The following are responses I wrote as part of an article on children’s health care by Richie Bernardo in WalletHub, April 2014. The article includes wonderful state by state comparisons of a variety of indicators of children’s health.

What are the most important steps parents can take to help their children grow up healthy?
Unfortunately, parents tend to be blamed when their children grow up to have health problems, but most parents cannot control the economic and environmental factors that allow kids to grow up in good health.

I’d like to say: provide a healthy diet, make sure your kids get plenty of fresh air and exercise, keep them away from known pathogens. Yet it’s important to realize that many — perhaps even most — parents cannot afford a consistently healthy diet and/or are working too many hours in order to pay bills for them to have time to cook healthy meals everyday. Similarly, parents don’t control the levels of air pollution and water pollution that their kids are exposed to, and many parents raise children in neighborhoods in which there are no safe, green spaces for kids to play. And, given that most kids grow up in households where all adults need to work in order to get by, parents cannot avoid sending their kids to school when they are a bit sick.

I do think that most parents can restrict their kids’ access to the most nutritiously unsound foods (for example, sweet soft drinks, candy, processed meats) and can encourage kids to participate in gym and other school activities. I also think parents can and should make their voices heard in their communities and to politicians. If there is garbage on the streets in your neighborhood, bug the City to improve garbage pick-up. If nearby factories are shooting toxic chemicals into the environment, organize a protest.

Another piece of advice I’d give parents (and I am speaking as a mother of four as well as in my role as a sociology professor) is to help your kids find something that they love doing: drawing, singing, playing ball, doing math equations — whatever your kid likes. When we do things that we enjoy we feel better about ourselves and about the world, and that feeling leads us to want to make healthy choices. And something that nearly every American parent can and should do – vote, so that we can build policies that nurture kids’ health.

Do you believe children are prescribed too much medication in the US today?
Yes. I am especially concerned about the over-prescription of psychiatric medication in order to control the behavior of kids. While some kids are in fact deeply troubled and need medication, we shouldn’t be drugging kids for being “too” active or “too” disobedient. I also am concerned about the over-use of over-the-counter medication for colds and coughs. Oftentimes, what kids (and adults) need is rest and soup, but television ads encourage us to purchase quick fixes for ailments both major and minor.

Do you think the government should ensure all children have health insurance coverage?
Yes, absolutely. It is devastating for parents not to be able to take their kids to the doctor, and untreated illnesses cause kids to fall behind in school and in overall physical, emotional and cognitive development.

In evaluating the best states for children’s healthcare, what are the top 5 indicators?
Since S-CHIP is a federal program, there is not a huge amount of difference between the states in children’s access to care. However, there are enormous differences among the states in adults’ access to care. In states that expanded Medicaid eligibility under the ACA, most adults now have healthcare coverage. In those states that did not expand Medicaid, the numbers of uninsured adults have remained higher.

While all parents do their best to raise healthy kids, parents who are struggling with their own poor health have the cards stacked against them. So, I’d say the number one indicator at this time in the U.S. is the overall rate of health care coverage for all people — children and adults. Other factors that I see as important include well-resourced school nurse programs, strong immunization programs, strong oral health care programs, strong vision and hearing screening and programs.

The Republican plan to eliminate or change substantial portions of the Affordable Care Act is likely to have a disproportionately deleterious impact on women. This is why.

 Women compared to men use more medical services and spend more on health care. Thus, any reduction in government support for health care will affect women more than men.

Women make more visits each year to primary care physicians than do men and are more likely than men to take at least one prescription drug on a daily basis.  According to the Health Care Cost Institute, “In 2015, spending was $5,684 per woman and $4,581 per man. …  From 2012 to 2015, the difference in spending between genders rose from $1,071 per capita to $1,103 per capita.  Per capita spending for women was higher than for men on every type of service, except brand prescriptions.”

Given women’s higher healthcare needs, the ACA protected women by requiring all plans to meet a minimum level of coverage that includes a basic basket of necessary services. The Trump administration has announced that they will reduce the price of premiums so that Americans can have more “choice” to select less expensive insurance.  Less expensive insurance typically covers less, which disproportionately hurts people who have need of more medical services. Lower premiums also may come with higher annual deductibles, meaning that people need to spend a large sum of money out-of-pocket before insurance will pay. Again, this places a particularly heavy burden on people who need more healthcare services.

In particular, women are more likely than men to suffer mental health challenges and women make substantially greater use of mental health services. Beginning in 2020, the GOP plan would eliminate the current requirement that Medicaid cover basic mental-health and addiction services. This roll back of mental health parity requirements will disproportionately hurt women.

 Women are less able than men to afford health care.

According to the Department of Labor, women earn less than men. In 2014, for example, women who worked full time in wage and salary jobs had median usual weekly earnings of $719, which was 83 percent of men’s median weekly earnings ($871).

The Republican plan emphasizes tax credits and health savings accounts, both of which are irrelevant to low-income Americans.

