrollment in Commonwealth Care -- the subsidized part of MA health reform. Note, please, the difference in enrollment between the no premium and the premium paying parts of this population:
|Care 1 - Monthly Enrollment|
Inside baseball, though important -- the high rate of initial enrollment in no-premium coverage related to the auto-enrollment of tens of thousands of individuals who were enrolled in the state's uncompensated care pool prior to the passage of the MA health reform law.
Bottom line -- expectations of large-scale, instantaneous enrollment in the ACA are unrealistic and uninformed.
Massachusetts has achieved a level of coverage which is higher than the likely full impact of the ACA ever -- about 97% of all state residents. The rest of the nation should be so lucky. AND, it did not happen over night. It was a slow crawl, not a sprint.
Keep your own, and your readers', and the public's expectations at a realistic level, please. You'll be doing a service.
It appears that part of the Budget/Debt Ceiling deal in DC may include a one-year delay in the collection of a fee on employer-sponsored health insurance to fund a temporary three-year reinsurance program to ensure a more stable individual health insurance market during its first three most vulnerable years.
Big deal or little deal? Little deal.
A similar program was run in Massachusetts in the first years of implementation of the 2006 MA health reform law to encourage health insurers to enter the program despite the risk that folks who signed up for their coverage might be, on average, sicker than the risk pool as a whole. So money was collected for the first few years to make payments to participating insurers who had a worse-than-average risk pool.
In drafting the ACA, we made sure that a similar mechanism was included for years 2014, 2015 and 2016. So $25 billion will be collected from employer plans -- whether traditionally insured or self-insured to finance state-based reinsurance programs (the U.S. Department of Health & Human Services will do the job in states that do not want to do it themselves).
$12B in 2014, $8B in 2015, and $5B in 2016. In 2014, this will amount to $63 per covered live, or $5.25 per month. In 2014 the fee amounts to .95% of total market premiums, dropping to .6% in 2015 and .35% in 2016. Helpful summaries here and here.
From the news accounts I have seen, the new Capitol Hill deal would simply push back the collection -- in the same amounts -- to 2015, 2016, and 2017. Treasury can front the money for 2014 that will be repaid on a one-year delayed basis.
The reinsurance program is important to health insurers who will be participating in the new individual market because there is no relevant experience to let them know who will sign up through the new Exchanges. And some will certainly be less lucky than others in terms of the risk profile of the new enrollees.
Unhappy with the new assessment are labor unions with their own health plans, often called "Taft-Hartley Plans." They had advocated with the Obama Administration that their enrollees should be able to claim the new tax subsidies provided through the Exchanges -- something the Administration said it could not do under the law. They wanted to be exempted from the Reinsurance fee, again something the Administration said it did not have legal authority to allow. So instead, they get a one-year delay.
If this is what it takes to get to a deal, then I'm all for it.
So eliminating the 2.3% tax on medical devices that was part of the financing of the Affordable Care Act/Obamacare is now on the chopping block as part of the contentious budget and debt limit negotiations in Washington DC.
In the larger scheme of things, this is not a big deal. Elimination will not harm the cornerstone policy initiatives in the ACA, and will have zero impact on the Medicaid expansions, the private insurance expansions and subsidies, the delivery system reforms, or pretty much anything else.
The device tax is one of the smaller elements of a large package of financing provisions to pay for the ACA. Yes, the ACA pays for itself and does not increase the federal deficit (I know Obamacare haters can't stand to hear this, and it's true -- Obamacare reduces the federal deficit, demonstrated repeatedly by the Congressional Budget Office and the Medicare Chief Actuary). And because the Medicaid expansion will roll out much more slowly than expected when the ACA passed, due to the June 2012 US Supreme Court decision that made the expansion a state option, the loss of $29 billion (2013-22) in revenue from cancelling the device tax likely will not change the ACA's overall favorable financial balance.
Politically, agreeing to a device tax repeal may enable President Obama to appear non-rigid on his signature initiative and willing to negotiate with Congress, albeit on a non-fundamental policy aspect.
So what's not to like? This:FULL ENTRY
Today's Arizona Daily Star offers the first answer: "Brewer says killing Obamacare now could cripple the state budget."
Yes it could, Governor Brewer, yes it could.
Some excerpts after the jump:
I know. I should be writing be writing about the federal government shutdown. But what the heck do I have to add? And here's something interesting:
Every week, the Robert Wood Johnson Foundation sends me an email digest of news from around the nation about advances, setbacks and developments in the war against childhood obesity. Often, I end up more depressed after reading it. But the digest of a week or so ago was so compelling, in a good way, that it made me wonder if there is something big going on that I have not really appreciated.
