Healthy Policy

Attention to the Uninsured

It's Cover the Uninsured Week, so I'll be posting something on the uninsured each day.

The Robertwood Johnson Foundation released a new report last week with standardly shocking findings about the uninsured and access to medical care.

So while others will persist with their false claims that the uninsured receive care, and therefore the problem is not immediate, remember this:

• 41% of the uninsured adults reported skipping medical care because of cost last year.  This number doesn't include the 20% of children who lack health insurance. 

• 23% of uninsured adults report their health as "fair" or "poor," compared with 12% of insured adults.

That percentage will tick higher and higher while we distract ourselves from solving this problem with brave new explorations into the world of Health Savings Accounts.  As health costs continue to outpace inflation markedly and wages remain stagnant, fewer and fewer of the uninsured will be able to afford any medical care.  State and hospital funds that currently act as reimbursement for the cost of acute treatment will cover less and less. 

This trend will happen faster than we expect; insurance indicators are ticking away at incredible speed.  Just as the number of employers providing health care decreased by 9% in five years, measures of the uninsured's health status will worsen.

Mass features reinstated

The Massachusetts legislature voted to override Romney's vetoes on Tuesday.  So the employer assessment of $295 is back (albeit still insufficient).  Other things reinstated include:

• Extension of dental and vision benefits to adult Medicaid beneficiaries and discounts on premiums and copayments for meeting wellness goals;

• A larger, revamped Public Health Council;
• A provision that would require a member of the Massachusetts House and Senate to participate in negotiations with the federal government regarding special Medicaid funding; and
• A provision that prohibits the Governor from making significant changes to mental health benefits without an explanation to the Legislature
  

These vetoed items actually say a fair amount about Romney.   Namely, that he could care less about tooth decay (for an explanation of why it matters to have dental care, go here) and doesn't think public health initiatives matter in the age of bird flu.   Too bad -- besides their disaster-combating aspects, public health initiatives need to play a large role in any reform overhaul, as the current incentives to be healthy are utterly failing. 

Luckily Massachusetts has a democratic legislature which has its priorities in line.

Canada, health care reform, and you

A few things in the health care debate have been riling my feathers lately.  The first is yesterday's post by Ezra Klein examining how the folks over at the right-leaning The Corner are busy questioning the definition of "is".    Ramesh Ponnuru writes:

I don't think [universal health care] is possible, actually. If you can't get an operation because your country's national health insurance system has you on a long waiting list, in what sense have you enjoyed "universal coverage"?

Ezra goes on to discuss how one can, in fact, define universal, and that definition is "everyone in the population receiving health insurance". 

Jon Cohn addresses the latter part of Ponnuru's argument over at The New Republic's blog, the Plank, and dug into the stats on waiting lists:

Here's the summary findings from an exhaustive survey by the Organization for Economic Cooperation and Development (OECD):

The health system in France is regarded as delivering high quality services, with freedom of choice and generally no waiting lists for treatments.
--Page 69, sourced to a 2000 study by a trio of academics

And: In Germany, "Waiting lists and explicit rationing decisions are virtually unknown."
--Page 70, citing a World Health Organization study.

If Ramesh knows something the OECD doesn't, I'd love to hear about it.

I'm going to throw myself into the fight here, and debunk another favored myth of the Right, which is that the Canadian health system is so bad, millions of Canadians come here for their health care. 

A 2002 Health Affairs paper examined hospitals near the border, as well as national surveys to tease out how many Canadians actually visit the U.S. to receive elective procedures.

In terms of hospitals along the border offering advanced treatments or special diagnostic technology (i.e. CT scans and MRIs), about 640 Canadians were seen, along with 270 for procedures like cataract surgery. They compare this to about 375,000 and 44,000 similar procedures in the region of Quebec alone during the same period. If you divide the total number of Canadians seeking those treatments in the US, divided by the number in Quebec alone that's about 0.09%.  Not even a tenth of a percent.

