"Reforming" Medicaid, or Cutting Medicaid: No shortage of folks to cast the first stone

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Jeff Colyer, MD, the Lieutenant-Governor of Kansas, has been leading an effort for Governor Sam Brownback to “reform” Medicaid for the state. This is of concern because the state faces the same budget crunches that are faced by most states and the relatively high cost of Medicaid as a percent of the state budget (about 22% in Kansas). Gov. Brownback wants to cut $200-400 M in Medicaid expenditures and is looking for ideas on how to do so. In the Fiscal Times, Blair Briody’s piece Medicaid’s Ticking Bomb Could Wipe Out State Budgets discusses the challenges states face with increased enrollment in Medicaid (6.5% in 2009) because of job losses resulting from the same economic crisis that has state revenues down. Of course, there is another solution, but (like most new Republican governors) Gov. Brownback and his legislature are firmly opposed to increasing revenues (ie, taxes)

Dave Ranney, reporting for the Kansas Health Institute, covered the second of two (so far) public forums, held in Wichita and led by Lt Gov. Colyer and attended by Secretary of the Department of Health and Environment Bob Moser, MD (Moser is a family physician; Colyer is a plastic surgeon). In Medicaid forum generates long list of reform ideas Ranney lists many of the ideas identified by working groups. They include:

• Enact policies that discourage non-emergency visits to emergency rooms.
• Remind families of their moral obligation to at least share in the costs of caring for frail elders.
• Reward behaviors that improve health. Discourage those that do not.
• Increase the numbers of nurse practitioners in the state’s rural areas.
• Let Medicaid beneficiaries know how much their services cost.
• Do more to promote “living wills” and hospice care, less to promote nursing home care.
• Limit families' ability to switch managed care providers more than once a year.
• Do more to encourage businesses to hire disabled people.
• Approach companies like Home Depot and Lowe’s about helping people with disabilities make their homes accessible; installing wheelchair ramps, for example.
• Foster home-like homes for frail seniors or disabled people who might otherwise move to a nursing home.
• Reduce the potential for fraud and abuse by not allowing family members to be paid for caring for elderly relatives.
• Close one or both of the state hospitals for people with severe developmental disabilities.
• Find ways to better coordinate patient care.

Something is missing from this list. That would be any suggestion that the state has a responsibility to provide quality health care to Medicaid recipients. Of course, that might cost a lot more, not less money. Some of these ideas are reasonable, like asking Home Depot and Lowe’s to help people, encouraging businesses to hire the disabled, and developing “home-like homes” (I love that; as opposed to ‘non-home-like homes’, or ‘home-like non-homes’?) for frail seniors and disabled people. They might even help some folks, but they are unlikely to save Medicaid much money.  Others, such as increasing the number of nurse practitioners in rural areas, are good ideas, but without a strategy that addresses how are of little use. Nurse practitioners do not locate in rural areas for the same reasons that physicians do not: because they are often from urban areas and can make more money in urban areas, particularly working in subspecialties rather than primary care. Paying them more to work in rural areas might be effective, but that also would cost more money.

Closing the state hospitals for people with severe developmental disabilities would probably save money, but only if adequate services can be provided for them in the community. Whoops, that will also cost more money. And that money will be vulnerable every year, especially when there is a budget shortfall. We have experience in this area. Several decades ago, across the country, we closed state mental hospitals because we could provide better mental health care in community mental health centers while giving the patients a better shot at a higher quality of life. Unfortunately, after “de-institutionalization” (as it was called), federal and state governments ratcheted down funding for community mental health services. The result? Lots of homeless, under-treated, mentally ill people. It is not clear to me that those with severe developmental disabilities will even do as well.

Doing more to promote “living wills” and hospice care might be good for many people, Medicaid or not, as would finding ways to better coordinate patient care. Of course, nursing homes are businesses, and state government wants to be business-friendly.

The most obvious characteristic of the list is that most of the suggestions fall squarely in the category of “blaming the victim”. They are mean-spirited and reflect a definite sense that the people who are receiving Medicaid are, by and large, irresponsible, manipulative, and wasteful. Certainly they are not anything like the people making the suggestions! Thus, we should limit their ability to change providers and we should emphasize the importance of families taking care of their elders (whether those families have any resources or not; whether they have families or not). In the cases where they do have families we need to reduce the potential for fraud and abuse by not allowing family members to be paid for caring for elderly relatives, enact policies that discourage non-emergency visits to emergency rooms, let beneficiaries know how much their services cost. How these would save money without hurting the health of beneficiaries is not made clear. What if the providers are not meeting the patients’ health needs? What if the frail elders (and here I assume that we are talking about people who receive both Medicare and Medicaid, known as “dual-eligibles”) do not have families, or if their families are without resources? What if they do have families and now those family members cannot go out and get a job because they are caring for frail elders but we won’t pay for it? And what is the point of reminding them what their benefits cost? It is presumably health care providers who order the tests and treatments, and these are based, presumably, on medical need.