Look at these headlines (all linked to the primary source):
With Tastes Growing Healthier, McDonald's Aims to Adapt Its Menu
New York Times, Stephanie Strom, 09/26/2013
Decades of Watching America’s Kids Get Heavier, Are We at a Turning Point?
Washington Post, 09/27/2013
Starting to Pay More Attention to Fruits and Vegetables
National Journal, Elahe Izadi, 09/18/2013
Cafeterias, Vending Machines Trading Sugar, Fat for More Healthful Fare
Washington Post, Lenny Bernstein, 09/27/2013
First Nonprofit Supermarket to Open in Chester
Philadelphia Inquirer, Alfred Lubrano, 09/25/2013
Green Bay Representative Drafting Physical Activities Bill
Wisconsin State Journal, Andrea Anderson, 09/26/2013
School Officials Say They're Prepared for Tougher Breakfast Regulations
Casper Star-Tribune, Leah Todd, 09/20/2013
Can New Haven Drop 375,000 Lbs. in Two Years? That’s the Goal
New Haven Register, Jim Shelton, 09/25/2013
Obesity Rates among Low-Income Families Decline in New Mexico for First Time
Las Cruces Sun-News, Andi Murphy, 09/25/2013
Could Be Hub of Activities and Economic Growth
Cincinnati Inquirer, John Johnston, 09/23/2013
Combat Childhood Obesity, Food Marketing Needs to Change (Opinion)
Jackson Clarion Ledger, Lynn Evans, 09/23/2013
Sioux City, Gym Class Reinvented to Combat Obesity
Sioux City Journal, Nate Robson, 09/22/2013
Wyoming, New Mexico, Mississippi, Ohio, Iowa, Connecticut, Wisconsin, Philadelphia.
It's not any single one of these twelve articles from newspapers all over America; it's the totality. Read the list again, and try to get the total effect. Let it reach you and get into the mindset that we may already have turned or are turning the corner in addressing America's obesity challenge. Numbers seem to be going in the right direction -- but how real is that versus a statistical blip?
What these articles convey is that the underlying culture of America -- when it comes to nutrition and eating -- is changing. The way we talk about and do things around here, meaning the kitchen, the dining room, the cafeteria, the restaurant, the food stand, the supermarket, the farm stand, is changing, in the right direction.
Some will say it's the bias of the aggregaters. But I've seen plenty of bad news links over years. Without empirical proof, I hypothesize that a shift is under way. In spite of the huge financial advantages enjoyed by the purveyors of unhealthy and harmful eating choices, perhaps the truth is just too obvious. Healthy eating and physical exercise make too much sense.
It's not just the varied geography. It's also the mix of public policy and private initiatives. It's not just one, it's both, reinforcing each other. It's not diet OR exercise -- it's nutrition AND exercise.
And it's not a message to relax. let down our guard, or declare victory. It's a message that we can make progress, so let's pick up the pace and redouble our energy to win.
And I don't say that very often. But today, I have a new hero.
It is Steve Beshear, the Governor of Kentucky who has an editorial in today's New York Times titled "My State Needs Obamacare Now." Yes, Kentucky -- home state of Senators Mitch McConnell and Rand Paul, both arch-enemies of Obamacare. You can click and read, but this editorial is so darn good, I'm reprinting in toto below.
Not only does Beshear tout the economic benefits of the Affordable Care Act for Kentucky, he courageously highlights the reality that the health status of Kentuckians is among the worst in the nation, and that implementing the ACA is a cornerstone of a strategy to begin turning around the state's discouraging health indicators. I recall being at a conference for state legislators about a year ago and having the opportunity to converse with a senior legislative leader from Kentucky. I asked him, as politely as I could, how much folks inside Kentucky were concerned about the poor health status of the people.
"That's just because we have so many poor people," was his reply.
So, if they die early -- maybe that will improve the state's health indicators? [Head scratch]
Anyway, for something completely different, please read the wisdom of Governor Beshear:
FRANKFORT, Ky. SUNDAY morning news programs identify Kentucky as the red state with two high-profile Republican senators who claim their rhetoric represents an electorate that gave President Obama only about a third of its presidential vote in 2012.
So why then is Kentucky -- more quickly than almost any other state -- moving to implement the Affordable Care Act?
So it looks increasingly as though this coming weekend, Washington DC will reach yet another futile fiscal Armageddon, resulting in the second federal government shutdown ever (the first instigated by the Newt Gingrich Congress in 1995), this time as a result of Republican efforts to defund the Affordable Care Act/Obamacare. If that were not enough, we may well have another round in late October over raising the federal debt ceiling.