But the most striking stats come from the Canadian National Population Health Survey (NPHS).  From the article:

Only 90 of 18,000 respondents to the 1996 Canadian NPHS indicated that they had received care in the United States during the previous twelve months, and only twenty had indicated that they had gone to the United States expressly for the purpose of getting that care.

Only 20 of 18,000 sought care in the United States.  I can't believe how many people are coming over here!  Their system but be truly awful.

But let's give this number some context. We've all heard about seniors getting their prescriptions from Canada. (Hell, even driving to visit my sister at college in rural Kansas, I saw a billboard for "Canada Drug of Topeka!") But how many seniors really do that? Is it exaggerated, like the claims of Canadians coming stateside?

Polling data from 2003 (approximately a year after the Health Affairs article) indicates that 8% answered YES to the following question:

"Have you ever bought prescription drugs from Canada or other countries outside the United States in order to pay a lower price?"

If 8% of the 18,000 Canadians polled in NPHS had expressly sought care in the United States, that would be 1,440. Not 20, as the survey showed.

In other words, we have 72 times the number of Canadians seeking care in the US going to Canada (or at least calling there) to get prescriptions.

What angers me so much about the Right's rhetoric on health care reform is that their arguments are so weak that they're now essential questioning the definition of "is".

Universal health care has been achieved in dozens of nations on this planet.  One of which has some waiting lists, while others have essentially none.  According to surveys, less than 0.1% of Canadians are expressly seeking care in the U.S. 

The bottom line is our health care is twice as expensive, fails to cover 46 million people, has questionable quality, kills around 100,000 people a year from error, and for all this we have worse health indicators (i.e. lower life expectancy, higher infant mortality, etc).  Other countries do it better, and they do it with the help of government to pay for health costs.    

We can at least move to a system where everyone has health insurance. Or, you can believe the folks over at the Corner who are arguing that universal coverage doesn't exist.

What do you want? 

Would-be reformers, take note

Ezra writes:

Among the many reasons I'd prefer not to be a politician, navigating the remarkable confusion of your constituents as to their opinions on public policy issues ranks high up there. They're for abortion, for abortion restrictions; for lax immigration laws, in favor of draconian enforcement; for going through the UN, enamored with acting unilaterally; for tax cuts, for spending increases; and on and on it goes. The phrase "mutually exclusive" is absent from America's political vocabulary, as is the concept of a "tradeoff."

He's right on the mark. That's why we have a war that, if there was a draft, no one would want to fight, a war without any tax increases. This logic extends to health care reform and our quest to fix the system.

Just look at my post from yesterday, where I discussed the ramifications of Gov. Romney vetoing the employer assessment. 

When I attended the National Health Policy conference in February, an entire presentation was devoted to the idiosyncrasies of health policy polling. Sure, the vast, vast majority of Americans are in favor of reform, and a majority will even support a "modest tax increase". But if you name any specific dollar amount of that tax increase, the foundation of support crumbles.

I wish I could say, "This is a cultural problem; let's try and fix it." But the truth is that this is a symptom of democracies -- when you're insulated from making the calls, it's easy to support or protest them. A change in perspective, where people bring themselves to support reform with trade-offs, only occurs in the face of substantial problems and hardship (like premiums reaching $20,000/family in today's dollars).

In the meantime, we should keep talking about all the things that are wrong with the U.S. health system, and all the ways other countries succeed where we fail. That way, when it's time for reform, the foundational message and education will have been laid, and coupled with the public's willingness (if not desperation) to act, efforts will hold strong.   

Romney says no to employer assessment

The Boston Globe is reporting that, in a show of his Republican colors, Massachusetts Governor Mitt Romney will sign the new health bill, but veto the employer assessment (you know, the paltry $295?). 

This bill is shaped with the assumption that the vast majority of employers will not drop coverage of their employees.  It does not make plans for what to do (and in particular, how they would pay for it) if that is the case.  $295 is significantly lower than originally proposed, and that number is already causing uneasiness.

Fortunately, there are more than enough Democrats to override Romney's veto.  But it still sends a message that employers shouldn't be punished for not providing insurance.  If you're like me, and you want to uncouple the employer-insurance relationship, that's just fine.  But MA hasn't planned for it, and who knows how they'll handle it if there's an exodus of employers from the system.

