Blog Posts (15)
February 10, 2017
|By Kathy Greenlee, JD|
I recently learned the Irish superstition that you should exit by the same door through which you entered. The Affordable Care Act will most likely not have that option. The door it entered is closed.
I also recently revisited the unusual circumstances that allowed the ACA to become law. In early 2010, the Democrats held a 60-vote majority in the United States Senate. Then, in August, Massachusetts Senator Ted Kennedy died. In the election for his successor, Massachusetts elected Scott Brown, a Republican. Between the November election and Scott Brown’s swearing in, the Senate approved the ACA. When Senator Brown took office, the Democrats lost their super majority. The House had already passed the law, so they quickly moved to pass the Senate bill. Having 60 votes in the United States Senate is a big deal. The Senate rules are such that the chamber requires a supermajority – 60 votes – to cut off debate and take a bill to the floor for vote. Law, Regulations and Money The ACA is anchored by three things: the law, regulations and money. Currently, the Republicans have a majority but not a supermajority. They don’t have 60 votes to pull the law off the books. They do, however, have enough votes to control the money. The ACA will be made ineffective and inoperable because the funds needed to make the law work will be removed. Money supports the subsidies for qualified people who purchase insurance through the exchanges. Federal money is used to match state money for Medicaid expansion and long term care rebalancing incentives (incentives for states to purchase community rather than institutional services for long term care). It takes money to close the Medicare prescription drug plan donut hole. The first and most active battles in Congress will focus on money. And that battle has begun. The current 2017 federal fiscal year began on October 1, 2016. But, Congress has not passed a budget for this current year. Congress intends to use the current budget to gut the provisions of the ACA that are budget related. Then, immediately thereafter, the Trump administration will present Congress with a proposed 2018 budget and Congress will begin to work that budget this summer. The ACA will likely remain on the books, but won’t be operable as a comprehensive law. The non-budgetary sections will remain but will be largely inert. While Congress assures the money dries up, the Trump Administration can begin the process of rolling back the thousands of pages of regulations that support the implementation of the law. Repealing regulations is time and labor intensive. ACA regulation repeal will be a steady slog likely to drag on through most of 2017 and into 2018. Regulations are behemoths. As you watch events unfold, keep in mind the three anchors I mentioned earlier: the money, the regulations and the law. The Republicans in Congress and in the White House will drive the budget and the regulations. They won’t need Democratic support to do so. But, to pull the remnants of the law and to pass a new law, Senate Republicans will need to find Democratic allies to help them get the 60 votes they need to cut off debate and pass legislation. The Democrats had 60 votes when the ACA passed; the Republicans currently do not. The 60-vote door will have to be unlocked in order to make new law. Next up: Let’s talk in more detail about an ACA budget hot topic: Medicaid. Kathy Greenlee joined the Center’s staff as Vice President for Health Policy and Aging in November 2016 after serving the past seven years as Assistant Secretary for Aging in the U.S. Department of Health and Human Services.
November 4, 2016
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 … Continue reading →
The post Is It Fair to Reward Medicaid Patients for Receiving Flu Shots? appeared first on PeterUbel.com.
August 9, 2016
For a great nation like the United States, it is not only
embarrassing, but also morally reprehensible that there are still millions of
American citizens who in principle could have healthcare coverage but are being
denied that benefit for purely political reasons. Ideologically driven
governors in Red states would rather defy the efforts of President Obama to
expand healthcare coverage for all their citizens than provide this most basic
human service to their citizens. I draw this conclusion simply because their
alleged reason for refusing to expand Medicaid—that expanded coverage will be
unaffordable—is simply not true. With Medicaid expansion, the federal
government will significantly underwrite most of the costs and without states
are on their own in the most inefficient healthcare system possible—they get no
access to basic primary care but if they get acutely sick they can show up at
an ER and utilize the system at time where cost is exorbitant and goals are
limited. It is an abomination how healthcare has been a political football for
decades while people with medical needs are allowed to suffer and die.
But it is not just patients without healthcare coverage who
lack access to medical care—it is also millions of patients with coverage. Medicaid
currently covers over 70 million Americans, yet many of these patients are not
able to find a physician who will accept them. In a 2011 national
survey of physicians, 31% were unwilling to accept Medicaid patients; in
certain states the rates are much higher—for example, in New Jersey only 40% of
physicians accepted Medicaid patients. When reimbursement
rates are increased, these rates of physicians willing to accept Medicaid
patients also rise. Clearly if we are going to expand healthcare coverage in
the United States, we must ensure that physicians are provided a fair
reimbursement for the services. But there are other barriers other than
Another important barrier is the fact that many poor
patients live in areas of the country where there are shortages of physicians.
Up to 60% of the underserved
areas in need of primary care physicians are in non-metropolitan areas. Physicians’
reticence to work in areas with high concentrations of patients whose primary
insurance coverage can be partly explained by lower than average compensation
rates but not entirely. Other barriers may include most physicians wanting to
live in metropolitan areas and not wanting to deal with more patients with
complex issues, such poverty and poor education. Moreover, physician specialist
simply make much higher incomes in larger metropolitan areas. In the past the
choices of individual physicians coincided with the general health needs of
society. It appears that in today’s society, there are serious health needs of
large segments of society going unmet.