It is actually, by and large, a pretty ugly list. Maybe we should remind the members of these citizens’ panels what their benefits cost. Are they paying out of their pockets for their health care, or do they have insurance? Is there anything more morally acceptable about receiving inappropriate, medically unjustified, non-evidence-based health care if one is insured by something other than Medicaid? Or is not receiving appropriate, medically justified, evidence-based health care more acceptable if one is on Medicaid? In my last post I cited the June 28, 2011 NY Times article, “New prostate cancer drugs extend lives but raise costs”, in which Andrew Pollack notes that Medicare is going to look into whether to pay for drugs that may extend life for a few months but cost upwards of $90,000 per course of treatment, but that “…some patient advocates and politicians portrayed the review as a step toward rationing.”  I hope that these are not the same people who are advocating rationing for those who are poor.

Because that is what Medicaid patients are. Poor. Not all poor people get on Medicaid, of course. In most states, including Kansas, only poor people who are children and their mothers, severely disabled people, or people in need of long-term care, are on Medicaid. Not undocumented people, not childless adults no matter how poor or in need of health care. But everyone on Medicaid is poor. If there were any poor people on these panels, whether or not they were Medicaid recipients, you can be sure that these suggestions did not come from them. There is not a single working-class, middle-class, professional or upper-class member of any of these panels who would want to change places with these poor people so that they can get Medicaid. It is so much easier to judge others.

The reality is that the most useful suggestions will not save much if any money, and most of the rest are mean. In an Op-Ed in the Wichita Eagle, state Rep. Jim Ward (D-Wichita) suggests that the cuts first “Do no harm”. He states it is from the Hippocratic Oath, which it is not really (see Physician Oaths and Social Responsibility, July 7, 2011), but it is a good idea. Another really good idea is close management of the sickest, highest-cost, highest-risk patients using health coaches or promotoras (such as those described by Dr. Atul Gawande in The hot spotters: can we lower medical costs by giving the neediest patients better care?” and discussed by me in Freedom abroad, health at home: experiments in preventive health care, February 13, 2011).

The necessary step to both maximizing health and minimizing cost is to have a single-payer system so that we are all in the same program, so that cutting your benefits cuts mine. Then we can make wise decisions on the most medically appropriate, as well as cost-effective, way to spend that money.

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The White Coat Ceremony: New medical students and hope for the future

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I recently attended the “White Coat Ceremony” for entering medical students at the University of Kansas School of Medicine. The entering class, having completed their week of orientation, is welcomed to the school by its dignitaries in front of an audience of their families, friends and loved ones. Then each student walks to the stage while his/her name and hometown are read, and has a white coat placed on them by a member of the faculty. They then take an “Oath of Commitment” (different from the “Oath of Hippocrates” they will take at graduation) and at the end, in a semi-joke, told that “Classes start Monday at 9!”

Hokey? Well, maybe a little when it’s described, but very moving in person. Each one of the 175 people receiving the short white coat (traditional for students) is an individual person who has worked very hard to get there and they are (I assume almost all if not all of them) sincere and committed to helping people and making a difference. If studies have shown a scary drop in empathy in medical students in their 3rd year (Are we training physicians to be empathic? Apparently not., September 12, 2009), that is more than 2 years off. If long hours of classes and studying what will often seem trivia in the biomedical sciences scarcely related to being a doctor will fill most of those 2 years, it is not on the agenda today. Today it is about “keeping their eyes on the prize” but also recognizing it will be hard work. In the Oath of Commitment they pledge to work hard, to know their limitations and seek to learn enough to overcome them, and to be life-long learners. They say:

"I will strive to preserve the dignity, the humanity and the privacy of all my patients, and through my openness and kindness I will seek to earn their trust in turn.
I will treat my patients and my colleagues as my fellow beings and never discriminate against them for their differences; and I will ask that they do the same for me.”