According to the Department of Labor, women are more likely than men to be among the working poor. This is the group that has the most to lose with the Republican plan to decrease subsidies and eventually eliminate the Medicaid expansion.

The Republican approach to Medicaid disproportionately impacts women.

Nationally, women make up 56% of Medicaid recipients (in 2015). In states that did not expand Medicaid under the ACA, women are an even greater proportion of Medicaid recipients. In South Carolina, for example, 67% of Medicaid recipients are women. In Nebraska 66% are women. Thus, phasing out the Medicaid expansion will disproportionally hurt women.

The ethos of suspicion directed at Medicaid recipients will further hurt women. For example, the Republican plan requires states to re-determine Medicaid eligibilities “no less frequently than every six months.” Given that women bear the greater share of responsibility for arranging health care in American households, the need to frequently recertify eligibility will place an increased time burden on women to keep track and show evidence of eligibility.

Near elderly women are at particular risk of losing coverage under the Republican plan.

Women are less likely than men to be insured through their own job (35% vs. 44% respectively) and more likely to be covered as a dependent (24% vs. 16%), a disparity that reflects the fact that women are more likely than men to work at part-time jobs in order to carry out duties as primary caregivers for children, sick and disabled family members, and elderly parents.

At the same time, many American women are married to men who are slightly or significantly older than they. This means that when the husband retires and becomes eligible for Medicare, the wife loses the “dependent” coverage she had while her husband was employed, but she herself will not yet be Medicare eligible.

This age group has particularly high healthcare needs that may become exacerbated while waiting for Medicare eligibility.

Under the A.C.A., plans can charge their oldest customers only three times the prices charged to the youngest ones. The Republican plan allows insurers to charge older customers five times as much as younger ones and gives states the option to set their own ratio.

Planned Parenthood

The Republican plan singles out Planned Parenthood, prohibiting federal funding for Planned Parenthood for one year beginning with the enactment of the law. This will have a disproportionately negative impact on women.

Two and a half million women and men in the United States annually visit Planned Parenthood affiliate health centers for a variety of healthcare services. Most of these people are women who would stand to lose a wide range of primary healthcare services including, but not limited to, contraception.

 Abortion

Under the Republican plan, qualified health plans cannot include abortion coverage except for pregnancies that present life-threatening physical risks (not mental health risks) and pregnancies that resulted from rape or incest.

This provision not only reduces access to a needed medical procedure, but it also seems to require some sort of process for determining whether a pregnancy is life-threatening or confirming that a pregnancy is a result of rape or incest. This potentially could force women to prove (to the satisfaction of an insurance company) that she indeed was raped, and it certainly would delay performing the abortion – a delay that in and of itself presents health risks to women.

The Republican plan does allow insurance to pay to treat “any infection, injury, disease or disorder that has been caused or exacerbated by the performance of an abortion.” Since legal abortions performed by a qualified medical provider in a suitable medical setting are extremely safe, this provision seems to be set up for women who have resorted to “backstreet” abortions. While it is unlikely that the plan’s intent is to encourage illicit abortions, this provision seems to acknowledge that an increase in unsafe abortions may be a consequence of the plan.

This analysis was prepared by Susan Sered on March 8, 2017. Healthcare legislation currently is highly volatile with many changes proposed. Stay tuned – I will come back and update this analysis as more information becomes available.

Related articles: Uninsured in Texas, Then and Now     Faces of the Newly Insured      Health Insurance Roulette: The House Always Wins

In previous posts, I shared stories of Americans who had been uninsured when I first met them a decade ago and who, in the wake of the ACA, now are insured. These stories were inspiring, encouraging and – in a few cases – disappointing in that health insurance alone cannot make up for a lifetime of sub-par living conditions, harmful working conditions, and the cumulative ill effects of inadequate health care.

As the president-elect and Republican congressional leaders are reiterating promises to repeal the Affordable Care Act, it’s crucial to remember what it’s like for Americans to try to scrape by without dependable access to health care. The experiences of people living in states that elected NOT to expand Medicaid eligibility under the ACA serve as a wake-up call for what things were like during the bad-old-days. In this article published in Health Affairs I share the story of Texas parents valiantly struggling to care for a child with disabilities, even while their own health deteriorates due to lack of medical attention.

I ended that article with a section I called “Playing Prophet.”

For the time being, at least, it seems unlikely that the Texas health care landscape will change. The barrage of anti-Obamacare radio, television, and billboard ads I heard and saw when I visited Texas during my research represent a well-financed campaign that, unfortunately, has convinced even those people who would benefit the most from the ACA.

Luis and Daniela’s situation probably won’t change much, either. Luis will get older, still working long shifts driving trucks and loading and unloading them. Daniela will age, too, still lifting Alexa. Alexa will never be able to care for herself. And her brother, now a teenager, will age out of CHIP and either become one of the lucky few in the Rio Grande Valley who finds a job that offers insurance or hope and pray that he remains healthy enough not to need much medical care. It’s likely that the next time I visit them, either Luis or Daniela, or possibly both of them, will have become too disabled to continue working and finally will have health care coverage through Disability—which will come at the price of a substantial drop in family income as well as a blow to their self-esteem as providers. It’s hardly an ideal solution for their family or for Americans overall.