Following these developments, I have noticed that there is one group of influential and important figures from whom we have heard nothing. I refer to Republican governors who have embraced the ACA's Medicaid expansion beginning on January 1 2014. I am talking especially about these folks:
Jan Brewer, Arizona
Chris Christie, New Jersey
Jack Dalrymple, North Dakota
Susana Martinez, New Mexico
Brian Sandoval, Nevada
Rick Snyder, Michigan
John Kasich of Ohio and Rick Scott of Florida might also be mentioned, though unlike the others, they have thus far been unable to convince their legislatures to go along with the Medicaid expansion. But the six above endorsed the expansion, won agreement from their respective legislatures, built the expansion and resulting huge federal financial participation into their fiscal year 2014 state budgets, and have been busy preparing for implementation. They each invested substantial personal political capital to win approval of the expansion, not because it was good for Obama, but because it was good for their respective states.
One of the primary Congressional Republican attacks on the Medicaid expansion is that, of course, you can't count on Washington DC to keep its promises. Seems as though the Republicans now are out to prove it themselves.
I wonder how these Governors feel about their Congressional colleagues working to shut down the federal government and to default on the nation's debt to prevent their states from getting federal dollars to honor the states' decisions to expand Medicaid to the nation's neediest uninsured?
Maybe someone should ask them?
In mid-August, I posted an entry called "The Wellness Wars" concerning new workforce wellness requirements at Penn State University (PSU), including $100 per month fines on workers who fail to comply. Under the new rules, faculty and staff (and their respective spouses if covered under PSU's health plan) were required complete a mandatory, detailed, personal health questionnaire along with other tests such as biometric screenings that include body mass index (BMI) measures and cholesterol and blood-sugar tests to avoid the fines.
Many faculty and staff objected and launched a campaign to pressure PSU officials to cancel the fines. Employers across the nation are becoming more assertive in creating incentive and penalties to get workers to change their health habits. The PSU fines became a flashpoint in this growing controversy -- which has accelerated because of the Affordable Care Act's provisions giving employers more flexibility to incorporate wellness rewards and penalties into their health plan designs.
Who would win -- PSU officials or the protesting faculty and staff?
Here's the Penn State announcement -- winner: faculty and staff:
UNIVERSITY PARK, Pa. – A $100 monthly surcharge for Penn State employees who fail to participate in a screening portion of a new wellness initiative has been waived by the University, according to President Rodney Erickson, who said his administration has clearly heard the concerns from faculty and staff on the issue. In addition, a joint task force will be formed to provide advice on the implementation of the program and on health benefits matters.
"We have decided to suspend the $100 per month surcharge so that people who are uncomfortable with any aspect of the survey will not feel as if they are being penalized," Erickson said. "There is still a tremendous financial challenge that we must address in the coming year and beyond, but we also need to acknowledge the concerns of employees and seek their advice on how to overcome these fiscal roadblocks and still provide quality health care."
You can be sure that employers all of the nation are aware of this development. Does this spell the end of these kinds of penalties? I don't think so. I do suspect employers contemplating wellness penalties on their workers will be more likely to think twice. This skirmish is over for now -- the wellness wars, I predict, are just warming up.
(Correction: Edited to reflect that PSU is a "state-related" university, though not a public university in the commonly understood sense.)
Tonight was unusual. Sitting in a large meeting room in Temple Israel on the Boston/Brookline border were about 250 members of the Greater Boston Interfaith Organization (GBIO), in a meeting with four major hospital CEOs, four major health insurer CEOs, state officials, and sundry others to talk about rising healthcare costs.
The CEOs were heavy hitters: Gary Gottlieb of Partners, Ralph de la Torre of Steward, Kate Walsh of Boston Medical Center, Kevin Tabb of Beth Israel Deaconess, Andrew Dreyfuss of Blue Cross Blue Shield, Jim Roosevelt of Tufts Health Plan, Jay Gonzelez of Celticare, and Deborah Enos of Neighborhood Health Plan. Each had four minutes to explain to the audience what they were doing to reduce costs and improve quality.
Sitting in the audience were the Executive Director and three members of the new Massachusetts Health Policy Commission which is charged with enforcing the new state-mandated limit on health care cost growth.
Many GBIO members had real and serious concerns, such as Marvin Miller who runs his own small business and has seen his company's insurance premiums rise from $70,000 in 2003 to $200,000 last year, even with 15% fewer employees; his per employee health insurance costs have risen from $2060 to $6900 even as deductibles have skyrocketed.