This expostulation of altruism is, obviously, in marked contrast to the mean-spirited negativism that is characterizing the political campaigns of the day in Kansas (and elsewhere) that I recently addressed on this blog (The political campaign and the future of health reform, July 28, 2010), and criticized in the July 30, 2010 editorial in the Kansas City Star, which notes that, while Nancy Pelosi is not running in Kansas, candidates (mostly conservative Republicans) are attacking their primary opponents (mostly conservative Republicans) by calling them supporters of the Speaker, and even (gasp!) the President. In a few cases, such as the Republican primary for Secretary of State, Elizabeth Ensley, the well-qualified, highly-endorsed candidate surprises Star interviewers by "...blurting out 'I’m pro-life.' When asked what that had to do with the record-keeping office for which she was running, she answered, 'Well, nothing, but people always seem to want to know.’ Of course, Ensley could be forgiven for losing focus. Her GOP opponent, Kris Kobach, is trying to define the race as being about illegal immigration. It’s not.”

I really enjoy hearing where the students are from. Some are from surrounding states like Missouri and Colorado and Nebraska, some from farther away like California and New York, and even a few from other countries. But most are from Kansas, and from all over Kansas. Yes, there are higher proportions from the metropolitan areas of Wichita and suburban Kansas City; but also from the “larger” (for Kansas) cities like Lawrence and Topeka and Hutchinson and lots from places like Goodland and Oberlin and Neosho and Medicine Lodge, where maybe, if the people there are lucky, some of them will return to enter practice.

And then the “Doctor’s Notes”, the student a capella singing group, did a beautiful rendition of John Lennon’s "Imagine". It’s a very lovely song, and it expresses sentiments that are very different from those we are hearing on the local and national political scene. Worried about Nancy Pelosi? Barack Obama? They’re nothing but compromising politicians; our students sang Lennon’s lyrics:

“Imagine there's no countries
It isn't hard to do
Nothing to kill or die for
And no religion too,”

Not a position likely to garner a lot of votes in Kansas. I don’t know the politics of the students in the entering class, or their families, are, but having watched the volunteer work of their predecessors, in the student-run free clinic in Kansas City and in work around the world, I wouldn’t be surprised if many of them see some of their beliefs reflected in the verse that says:

“Imagine no possessions
I wonder if you can
No need for greed or hunger
A brotherhood of man
Imagine all the people
Sharing all the world...”

OK, maybe not the “no possessions” part, but caring for others part. And, if we are lucky, they will continue to care. They will maintain their empathy through the 3rd year of medical school and beyond. They will be life-long learners who care for people and about people, and live a life not simply of service, but of brotherhood. They will truly be healers, and not destroyers. It’s way too early to know, but we can hope that they will be.

Imagine.
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The political campaign and the future of health reform

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The headline story in the June 28, 2010 issue of the Kansas City Star, by Dave Helling and Steve Kraske, is “Mailings turn aggressive”. It is about direct mail campaigns by those seeking elective office, how they have become a major part of the campaigning, and how the content is almost entirely negative – and sometimes hard to believe. For example, a state legislator running for Congress has a mailer attacking his primary opponent as a “Nancy Pelosi Democrat”, although the only obvious similarity this “staunch conservative” former legislator has with Ms. Pelosi is that they are both women.

The more interesting aspect is not the attack aspect of the ads, but that most of the non-attack “positive” campaigning, touting the candidates’ strengths and thus implicitly responding to attacks, is (among Republicans) to emphasize their negativity. Jerry Moran, a Republican congressman from Kansas’ “Big First” district is running against Todd Tiahrt, congressman from the 4th district (Wichita), for the Senate seat of Sam Brownback (who is odds-on favorite to be our next governor). Both have essentially the same, straight-down-the-Republican-line voting record, but Tiahrt has accused Moran of being less conservative. A recent Moran ad indicates that he fights for Kansas and then lists all the things he has opposed – which is essentially everything that the Obama administration has done. Moran is a nice, personable man and presumably has some good positive ideas, but apparently in the campaign it is not cost effective to promote them. (Note that the Tiahrt campaign takes the same tack, except when attacking Moran for not being conservative enough.) In the Republican primary proudly embracing charter membership in the “Party of NO” is apparently the name of the game, It is possible that in some parts of the country, candidates in the general election will feel pressure to say what they are for, but only if absolutely necessary. In Kansas, where the Republican nominee is pretty much guaranteed victory in most venues, it probably won’t.