Post-election, this prophecy actually feels overly optimistic. In light of Republican promises to privatize Medicare — as well as the president-elect’s mocking impromptu performance and history of unethical practices regarding people with disabilities — I fear that the family’s worry that Daniela will end up in a horrid, underfunded institutional will happen sooner rather than later.

This brief is offered as a contribution to current deliberations regarding Medicaid expansion and healthcare reform in the Idaho state legislature. Idaho, like many other “blue” states, did not accept the Affordable Care Act’s Medicaid expansion. As a consequence, Medicaid in Idaho, at this time, is only available to children, pregnant women, parents of children under the age of 19, disabled people and the elderly. Even within those categories not many meet the Idaho Medicaid criteria: A family of 4 must earn less than $650 / month to qualify.

Research Findings

In 2003 I conducted in-depth interviews with uninsured individuals and families in northern Idaho, south-central Illinois, Texas, Mississippi and Massachusetts. All 37 Idahoans – at the time – were in the work force, though many were struggling to maintain a level of health sufficient to allow them to continue working and caring for their families. As I wrote in Uninsured in America: Life and Death in the Land of Opportunity (University of California Press, 2015), I was struck by the “rugged Idahoans” who shared with me stories of swallowing handfuls of Ibuprofen each day in order to manage pain, using a pocketknife to shave off bone spurs from their feet, turning to friends who worked as aides at nursing homes for help bandaging wounds, and confronting medical bills of $100,000 or more in the wake of an accident or health crisis.

In 2015 I returned to Idaho and the other four states in which I had carried out research in 2003.

  • In Idaho I looked for 37 people and was able to re-interview 20 of the 37.
  • Five of the 37 were dead: all five had passed away prematurely (in their 40s, 50s or early 60s).

One of the dead, who passed away at the age of 58, had worked in the mines his entire life. He left behind a wife and children.

  • Five are now recipients of SSI or SSDI by virtue of having become too disabled to continue working.

Jane used to work at three jobs: cleaning houses, doing laundry in a nursing home, and waitressing at a café. “Eventually I cut back to just the café job because it was my social life,” she explained, “but finally I couldn’t do it anymore. I even kept working through double pneumonia because I had to pay my bills, but eventually I had to stop because of my legs – you see my feet and ankles hurt and then turned black.” When she was finally diagnosed with diabetes at a free clinic she was told that she most likely already had diabetes for seven to ten years, but it had never been diagnosed or controlled. The staff at the free clinic would give her free samples of her medication whenever they had it available, but that was not a consistent source. At age 57 Jane was granted Disability (SSDI), but then had to wait two more years to become eligible for Medicare. By 2015 was able to access care through Medicare and Medicaid, but it was too late. She now is housebound.

  • Five now receive insurance through their employers and none of the five are able to cover their dependents through their employers. According to the Idaho Department of Labor, approximately 95% of Idaho businesses employ less than 50 workers, exempting the businesses from the ACA mandate to provide health insurance.

Marla and Peter, parents of three young children, were uninsured when I met them in 2003 and remained uninsured until a year or so ago. This was challenging because Peter has a blood disorder, ulcerative colitis and glaucoma. Throughout his adult life he has worked steadily for a company that he likes and likes him, but does not provide health insurance. When their kids reached school age Marla took an office job, but it did not provide health insurance. To take care of her family’s health needs, Marla drove them to doctors all over the northern part of the state – sometimes putting hundreds of miles on the car. At each office she would accumulate a manageable bill that they tried to pay off over time. Typically, the doctor would not see them again until they fully paid the bill. Knowing they needed healthcare coverage, Marla began to work for another small business owner who agreed to pay half of their monthly health insurance premium. But the remaining half was so high that after it was deducted from her salary she ended up taking home about $5 / hour. In 2015 she moved to a job with somewhat better insurance. Her premium now is $250 / month, but the deductible is $3000 per person and there are hefty co-pays and co-insurance.

Al, a farmer in his early 60s, was embarrassed to admit to liking “Obamacare.” But he certainly has benefitted from expanded healthcare access. Diagnosed with lung cancer a number of years ago, he had not been able to obtain health insurance before the ACA because of his pre-existing condition. During those years, hospital bills were as high as $300,000 annually, leaving him in horrendous debt. Now he pays $12 / month for insurance through the Exchange and his doctor is satisfied that “there are no new tumors.”

  • Four had moved out of state, primarily in order to access healthcare in Washington or other states that have expanded Medicaid under the ACA. No one in Idaho was receiving Medicaid in 2015.

Chris and Brittany, a vivacious couple in their thirties, moved from Idaho to Washington several years ago after Chris injured his leg on a construction job and the workers compensation ran out before the surgeries he needed were completed. While Chris was out of work Brittany took a job at a restaurant in order to tide them over. With her salary they earned too much for Chris to qualify for Medicaid and get his leg fixed. But without that salary they couldn’t survive. Today, they both are healthy and productively employed in the state of Washington, where they are raising their children and waiting for the day when it will be possible for them to return home to Idaho.