The evening easily could have been a formula for anger, yelling, and finger pointing. And it didn't happen. What happened instead was intense listening, polite applause, and a pumped-up commitment to stay on top of the issue by all in the room.
I recommend this article -- The Public and the Conflict over Future Medicare Spending -- by my HSPH colleague Bob Blendon and John Benson in last week's New England Journal of Medicine for a clear-eyed look at public attitudes about Medicare. It's not a pretty picture. Their thesis: "...there exists today a wide gap in beliefs between experts on the financial state of Medicare and the public at large." Let's boil it down to the essentials.
First, though the growth in Medicare spending has slowed dramatically during the past five years, and accelerating since passage of the Affordable Care Act/Obamacare, "the public is unaware of this." Fully 62% believe Medicare spending is rising faster than it was five years ago.
Second, despite this erroneous pessimistic belief, few Americans (between 10 and 36%) support major Medicare reductions to reduce the federal deficit.
Third, only 53% of Americans realize that Medicare is one of the largest accounts in the U.S. federal budget, and only 31% see it as a major contributor to the federal deficit.FULL ENTRY
Consider two disconnected stories out today. First, according to a new CNN poll, support for the Affordable Care Act/Obamacare among the public continues to be mediocre at best and has dropped further. Second, a Politico story reveals that a secretive non-profit organization, called Freedom Partners, spearheaded by the uber-wealthy right-wing Koch brothers, has been pumping hundreds of millions of dollars into groups dedicated to killing the ACA.
Gee, might there be a connection?
"There has also been a huge disparity over the past couple of years in ad spending over the issue, with groups opposed to Obamacare greatly outspending those in favor of the measure. The new poll suggests the negative advertising may be taking a toll. The forces opposed to the health care law have also been much more active on social media than those supportive of the law."
Nearly every time I speak to a physician audience, I get at least one question on medical liability reform (or "medical malpractice," a term many physicians dislike). When pressed about what reform they would prefer, the most common answer is the imposition of strict liability caps on pain and suffering such as those in Texas and California. For many physicians (Majority? Who knows? Clearly a lot.), this is the holy grail of health reform and Texas is the promised land for how physician practice ought to be in the U.S. of A.
Whatever your view, I urge you to read this article from the Texas Observer which I found from this post at the Incidental Economist. It's about the collapse of physician oversight in Texas that allowed a neurologist named Christopher Duntsch (right) to leave two of his patients dead and four paralyzed before the Texas Medical Board got around to suspending his license.
Saul Elbein writes:
"...the real tragedy of the Christopher Duntsch story is how preventable it was. Over the course of 2012 and 2013, even as the Texas Medical Board and the hospitals he worked with received repeated complaints from a half-dozen doctors and lawyers begging them to take action, Duntsch continued to practice medicine. Doctors brought in to clean up his surgeries decried his 'surgical misadventures,' according to hospital records. His mistakes were obvious and well-documented. And still it took the Texas Medical Board more than a year to stop Duntsch -- a year in which he kept bringing into the operating room patients who ended up seriously injured or dead."
Perhaps you've never heard of Bull Connor, though if you lived through or studied the 1960s U.S. civil rights era, you know who I mean. This is from Wikipedia's biographical sketch:
Theophilus Eugene "Bull" Connor (July 11, 1897 - March 10, 1973) was the Commissioner of Public Safety for the city of Birmingham, Alabama, during the American Civil Rights Movement. His office gave him responsibility for administrative oversight of the Birmingham Fire Department and the Birmingham Police Department, which had their own chiefs. Through his covert actions to enforce racial segregation and deny civil rights to Black citizens, especially during the Southern Christian Leadership Conference's Birmingham Campaign of 1963, Connor became an international symbol of racism. Connor infamously directed the use of fire hoses and police attack dogs against peaceful demonstrators, including children.
What does Obamacare have to do with civil rights? Quite a bit: 55% of all nonelderly uninsured Americans are non-white and will disproportionately benefit from the ACA's coverage expansions. Congressman Jim Clyburn (D-SC) calls the law "the civil rights act of the 21st century." When Republican Presidential Nominee Mitt Romney appeared before the NAACP in July 2012, he received one emphatic round of boos when he committed to repealing Obamacare. Hispanics show similarly high levels of support for the law.
The ACA is about a lot more than just civil rights. And make no mistake, the ACA is about civil and human rights.
The new Kaiser Health Tracking Poll, released on Tuesday, always provides food for thought. Three numbers stuck out for me: 43, 37, 57.