In a recent article in Health Affairs, “The political challenges that may undermine health reform”[1], Theda Skocpol ties some of these trends to the future implementation of health reform. She accepts that there will be Republican gains, but also discusses the ways in which Democrats will likely respond, hoping to blunt those gains and prevent a complete Republican takeover of Congress. In its absence, she notes it is likely that most of the part’s of PPACA will be implemented, slowly and quietly, although some of the parts most likely to engage support (elimination of discrimination against those with pre-existing conditions on the individual market and allowing children to stay on their parents’ policies until 26) are front-loaded, going into effect this year. Among the most interesting things she says (to me, a non-political scientist), is that “Political scientists have long know that Americans are what is called ‘operational liberals’; they like specific government benefits. Yet these same Americans are also ideologically conservative, when arguments about government versus the free marked are posed in general rhetorical terms.”

Actually, this makes it almost sound like Americans are “operationally selfish”. Indeed there are many who are, like the family physician I knew in Texas who would mostly rant against the liberals in Washington and the need to elect more conservative Texans, until, in a cost-saving measure pushed through by those fiscal conservatives, the government delayed sending out Medicare payments to physicians. That was intolerable to him! Dr. Skocpol continues: “That is why we will see Republicans doing all they can to keep the argument at the systemic level through early 2012, when they hope to elect a president who will support repeal or make fundamental changes in the 2010 legislation.” No question that arguing against Big Government is going to win more votes than opposing Medicare, or Social Security. And few of the reliably conservative Republican farmers in Kansas (or elsewhere) are going to be won over by arguments against agricultural subsidies. In Missouri, which has more Democrats than Kansas but has a legislature controlled by Republicans, a statewide referendum is about to take place which would prohibit the federal government from forcing people to purchase health insurance. It is being sold with “freedom” arguments, and might well be unconstitutional, but it will be interesting to see how people vote. When turnout is light, the poor and uninsured are less likely to turn out than those who, like the bill’s legislative sponsors, already have insurance; in particular older voters, already receiving Big Government Socialized Medicine Medicare are likely to vote.

While there is much to criticize in PPACA (done very well by John Geyman, “Hijacked: Stolen health care reform V” in the Huffington Post), there is definitely some good. The insurance companies have backed off their threats to not cover people (or at least children) with pre-existing condition, suggesting that people will begin to see some real benefits. The real issue is seen in Dr. Skocpol’s final sentence, above; the Republicans are running on general conservative principles, but should they gain power they will implement a very anti-regular-people agenda, as was done under the Bush administration. This is not limited to health care; while “everyone” (me, for sure!) hates the bankers who brought on the financial crisis (see Maureen Dowd in the NY Times, July 28, 2010: “Washington gave the Wall Street banks billions, and, in return, they stabbed us in the back, handing out a fortune in bonuses to the grifters who almost wrecked our economy”), the Republican party leadership, far from punishing them or reining them in, has tried to block legislation that would even gently restrict their most outrageous activities.

If we are lucky, maybe voters in Missouri and in other places will show that “operational liberals” who “like specific government benefits” are not all like that Texas doctor, and will also support specific benefits that help others. We have seen many polls showing that a majority of Americans favor universal health care even for all, so the sense of common purpose is not dead. Maybe they won’t, but we can hope.

[1] Health Affairs, July 2010; 29(7):1289-91.
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Poverty and Uninsurance Diverge: So let’s solve the problem!

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Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.

This means, obviously, that there are many non-poor uninsured people, and this is a national phenomenon. For most of this century, poverty and uninsurance rates tracked together. But in the late 1990s, with poverty rates decreasing, uninsurance rates continued to rise. With the recent recession, both have climbed, but uninsurance is rising at a higher rate. (See graph).

This dissociation between poverty and uninsurance is a very troubling phenomenon; while it is bad enough for poor people to not have financial access to health care, more and more of the uninsured are not poor.

Thus the case for health reform: let’s do something about this. Let’s dissociate the “privilege” of having health insurance from being employed by an entity large enough to afford to provide it, and make sure everyone has financial access to high quality care. Unfortunately, the current plans in the Congress will not do so. The recent assurance by Senate Majority Leader Reid that the Senate bill will contain a “public option”, as will the House bill, obscures the fact that the public option it contains will be weak; in an ostensible effort to not give the public option an “unfair advantage” over private insurance plans, it has been given an unfair disadvantage – it will not be able to use its public status to set rates for provider compensation, as does Medicare, or for drug prices, as Medicare (under the bad restrictions of Part D) also does not.

This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?

Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada”[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.

The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.

Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.

I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.

*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.

[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.
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