 Policy Recommendations

  • Senate Bill No. 1204, an act that proposes expanding Medicaid eligibility to persons under age 65 whose modified adjusted gross income is one hundred thirty-three percent (133%) of the federal poverty level or below, is an excellent first step towards allowing all Idahoans access to appropriate healthcare services and thus the ability to maintain better health.
    • Those with incomes below 133% of the federal poverty level cannot afford to pay for appropriate medical services. As a consequence, their health deteriorates and/or they amass medical bills that eventually are passed on to the counties or the state.
    • Idaho hospitals and clinics, for the most part, already accept Medicaid payments. Thus, the infrastructure is in place and implementation of this expansion should not involve additional costs or bureaucratic complications.
  • The proposed Primary Care Access Program (PCAP) is unlikely to substantially improve access to healthcare for Idaho’s low income residents.
    • While primary care is the core of any healthcare system, the reality of today’s complex medical world is that primary care visits alone are rarely sufficient for diagnosing or treating serious illness. For primary care providers it is frustrating not to have the capacity to send patients for tests, procedures or specialist care. Patients will find themselves in the frightening position of being told by a primary care provider that they need certain treatments but that the primary care program does not cover them.
    • There is no evidence that access to primary care alone, without parallel access to other medical services, improves the health of populations.
    • According to the published description, “The program requires payment for services on a sliding scale fee, which encourages greater personal responsibility for the patient’s own health.” Given that this program is aimed at people with very low incomes, it is more likely that fees will function as deterrents to care rather than as encouragement of personal responsibility.
    • In my research in Idaho I have never spoken with a single individual who can afford healthcare but irresponsibly chooses not to seek it. The most common reasons for not seeking care are: lack of insurance, deductibles that are too high to meet, lack of transportation to healthcare centers, inability to take off time from work during clinic hours.
    • By limiting access to healthcare to specific health centers, this proposal fails to address the needs of many Idahoans who do not live near any of the specified health centers.

 

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Acknowledgments: In addition to the uninsured and formerly uninsured individuals whom I interviewed, I spoke with Terri Sterling, ICAN; Charlotte Ash, Snake River Community Clinic; Ken Whitney, Jr., Mayor of Troy; Dr. Richard Thurston, St Maries Volunteer Clinic; Donald Duffy, Panhandle Health District; Moriah Nelson, Idaho Primary Care Association; Pam McBride, Clearwater Valley Hospital, Orofino; Ashley Piaskowski, Heritage Health, Coeur d’Alene; Dr. Ted Epperly, Idaho Healthcare Coalition and Family Medicine Residency of Idaho; Stephen Weeg, Board Chair, Idaho Health Insurance Exchange. I thank all of these people for taking the time to share their expertise with me. All opinions and errors are my own.

 

Contact Information: Susan Sered, PhD; Department of Sociology, Suffolk University; 73 Tremont Street, Boston MA 02108

Email: ssered@suffolk.edu

For more on this research see Health is Where the Home Is   Health Insurance Roulette: The House Always Wins   The State(s) of the Affordable Care Act     

A decade ago I traveled to the Mississippi Delta, Texas’s Rio Grande Valley, the rust belt of Illinois, the mountains of northern Idaho and the cities of eastern Massachusetts in order to learn how uninsured Americans manage (or don’t manage) their health and healthcare in diverse circumstances. This spring and summer I returned to these communities to seek out the same individuals and families I’d met ten years ago. I wanted to hear how they’ve fared in the wake of the Affordable Care Act.

It is clear to me that June 23, 2015’s Supreme Court ruling in King v. Burwell is good news for millions of middle-class Americans living in states whose leaders chose not to set up insurance marketplaces (“exchanges”). People in those states will not lose their insurance subsidies because the federal rather than the state government facilitates the exchange.

The states impacted by King v. Burwell are, however, mostly the same ones impacted by the 2012 Supreme Court ruling (NFIB v. Sebelius) which allowed states to opt out of the ACAs Medicaid expansion. Lower income people in those states will continue to fall into the coverage gap — the no man’s land for people who earn too little to qualify for subsidized insurance through the exchange but who do not qualify for Medicaid in their home states. In some of those states only extremely poor parents and children are eligible for Medicaid, leaving large numbers of people who are childless or near elderly or poor but not destitute unable to access healthcare.

Texas, one of the states that did not expand Medicaid, has a federally facilitated marketplace. During my return trip to the Rio Grande Valley, I was able to locate 18 of the 26 individuals and families (all adults) I’d met a decade ago. At the time, all were uninsured. Fourteen of the 18 are now insured – a figure that, on the face of it, looks encouraging.

However, of the 14 who are insured, 5 now are covered by Medicare via Disability (as a consequence of becoming sufficiently disabled to qualify for SSI or SSDI). In other words, a third of the newly insured people are covered because their health deteriorated to a the point in which they no longer are able to work. One person is covered by Medicare because she is over 65. Two people have Medicaid but only as a supplement to Medicare; no one qualified for Medicaid as their primary insurance.