But even in Blue states like California, with Medicaid
expansion, many patients have what looks like good health care coverage and yet
are often unable to find a physician or qualified health care professional to
meet their needs. This is particularly problematic for patients with mental health
issues. A recent
story on NPR about a mom with a 12 year-old son provides a great
illustration. To start with this mom is forced to pay high copays of $75 per
session for needed therapy for her son—for working people, living on pay check
to pay check, serious health needs can easily go unaddressed. The 2008 Mental Health Parity Act and the
Affordable Care Act (ACA) insurance companies attempted to fix some of the
problems like preventing insurance companies from charging higher copays for
mental health services than other services. But insurance companies still find
ways to skirt the law “sometimes through subtle, technically legally, ways of
limiting treatment.” The mom
in this story discovered one of those ways when she tried to schedule an
appointed with one of the therapists her insurance company would cover for a
lower copays of $20. The problem was there were no therapists willing to accept
her son. The insurance companies are at least superficially in compliance with the
law, but there are no therapists, or very few, that are available for new
patients. Part of the problem is that millions of new patients with mental
health issues have signed up under the ACA, have coverage, but cannot find a
qualified healthcare professional to care for them.
problems to which I have alluded are characteristic of a healthcare system
filled with inefficiencies and bloated costs. There are many reasons to account
for why these inefficiencies exist, which I won’t get into here. But as a
I am reminded of the Physician’s
Charter from the American Board of Internal Medicine (ABIM), which embraces
a bold, robust set of professional obligations charging physicians to expand
access to medical care for all patients and to promote social justice. Under
the heading of Social Justice, it states: “The
medical profession must promote justice in the health care system, including
the fair distribution of health care resources.”
At my medical school we
are teaching our new physicians they have an obligation to advocate for all
patients and help expand access to healthcare. I must admit I am worried that
the challenges they will face will be nearly insurmountable without significant
change at the political level and many other policy changes, like greater
parity in incomes between specialists and primary care physicians and tuition
debt relief. But, patients, which includes all voters, must do our part too as
citizens involved in the political process and support candidates that in turn
support access to quality public healthcare for everyone. These concerns should
weigh heavily in the choices we make at the voting booth this fall. Getting
basic healthcare coverage for all citizens should not be this hard.
August 1, 2016
On July 25, 2016, inmates
incarcerated in Tennessee prisons filed a class action lawsuit against the
state’s Department of Corrections “asking the court to force the state to start treating all
inmates who have the potentially deadly disease [hepatitis C].”
The inmates are represented by several advocacy
organizations: American Civil Liberties Union, Disability Rights Tennessee, and
No Exceptions Prison Collective. The gist of the lawsuit centers on a claim
that failure to provide inmates with what now is believed to be standard of
care treatment for hepatitis C is “cruel and unusual punishment” and
prevalence of hepatitis C in Tennessee’s prison and adult general populations have
been estimated at 23% and 4.4%, respectively. Moreover, there are more
persons incarcerated in Tennessee than just the state’s prison system. One
Tennessee county jail recently reported that 92% of its detainees had hepatitis
C! Tennessee counties are
usually financially responsible for the health care costs of those jailed
within their jurisdictions.
news accounts that are reporting the story the principal issue clearly is money.
The medicine – which is an extremely effective cure – costs about $1000 per pill
to be taken daily for 12 weeks. The estimated cost per patient is about
$84,000. The total cost to the Department of Corrections is staggering given
the numbers of patients that may require treatment.
the unstated – the implied – more pressing issue from the story is not just cost,
it is fairness and justice for all Tennesseans. The Tennessee legislature is
responsible for the budget that funds both the Department of Corrections and
the state’s Medicaid program. To assure treatment for Tennessee inmates and not
provide full coverage for Tennessee’s Medicaid population who are also infected
with hepatitis C would be clearly discriminatory, and possibly would not stand
up to a constitutional challenge under the Equal Protection Clause. It may
place the Tennessee legislature in the untenable position of having to provide
treatment for coverage for both groups or neither group, and if it opts to
provide treatment to then find the unbelievable sum of money to fund the costs.
Tennessee legislators and their constituents may find it a bit hard to swallow
if the state funds the costs of hepatitis C treatment for prisoners and not the
poor and disabled patients covered by Medicaid. Legislators and citizens may
see prisoners somehow as less worthy? But the comparisons won’t stop with
prisoners v. Medicaid patients, some might question the fairness of Medicaid
patients being eligible for hepatitis C treatment when working Tennesseans with
health insurance provided through employer-based plans are somehow less
eligible for treatment, or have to incur out-of-pocket costs for treatment when
prisoners and Medicaid patients do not? With the costs of treatments coming
from so many pots – Medicare, Medicaid, employer-based insurance plans,
federally funded programs for the military and veterans – the fairness issues
that will arise with future innovative and individualized – and undoubtedly
more expensive – options will only grow.
June 9, 2016
STUDENT VOICES By Melani Shahin In October 2014, Oregon became one of the few states to cover hormone suppressant therapy for transgender minors under Medicaid. The purpose of this treatment is to temporarily suppress puberty in transgender young people via … Continue reading →
October 21, 2015
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.
The post Unnecessarily Uninsured appe...
October 7, 2015
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 … Continue reading →
The post Is It Fair to Reward Medicaid Patients for Doing What They’re Supposed to Do? appeared first on PeterUbel.com.
September 10, 2015
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 … Continue reading →
The post Look What Obamacare Has Done Now appeared first on PeterUbel.com.
June 9, 2015
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 … Continue reading →
The post The Outlier Problem of Healthcare Spending appeared first on PeterUbel.com.
June 4, 2015
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 … Continue reading →
The post When It Comes to Controlling Healthcare Costs, the Government Outperforms Private Industry appeared first on PeterUbel.com.
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