Tag: Patient Protection and Affordable Care Act

Apolitical Intellectuals Teaching Health Policy?

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Collection of health politics and policy teaching materials on my desk at work.

Is it desirable, indeed, is it even possible to teach health policy without also teaching politics? What would it mean to be an apolitical intellectual teaching health policy to future health care professional students?

As a lyrical definition of ‘apolitical intellectual,’ here are the first stanzas of  a poem by the Guatemalan poet and revolutionary Otto Renee Castillo, translated by Francisco X Alarcón. The full text of poem is available here and a powerful ‘spoken word’ version using a slightly different translation is available here .

APOLITICAL INTELLECTUALS
One day
the apolitical
intellectuals
of my country
will be interrogated
by the humblest
of our people.

They will be asked
what they did
when their country was slowly
dying out,
like a sweet campfire,
small and abandoned.

Basically, as I would interpret it, apolitical intellectuals have a lot of book knowledge and an escapist ‘life of the mind’ sort of attitude, but no practical, down-to-earth working knowledge of power and privilege. I do not aspire to be an apolitical intellectual teaching health policy to future health care professionals.

But I do aspire to be balanced and fair in my approach to teaching health policy. That is one of my prime duties as a teacher. Since I lean towards the Progressive side of politics, especially as politics relates to health and social justice issues, I bring that lens to the teaching of health policy. Many of my health policy current events articles come from the NYT or the (non-partisan but still left-leaning) Kaiser Family Foundation, and many of my videos (as in the photo above) are produced by PBS. I have tried, with limited success, to bring in more Conservative-leaning course readings, videos, and guest speakers. I find that it is difficult to find credible, intelligent, research/data-backed Conservative sources.

If I were teaching health policy at a university in close proximity to Washington, DC, I would probably have better luck finding good Conservative-leaning guest speakers. For instance, the DC-based Heritage Foundation has much different politics from my own, but they are credible, intelligent, and thought-provoking. They currently have an interesting section on their website: “Stop Obamacare Now.”

Since I am about to go on a year-long sabbatical in order to focus on my Skid Road and Soul Stories research and writing projects, I get to put away my health policy teaching materials. Both projects are public scholarship focusing on health policy for homeless and marginalized populations. As such, they are taking me even further away from being an apolitical intellectual. I consider that a good thing, but I do wonder how it will affect my teaching of health policy once I return to the university.

Got Medicaid (Expansion) Virginia?

DSC00367_2My hometown of Richmond, Virginia is fond of putting large statues of white men on horses in the middle of its streets. Richmond is also the setting for a political and health care drama of Southern Gothic proportions. Virginia is an ACA non-Medicaid expansion state, but the state’s leaders have been debating Medicaid expansion over the past year. Earlier this month Phillip P. Puckett, a Virginia Democratic state senator, suddenly resigned to take a job on the Virginia tobacco commission. Curious circumstances surrounding his resignation have led to an investigation by the U.S. Department of Justice and the FBI, as reported in this recent Richmond Times Dispatch article. His resignation flipped control of the Virginia State Senate to Republicans intent on blocking Medicaid expansion efforts. Today Virginia Governor Terry McAuliffe announced his plan to bypass the recalcitrant Republican General Assembly and expand Medicaid to 400,000 low-income Virginia residents. (see: Modern Healthcare Va. Governor to Bypass Lawmakers, Expand Medicaid, 6-20-14). Governor McAuliffe also plans to block funding a $300 million facelift of the Capitol complex where many of the lawmakers have their offices. The bright and shiny Virginia State Capitol is shown in this photo I took about a year ago.

Medicaid plays vital roles in people’s lives and in our health care system. Medicaid improves access to basic health care services for millions of our children, low-income adults, the elderly (long-term care services), and people with disabilities. Medicaid saves lives. Medicaid funds large portions of our public hospitals, health centers, and nursing homes. Without Medicaid, most of our children’s hospitals would be forced to close.

Several of my struggling small business owner nieces and nephews who live in Virginia would benefit from Virginia’s Medicaid expansion. My elderly father who lives in Richmond would benefit from Medicaid expansion for long-term care services not covered by Medicare. My own son who lives in our Medicaid expansion state of Washington is about to get Apple Health, our version of Medicaid because the University of Washington has ended their student health insurance plan–or at least what was masquerading as a health insurance plan (see my previous post, “My Young Invincible, His Lost and Found Toe, and University Health Insurance that ‘Technically Isn’t'” 4-23-14).

Virginia and other Southern states have high ratios of physicians to the general population, yet have the worst poverty and shortest life spans of any region in the U.S. Virginia has the second highest number of free clinics in the country. North Carolina has the most and Georgia is close to Virginia’s number. Most of the free clinics are faith-based and pride themselves on not accepting any ‘government handouts.’ This generally includes the clinics not accepting Medicaid or Medicare reimbursements. These Southern states are part of the Black Belt of entrenched poverty and severe health inequities. Are free health clinics part of the solution or part of the problem?