All 4 of the uninsured people fall into the coverage gap – when they applied for insurance on the exchange they found that their incomes are too low to qualify for subsidies. The experiences of the Martinez family (a pseudonym) are typical. Maria works full-time in a food service job that provides health insurance for her but requires a bi-weekly payment of $250 to cover her children. Her bi-weekly income is $500, so she had to turn down the coverage. Her husband, Enrique, is a truck driver whose employer does not offer insurance but he earns too little to qualify for a subsidized premium on the exchange. For a short time their youngest child was eligible for Medicaid (CHIP), but then Enrique’s income went up (marginally) and she no longer qualified. In 2013 Enrique spoke with an ACA enrollment specialist who helped him apply for an exemption from the penalty for not having insurance. In 2014 he forgot to re-apply and had to pay $190 in fines ($95 for himself and $95 for their 21 year old child.) In the meantime, he takes medication for high blood pressure when the border with Mexico is safe enough for him to cross over and buy pills there. I make no claim to extraordinary prophetic powers, but my guess is that in another five years he will join the ranks of disabled Texans.

That leaves 5 who are insured via the exchange and 5 now insured through employers – certainly a step up from when I first met them. However, all 10 of these Texans are unhappy with their insurance, for the most part because of high deductibles and co-pays. Rosa, an energetic and articulate middle-aged woman, is reimbursed by her employer for part of the cost of the premium she purchased through the exchange. Because of her low salary she chose a “bronze” plan with a low monthly premium (all that she could afford) but a $4500 annual deductible and $1000 co-pay for hospitalization. With a history of tumors in her breast and kidney, she needs scans that she cannot afford even with insurance. I fear that she too, will join the growing ranks of Americans who are disabled.

Shortly after the Supreme Court’s ruling on the ACA, President Obama spoke from the Rose Garden celebrating our national declaration that health care is a right, not a privilege. Now the challenge is to turn that declaration into reality on the ground – even in states whose leaders would rather thumb their noses at the feds than allow residents of their state to access the care that they need in order to remain healthy.

For more on health insurance read  Health Insurance Roulette: The House Always Wins

For more on the original research in the five states read  Uninsured in America: Life and Death in the Land of Opportunity

 

 

After running on a campaign of new and smart ways to reduce government spending, Massachusetts Governor Charlie Baker (R) has proposed budget cuts for fiscal year 2016 that are neither new nor smart — going after the low-hanging fruit of government funded Medicaid (MassHealth) for the Commonwealth’s poorest, sickest and most vulnerable residents. Most of the proposed savings to MassHealth in Gov. Baker’s plan are merely a matter of bookkeeping – shifting costs from fiscal year 2016 to fiscal 2017. But the Administration also aims to reduce spending by requiring over one million residents enrolled in MassHealth to prove that they are still eligible. Though the Administration has not provided an estimate of how many ineligible people are enrolled, Baker’s budget team estimates that this move will save the Commonwealth $210 million.

The immediate plan is for the Commonwealth to contact 1.2 million people who were automatically re-enrolled in MassHealth when the Health Connector (‘Exchange’) website experienced technical failures in 2013. Each of these people will receive two letters asking them to reconfirm their eligibility. After 60 days those who do not respond will lose coverage. That may not sound unreasonable, but as a sociologist who works with low income women, I suspect this plan presents disproportionate hardships for residents who do not have permanent addresses or who struggle with understanding government forms and with gathering the required documentation; that is, the people who most need consistent healthcare coverage. Individuals who lose eligibility will be allowed to re-certify in the future, but the immediate effect will be disrupted care and an uptick in expensive emergency department usage.

The scanty information released by Governor Baker’s office indicates three categories of potentially ineligible people who would be eliminated from the MassHealth rolls. The most straightforward are people who still are on MassHealth plans but have moved out of state and receive coverage elsewhere. These people, however, would not seem to account for much spending given that they have other insurance where they actually live so are unlikely to use MassHealth benefits. The second category is people who have had a change in income sufficient to place them over the eligibility threshold. Given the absence of a meaningful economic recovery for low wage workers in Massachusetts, this category likely consists of individuals and families whose current earnings push them marginally over the eligibility line. Switching these people from MassHealth to the heavily subsidized insurance policies that they are eligible for through the Health Connector is unlikely to make much of a difference in the budget.

A third category – people who are purposely cheating or “working the system” — has not been explicitly singled out in statements from the Governor’s office. But given 2010 gubernatorial candidate Charlie Baker’s fake electronic benefit cards that said: “Deval Patrick’s Massachusetts EBT Welfare Card. Swipe me for booze, cash, cigarettes, and/or lottery tickets at taxpayers’ expense,” weeding out Medicaid cheaters certainly lurks behind the call for re-certification. Again, we have no information regarding numbers, but we do know that hunts for fraudulent welfare claims consistently turn up very little cheating and thus very little cost-saving. Last year, for example, Maine Gov. Paul LePage (R) released data intending to prove widespread welfare abuse but in fact showed that 99% of all welfare benefit transactions were legitimate and legal.