It's never good to leave people without a parachute, and if Romney had his way we might see a lot of people crashing to the ground as their insurance is pulled out from under them. 

Random resource

Talk of the Nation is discussing Massachusetts and health insurance, tune in if you're an NPR nut like me.

Single payer vs. HSA's

Matt Holt has a great conversation going in the comment thread of this post.

More on Mass

After reading dozens of opinions and articles on the Mass Health Reform Bill, I want to put in some additional two cents.

I think people are being too harsh on this in general.  So what if Romney is running for president?  As Ezra excerpted (originally from Jon Cohn) over at TAPPED:

And while it will undoubtedly annoy some progressives who don't love the plan or think he's taking credit for an idea (and favorable circumstances) that fell into his lap, they should be thankful for this development.

Thankful, because nationally the most important impact of this new law may be on politics, not policy. Once Romney starts boasting about how he achieved universal health coverage in Massachusetts, it will become that much harder for conservatives to demonize the very concept as "big government." Oh, they'll try--and they'll have at least some success. But now Democrats will have this retort: If a Republican governor and leading presidential contender with strong conservative credentials thinks universal health care is a good idea, how radical an idea can it be?

Progressives are also screaming "follow the money!", which strikes me as ridiculous.  Is coverage only good if it comes from a "pure" place?  Is it more important to have insurers out of the equation NOW, or to get everyone covered affordably?  To me, it's obvious.  In an ideal world, private insurers would be out of the equation.   But this is far from an ideal world, and a world where we can get everyone into insurance without bankrupting ourselves seems good enough for me.  Keep in mind this is a state initiative, and compromises here are much different that what we'd want for a national system.  These reforms are laying the road to universal care, not the building. 

I also disagree with Joe Paduda that there will be a huge rise in demand.  Only 11% of Massasschussetts is uninsured; and they have huge free care pools.  There will probably be a small increase, but no rash of people all of the sudden having tons of elective procedures and crowding specialists.  There just aren't enough people without insurance to do that.

That being said, I have a few concerns:

• There is no dedicated funding source.  This program will absolutely fail if there isn't enough money for it.  State budgets don't have the ability to absorb cycling costs like the Fed.  This could prove problematic.

•  The penalty for not insuring employees is terrible.  It is much, much too low to be any kind of disincentive for dropping insurance.

• It's unclear what will happen with the number of employers dropping care.  This statement over at Ezra's is making me think.  I'm unsure whether we'll see that.  And without a stiffer penalty, we well might.  But taking it a step further -- what happens if employers do drop care?  There's the affordable option being subsidized by the state so they'll still be covered.  But costs to the state will greatly increase unless there's a new source of funding dedicated toward this problem.  It won't work if employers drop coverage and just pocket the money, or funnel it toward other expenditures.  The state won't be getting any more money to deal with the increased cost.

There will be many lessons learned from this experiment.  It's a major change, and it will give much insight into the "right" and "wrong" ways to reform.  I know we'll all be watching eagerly.

More on the MA bill

Ezra has a great round up of the MA bill, with some thoughtful questions and concerns about the bill's funding. 

Also see Leif Wellington Haase over at the Drug Bill Debacle.

Want some more money?

Graham writes about our inefficient health system, with a great way of framing what's at stake:

Would you mind having an extra $900 a year? (You’d also get another $900 per kid.) What is that—about the cost of a really nice vacation every year? Going to a great restaurant once a month? Several pairs of shoes, clothes, and diapers for a child?

Often people don’t realize that they have something to lose from this inefficient mess we call “The US Health Care System.” Even if they have health insurance. See, because every time that your employer’s health insurance premiums go up, that’s money that your employer can’t pay you as a raise. So all that raise that you’ve been wanting to get? Oh, you’re getting it—but it’s in the form of higher health insurance costs, not a fatter paycheck. (And you probably didn’t even spend more on health care this year than last, either.)

Go read the rest.