The deeply entrenched American notion of charity care as the way to provide safety net services engenders stigma, shame, dependency, and resentment among recipients. Charity care is especially pronounced in the Bible Belt South. People do not want to have to depend on the kindness of strangers. Charity care further fragments an already fragmented, disorganized health care system. Charity care clinics have to compete for donations, grants, staff, and patients. Charity care further fragments and separates us as members of society—sorts us into the haves and the have nots, into worthy and unworthy citizens. Charity care perpetuates poverty. Despite compassionate staff and health care providers, charity care is always leftover care, afterthought care, second-rate care. Charity care gets discouraging, both to give and to receive. I know this first-hand, having been on both the giving and receiving ends of charity health care.

Medicaid and Medicare are both basic entitlements; they are not charity care. So Virginians, come down off your high horses and get Medicaid expansion.

The Changing Landscape of Health Care Jobs in the United States

IMG_2285Attention all new nursing grads and other health care job-seekers: Today in the NYT there is a fascinating interactive feature “How the Recession Reshaped the Economy, in 255 Charts” by Alicia Parlapiano and Jeremy Ashkenas. It helps illustrate where the health care jobs are in our country, what the average salaries are within different sectors of the health care system, and what the trends are in terms of growth (or decline) of the different sectors.

Using data from the U.S. Bureau of Labor Statistics, the authors illustrate in easy-to-read charts how the number of jobs have changed for a particular industry over the past decade. These data are only available for private industries, so for health care, public health jobs are (unfortunately) not included. The only middle-wage private industries that did not lose jobs during the recession were those within health care.

One of the charts is titled The Medical Economy and here is what stands out to me:

  • Health care industries that were relatively unaffected by the recession and that have shown steady growth include home health care services, outpatient care centers (both general outpatient care and ones specific to mental health), and physician’s offices.
  • Health screening programs (including blood and organ banks) have recovered and grown.
  • Psychiatric and substance abuse hospitals have recovered and grown.
  • General medical-surgical hospitals remained relatively unaffected by the recession but appear to be mostly flat in terms of growth.
  • Specialty hospitals (excluding psychiatric and substance abuse) have recovered and grown, but they have shown a substantial decline in jobs since March 2012 (with a small blip back up over the past few months). I would imagine these changes for specialty care hospitals are correlated with the roll-out of ACA, especially changes to Medicare reimbursement for hospital care.

Take home lesson for people in the job-search mode within health care: Follow the money and look for jobs in the economically healthier parts of the U.S. health care system. Don’t rely on hospitals as the only places for job-searching.

Take home lesson for those of us in the role of nursing (or other health care professions) education: These ‘hard’ economic data provide even more good reasons to recruit and prepare students for work in primary care, community-based, non-acute care settings.

My Young Invincible, His Lost and Found Toe, and University Health Insurance That ‘Technically Isn’t’

IMG_1225 - Version 2Last fall I wrote about my 26-year-old son who lost his right big toe in a freakish university gym accident a day after his student health insurance officially took effect. (See my blog post Young Invincible Health Insurance Saga 10-5-13). He had aged out of my university job-based health insurance three months before and, much to my consternation, had ‘gone bare,’ unable to afford any of the health insurance plans available to him at that time. He signed up for the University of Washington’s School Health Insurance Plan (SHIP) as soon as he started in a graduate program there. As I drove him to the (University-affiliated) emergency department with his (found) toe, and then as a wonderful physician cheerfully sewed it back on, I breathed a huge sigh of relief that his SHIP would at least cover most of the cost.

Although, on second thought, as I wrote then:

“Even though he officially has health insurance to cover his expensive ED visit (X-rays, sutures, IV Vancomycin, physician quips) and ortho follow-up, I do not trust it. There are pages upon pages of exclusions to his health insurance plan, including bungee-jumping and intercollegiate sports–neither of which would seem to apply to losing a toe in ballet/karate. But I know how crafty and devious health insurance companies can be in trying to deny medical claims. I would hope that the university where I am employed and teach (and where my son is now a student) would have a decent health insurance plan option for its students. I guess I’m about to find out.”

And now, almost seven months later, I have discovered a very surprising answer: his university health insurance ‘technically isn’t health insurance.’ Silly us for assuming that something called a ‘Student Health Insurance Plan’ offered through a major U.S. public university was really health insurance!

This was explained to me today by a nice young representative who answered the phone at LifeWise, the insurance company that underwrites and administers University of Washington’s SHIP. I called to ask (nicely) how it was that they could still legally include a pre-existing condition exclusion since ACA/Obamacare requires insurance companies to cover people with pre-existing conditions (including the ‘pre-exisiting condition’ of being a woman, for which insurance companies charged more). I had done my homework on this, reading the user-friendly Healthcare.gov website to find that there was one exception to this rule: the benignly named ‘grandfathered individual health insurance plans.’ I wanted to know how SHIP could possibly qualify for this ‘grandfatherly’ exception category, and if they did, why they didn’t include that statement clearly in their information brochure as mandated by the ACA. LifeWise has hassled my son to prove that his torn off toe wasn’t a pre-existing condition and has refused to pay for some of his other healthcare claims.