The re-certification process in and of itself will be costly. If we calculate (modestly) 15 minutes for a government worker to process a straightforward re-certification, the 1.2 million re-certifications will take approximately 300,000 hours. And if we assume (modestly) a salary of $15 / hour for the workers who process re-certifications, the bureaucratic cost will come to 4.5 million dollars – a substantial chunk of what the Administration is looking to cut from the MassHealth budget and money that surely could be spent in a manner more conducive to protecting the health of Massachusetts’ residents.

These numbers are just an estimate, and I assume the Governor’s staff has more accurate numbers. But even if I’m off by 50%, we’re still looking at a cost cutting plan that is likely to cost the Commonwealth a great deal both in terms of salaries and in terms of health.

For more on the larger picture of  health care coverage click:  Health Insurance Roulette: The House Always Wins

“As Profits Roll In, Aetna To Expand On Obamacare Exchange In 2015” 

“The Obama administration issued rules to allow for a taxpayer-funded insurer bailout.”

According to Forbes Magazine, health insurance companies have recorded substantial profits in the wake of eight million people signing up for coverage during the first “Obamacare” open enrollment period. That’s great news for stockholders, CEOs, CFOs and a handful of other lucky people. But given that the United States spends more on healthcare while ranking at the bottom of the industrialized world in terms of health outcomes, this isn’t such great news for the rest of us.

The enormous resources that many Republicans have poured into attacking Obamacare have, to my eyes, lulled many of us on the left into forgetting that the Affordable Care Act was no more than a political compromise between middle-of-the-road Democrats and right-of-center Republicans. Though it includes a number of good provisions and a certain expansion of healthcare coverage, the ACA was never designed to overhaul the United States healthcare landscape. We still have a chaotic multitude of financing and delivery mechanisms. We still have for-profit and not-for-profit hospitals, though it’s not always clear which is which. We still use emergency rooms as expensive safety nets that by federal law are only required to assess and stabilize patients (and are allowed to charge a whole lot to do so), not to cure them. We still have a smorgasbord of donut holes, coverage gaps and nonsensical limits on rehabilitative services such as physical therapy. We still have no rational system for allocating services. Moreover, as the Forbes articles cheerfully proclaim, the ACA has been a bonanza for the very same insurance companies that have cherry picked “healthy” members, denied care to sick people, wasted healthcare dollars on astronomical administrative costs, and assessed outcomes in terms of the bottom line rather than in terms of health and well-being. The name Affordable Care Act obscures the reality that even with health insurance, healthcare is hardly affordable for most Americans.

Many of us on the left acquiesced to supporting the ACA because of a vague promise that this would be the first step to real reform, to developing a system of universal coverage in which all people have the right to healthcare. For the past six years I’ve been a good foot soldier for President Obama. I’ve donated money and signed petitions each time the Republicans come up with some new attack on Obamacare. But I want to be very clear: The ACA is not the endgame for progressives. It’s high time for us to stop worrying about the Republicans (who won’t pass any legislation in any case) and push forward a true progressive agenda.

Rights versus Responsibilities

Broadly speaking, there are two basic healthcare paradigms: healthcare as a human right and healthcare as a personal responsibility. Healthcare as a right rests on the deeper belief that all human beings are fragile creatures. Our two-footed upright posture makes us susceptible to injuries and accidents, and complicates the business of pregnancy and childbirth. We have long periods of infancy and childhood in which we cannot take care of ourselves. We live to be old enough for our bodies and (sadly) our minds to break-down over periods of many years. Our social instincts bind us in communities in which infections pass from person to person. Our large brains and nimble fingers develop remedies, manipulations and treatments that allow us to facilitate healing from the injuries and infections to which all humans are vulnerable. Recognizing both the universality and the unpredictability of those vulnerabilities, the rights paradigm valorizes and codifies our moral obligation to ensure that simply by virtue of being human we all have the right to appropriate, affordable, accessible and acceptable healthcare.

In the United States, in contrast, we typically understand both health as well as healthcare to be a personal responsibility rather than a human right. Each individual has a moral responsibility to take care of him or herself by exercising, eating nutritious foods, avoiding stress and going for annual exams such as mammograms (even if these “responsibilities” are impossible for many people to fulfill). Each is responsible for acquiring the resources to be able to afford healthcare which in effect frames healthcare as a privilege for those who can pay. Those unfortunates who can’t afford healthcare bear the responsibility for proving “true” neediness and for following through with requirements for certification and re-certification of that need in accordance with fluctuating policies and to the satisfaction of cadres of bureaucrats. Individuals also have the responsibility to take care of their own young children (this obligation does not extend to other family members or friends, though we do say nice things about people who do care for aging parents). Employers in certain types of companies have a responsibility to subsidize the costs of health insurance for their employees. And, under the ACA, individuals, with certain exceptions, have a responsibility (a.k.a. “individual mandate”) to be insured.