- 43% of Americans either believe that the Affordable Care Act is no longer law or are unsure.
- 37% of Americans say they have a favorable opinion about the ACA (42% unfavorable and 20% unsure).
- 57% oppose cutting off funding to implement the ACA.
God love Americans! Here's the jaw dropper:
Love the ACA or hate it, that's your red-white-blue privilege. But more than 2 of every 5 American adults are unsure whether it's law? Wow. I asked Mollyanne Brodie from the Kaiser Family Foundation whether the 43% skew in either direction in support or opposition to the law. She reported back that the poll crosstabs don't provide that information, but other surveys they have done show that no clear positive/negative trend among the deeply misinformed.
It received only scant notice in the U.S., and in Massachusetts, but earlier this month, a British commission formed to recommend improvements to the quality of medical care in the United Kingdom issued its final report. Why should anyone care on this side of the pond? Several reasons:
The commission was chaired by Dr. Donald Berwick, MD, current candidate for Governor of Massachusetts, former Acting Director of the U.S. Centers for Medicare and Medicaid Services (CMS), founder of the Cambridge-based Institute for Healthcare Improvement (IHI) and an internationally recognized expert on improving the quality and safety of medical care. Berwick took the (unpaid) chair job at the personal request of British Prime Minister David Cameron, following a quality of care scandal at Mid-Staffordshire Hospital that has shocked the British public. (Pictured: Berwick with US Health & Human Services Secretary Kathleen Sebelius.)
Americans have a thing about the British National Health Service (NHS) that is called love/hate -- even more intense than our feelings about the Canadian socialized health insurance system. Every NHS development is grist for the never-ending U.S. debate over the role of markets versus government in health policy.
For those who see the NHS as the world's leading example of life-threatening health care rationing (including, it would seem, every Republican member of the United States Congress), the Mid-Staf scandal is exhibit A for the follies and tragedy of government-run health care. Even for those who admire and respect the NHS, the scandal demands attention and accountability; the Brit's value of equitable and universal health care cannot excuse this major failing.
And because Donald Berwick is now campaigning to become Massachusetts' next governor in January 2015, this report will be dissected by his rivals -- should his candidacy become a serious threat. (I wrote an appreciation of Berwick's role in health care and in DC when he left CMS in late 2011.)
So the Report compelling from varied perspectives. (WBUR's Martha Bebinger did an informative interview with Berwick about the report earlier this month.) Let's dig in more deeply to see what's interesting.
"The current version of the wellness initiative rolled out by PSU [Penn State University] with Highmark Blueshield, WebMD and ICH [Integrated Corporate Health] is an invasion of privacy. The wellness survey questions are not posted anywhere for member evaluation before participation. The only way to evaluate the survey questions is by creating a WebMD account. When you create this WebMD account, it is VERY, VERY important to read the terms and conditions -- because you are giving WebMD immediate access to ALL your medical diagnosis and records. Later, when you sign into your Highmark account after creating this WebMD account, clicking 'rewards' automatically downloads all your medical records from Highmark to WebMD, without providing any warning about this data transfer. This includes all doctor diagnoses!!" -- N. Krishnan Kutty STATE COLLEGE, PA
"First, this is a serious intrusion into my privacy without me being proper informed. Second, any wellness program should encourage and reward people for participating in it not to punish them. Third, the questionnaire is intrusive, with many questions being confusing, misleading or simply improper. The numbers and recommendations are very general and essentially uninformative and I have to do all this only to receive this unsolicited and unnecessary information. I do my wellness program under the guidance of my doctor and everything I did to avoid penalty was complete waist of time and completely meaningless." -- Yakov Pesin STATE COLLEGE, PA
"I completed the questionnaire and was amazed and appalled by the questions asked and the results ('health profile') I received after completing this questionnaire. I perceive it as a gross violation of my privacy and offend to my feelings. Rather than 'think about my health', as one of the last questions suggested, it made me feel first humiliated then angry." -- Irina Mikaelian UNIVERSITY PARK, PA
"'Wellness' is not achieved through coercion." -- Denise Woodward STATE COLLEGE, PA
Check out this website for many more comments along these lines, more than 2,000 of them from the Penn State University faculty and staff who now must complete a mandatory, detailed, personal health questionnaire along with other tests such as biometric screenings that include body mass index (BMI) measures as well as cholesterol and blood-sugar tests. Employees who do not comply, as well as their spouses if covered under the PSU health plan, will be subject to $100 per month financial penalties.FULL ENTRY