Fancy Gambling

Insurance is, of course, a fancy form of gambling. We purchase car, house, health and life insurance because we want to cover our bases in the event of an unlucky spin of the wheel or tumble of the dice: a fender bender, a lightning strike, a heart attack. We gamble that we’ll get back more than we pay out and the insurance company gambles that they’ll pay out less than they take in. Some people enjoy the adrenaline surge of choosing a number at the roulette wheel or waiting to uncover the next blackjack card. I do not.

When I look at the state and federal exchanges meant to serve those Americans who need health insurance, I feel overwhelmed. I have neither the time nor the knowledge to calculate which plan is the most economical for my particular constellation of medical needs or the needs of my family. The exchanges offer me a variety of packages with varying divisions between upfront premiums, co-pays, co-insurance and deductibles. Should I choose a plan with a high premium but lower out-of-pocket costs down the road? That would be a good choice if I knew in advance that I’d have a lot of health issues down the line and if I had the ready cash to pay the upfront premium. Or should I choose a plan with a lower premium but higher deductibles or co-payments? That would make sense if I knew in advance that I’d have a healthy year – but who among us knows that we will? Actuaries calculate these things on the basis of large populations – not for one individual. Indeed, in calculations I have made based on the Massachusetts exchange (Commonwealth Connector) people are just as likely to “choose” a plan that ends up costing them more than a plan that ends up costing them less.

“Choice” is one of the ACA mantras – that Americans should be able to “choose” the plan that is “right for you.” But that choice is phony. We do not choose our diseases. We rarely choose our doctors or hospitals, and when we do that choice is seldom based on any real data. We almost never know enough about modern medicine to be able to choose our treatments. And alternative and complementary medicine that might constitute real choices (vis-à-vis conventional medicine) is not addressed in the ACA.

In healthcare roulette, putting your dollars down on the wrong number can cost you more than you would ever wish to lose. But like in all games of chance, you cannot know which number is right and which is wrong. Not being blessed with the gift of prophecy, most of us cannot predict what medical needs might arise in the future. Insurance companies, however, hire brilliant mathematicians – trained actuaries – who study massive amounts of data which enable them to calculate how much to charge so that the insurance company takes in more money than it pays out. As they say in Vegas, the house always wins. The Forbes reports make that abundantly clear.

Susan Sered is the co-author of Uninsured in America: Life and Death in the Land of Opportunity.

In response to reports of long-waiting lists, cover-ups and a toxic culture at the Veterans Administration, President Obama nominated Robert McDonald to head the VA. In his public address yesterday, the president praised Mr. McDonald’s long career in corporate America as CEO of Procter and Gamble. In what should be a red flag not only to progressives but to all of the 99%,  House Speaker John Boehner shares the president’s high opinion of McDonald: “Bob McDonald is a good man, a veteran, and a strong leader with decades of experience in the private sector. With those traits, he’s the kind of person who is capable of implementing the kind of dramatic systemic change that is badly needed and long overdue at the VA.” Given that Boehner is on record in favor of privatizing the VA, I can’t help but wonder what sorts of changes McDonald will implement. I also can’t help but wonder why President Obama seems to be falling for the same-old same-old idea that the private sector is better than the public center at just about everything.

McDonald’s nomination is not getting a lot of press. In progressive-leaning news sites it’s been shadowed by the Supreme Court’s Hobby Lobby decision allowing companies the “religious freedom” not to include contraception in insurance plans. But I see these two events as tightly linked — both are part of a growing movement to privilege corporations over people.

The cat’s out of the bag and I assume that McDonald will be a shoe-in to head the VA. But until that is made official we do have a window of opportunity to educate McDonald — who has no experience in health care or social services — about the issues he will face in his new job. To help in that endeavor, I have written an open letter to Robert McDonald. I truly hope he reads it!

 

Dear Robert McDonald,

There’s been a lot of noise lately about the mess at the VA (the mess you are being tapped to clean up), and I’m sure you’ve heard some big name politicians and pundits — including your friend John Boehner — calling for privatization or at least outsourcing of VA healthcare. You are going to hear from lots of people that government can’t do anything right, that the private sector is more efficient and more cost-effective, and that the best thing you can do for veterans is to give them the same choices about their healthcare that other Americans have.

I’m not going to waste your time telling you that the government actually can do a whole lot right. After all, you were a paratrooper so you know that government airplanes and parachutes generally work. I’m sure you have personal experience with well functioning traffic lights, the interstate highway system, safe drinking water and public libraries. And though you have no experience in the healthcare field, you likely know that in the US — where healthcare is structured around corporate models of private ownership, we spend more on health care and have substantially poorer health outcomes than countries with a national health service.

In order to do a good job for veterans you will need to understand why a market approach doesn’t work for healthcare. At Procter and Gamble your mission as CEO was to sell products to consumers who can make informed choices in the free market. But, as I’m sure you learned being a former military man and all, people don’t choose their injuries or illnesses. That makes it silly at best and cruel at worst to tell people to “choose” the health insurance plan that best “meets their needs.” Actuaries can calculate the odds of certain illnesses for population groups, but we mortal humans can’t foresee our own particular future health. Of course, “choice” is marketable in America and even is touted as a selling point for President Obama’s Affordable Care Act. But happily for you and your fellow service and former servicemen and women colleagues, neither the Department of Defense nor the Veterans Administration has ever bought into that idea.

But what about vouchers, you may ask. Even if we agree that all veterans should have the same comprehensive health care coverage, shouldn’t we give veterans the right to choose where they get their care?

Let’s think about that a bit. At Procter and Gamble you could ethically market Charmin’s squeezability over Cottonnelle’s extra-absorbent ripples because you understood that most consumers are capable of evaluating how well their toilet paper does its job. You also understood that in the long run it doesn’t make much of a difference which brand of laundry detergent a consumer uses; Tide may be a bit better or worse than Whisk, but choosing the inferior brand is not going to kill any consumers.

That model doesn’t work in health care. Most people cannot evaluate whether one type of medication, surgical procedure or therapeutic approach works better than another. Nor can most of us assess whether one hospital or healthcare provider has a better track record in dealing with particular health problems or types of individuals. Unlike in the choice of toilet paper or laundry detergent, these differences can be matters of life and death. Let’s take head injuries as an example. Now, someone who doesn’t know much about brains might choose a hospital that looks nice and new and shiny, that has friendly registration clerks, that advertises compassionate patient care. But, trust me, veterans with head injuries would do a lot better at an overcrowded and bedraggled VA hospital where the doctors are specialists in the kinds of injuries suffered in battle and where the cutting-edge research in the world on traumatic brain injuries is being carried out.

At Procter and Gamble you were charged with reducing costs so that you could increase profits for stockholders. And I understand you were good at that! Now, I’m not saying that you shouldn’t streamline VA services so that they will be more efficient. But I am asking you to remember to keep your eye on the only bottom line that really matters in your new job, and that is the health and well-being of our veterans.

I know this job will present many challenges for you, so in closing I’d like to suggest that you bring along with you to the VA one of the mottoes of commerce: The customer is always right. Please, Mr. McDonald, listen to veterans – to men and women, try to understand their concerns, and put their interests above those of politics.

I wish you great success. And please feel free to call on me for advice.

Susan Sered

More on the VA here: The VA Scandal: How About a Reality Check?

Author’s note: Friends and colleagues who know that I’ve spent most of the past decade working closely with criminalized women have asked me what I think of “Orange is the New Black”. While I could do without the dubious emphasis on sex among the women, and I doubt that women prisoners ever have the kind of power attributed to Red or Gloria, overall I think the series does a good job portraying women prisoners as real, complex human beings and of showing the miseries of life inside and outside of prison for most incarcerated women.

(A version of this post with fabulous photos: http://bitchmagazine.org/post/what-pennsatucky%E2%80%99s-teeth-tell-us-about-class-in-america)

I know she is supposed to be a cross between a villain and comic relief, but Tiffany “Pennsatucky” Doggett is my favorite character to watch this season on Orange is the New Black. For those (few) who have not watched the series, Tiffany is a caricature of an ignorant / hillbilly / Jesus freak / meth head. In the first season we saw her provoke and eventually fight Piper, the attractive, articulate protagonist and author of the book on which the series is based. At the start of season two, when Tiffany returns from a three week stint in solitary, even her former friends – the other poorly educated, young white women – turn on her.

Tiffany isn’t cute or funny or even a font of homespun southern wisdom. But in the midst of a prison culture formally and informally divided by race, Tiffany embodies an equally powerful yet rarely articulated social divide: class. Though white, she has nothing in common with the other white women: Machiavellian Alex (Piper’s lover and nemesis), gender savvy Nicky, hip Sister Jane or even Russian entrepreneur Red, all of whom are presented as smart, literate, able to plan and scheme, and holding some understanding of the outside world. Tiffany doesn’t even fit in with Morello, a none-too-bright white woman with a working-class accent who lives in a fantasy world of romance and Hollywood magazines.

The producers of the series provide viewers a clear visual cue to the class divide. The first time Pennsatucky opens her mouth we see a hideous display of broken and missing teeth. More than any other marker, teeth indicate class status. Perfectly white and straight teeth – the kind we see on celebrities — belong to the super rich who can afford costly cosmetic dentistry. Nicely aligned and healthy teeth are the sign of professional and upper middle class individuals who can afford regular dental care and basic orthodontia. Crooked teeth with delayed root canal work and a few crowns means the mouth belongs to a young or middle-aged middle or working class individual (someone with access to basic dental care but no more); a complete set of dentures indicate an older working class individual. And rotted teeth, like those sported by Tiffany, marks one as poor, a status with both economic and moral meaning. As I’ve been told countless times by Americans who do not earn enough to scrape by, being too poor to have respectable teeth is like wearing an “L” for loser on your face.

Teeth: The Orphan of the Healthcare SystemContinue reading