The LifeWise representative’s answer was that they weren’t a grandfathered plan, but that they didn’t have to follow many of the ACA mandates because ‘technically this isn’t a health insurance plan, it is a disability plan.’ Huh? She went on to explain that the fine-print ‘Note’ clause on the front page of their consumer brochure ‘clearly states this.’ I had the brochure on the screen in front of me and sure enough, right under the large purple banner/title “University of Washington/ Seattle ‘SHIP’ Student Health Insurance Plan” it has a teeny tiny “Note:This coverage is blanket disability insurance. Coverage provided is “excess” only and does not contain a “coordination of benefits” provision.” 

That is so (not) clear and transparent for any self-respecting university-attending Young Invinsible, not to mention their University Professor parent who, oh I don’t know, perhaps has a doctorate in health policy? Now I happen to have both ‘real’ health insurance and ‘real’ disability insurance through my university job and I know the difference between them.When I asked the LifeWise representative to please explain how SHIP was really S-DIP I suppose, she replied that she really couldn’t explain it: “of the hundreds of different insurance plans I deal with, this is a unique policy.”

Unique indeed. How can a university (‘my’ university no less) offer what it clearly labels ‘student health insurance’ when it isn’t really health insurance and therefore doesn’t have to comply with current ACA mandates? What will it take for our country to get a saner health care system?

 

Selfie-Healthy Health Care

IMG_1897 - Version 2What does Obamacare/ACA mean to me in terms of my personal health care now that the 2014 roll-out is officially in place?

I have the same job-based health insurance through the same health insurance company that I’ve had for the past two decades. I’m sure that they have continued to raise my deductibles and co-pays this year as they have in most years, but, truthfully, I have ceased to pay much attention to those details.

The biggest change that certainly has gotten my attention was a recent mailing I received with the following highlighted in bright orange: “Premium surcharges and a wellness incentive are coming! Take action on the four steps below.” I knew these were coming and had already taken their wellness survey back in December just for grins (see blog post My New Year’s Resolution: Avoid Wellness Programs, 12-30-13). As the blog post title implies, I had planned to ignore this Big Brother naughty or nice-style intrusion on my sense of privacy, but then I read the next highlighted item on the mailing: “What happens if I don’t respond…?” Answer: I’d start being charged a $25 per month tobacco use surcharge (even though I am a never smoker) and I’d forfeit a $125 reduction on my 2015 medical deductible. Opting out this year would cost me $425. The ACA/Obamacare allows employers to offer larger health/wellness incentives, up to 30% of the cost of coverage, so my health insurance company could hike up these ‘incentives’ (penalties?) considerably in the future.

Begrudgingly, I signed onto their website to attest to not using tobacco products. Then I chose a primary care provider (who I haven’t seen in two years because she is too popular/busy/on her way to becoming another burnout statistic). Then I had to re-take their silly, non-evidence based health assessment. It still tells me I need to stop eating a high-fat diet when I’m a vegetarian. Finally, I registered for one of their wellness program activities: doing at least 90 minutes of moderate to vigorous physical activity per week for at least 10 consecutive weeks. Walking, swimming, cycling, yelling profanities at my health insurance company and our health care system…..Great. OK. Go away you silly premium surcharge/personal wellness incentive that raised my blood pressure!

Just when I thought I was done with all of that for the year, I got an e-mail invitation from my insurance company inviting me to enter a HealthieSelfie photo contest on their Facebook page. All I have to do is ‘snap a selfie’ of my wellness goals and send it to them, to what? share with all their other selfie health care absorbed health plan enrollees? The ultimate of (flat, fit, no flab allowed) navel-gazing healthism? An example of medical sociologist Deborah Lupton’s imperative of health? A fun, harmless, effective way to use social media to promote personal health (and thereby enable the health insurance company to reap more health plan profits)? Yes to all of the above.

Having never taken a selfie before, my first attempt resulted in a photo of my thumb. I find deep symbolism in that. The photo here is my second attempt, and shows me ‘doing’ my 2014 selfie-wellness goal: Less time trying to figure out our crazy health care system and more time in my garden playing with my Corgi.

New Zealand Postcards: What Do You Think of Obamacare?

DSC01678Besides having a severe case of jet-lag and change-of-hemisphere-lag upon returning to Seattle from New Zealand, one of the more disorienting re-entry issues I’ve encountered this week has to do with our health care system.

While in New Zealand for three months, one of the top questions I was continually asked (right after ‘How do you like New Zealand?’ Answer: ‘I love everything about it except your crazy roads and drivers!’) was, ‘So what do you think of Obamacare?’ My answer was, and continues to be, ‘Good and bad things, but it’s at least a step in the right direction.’

New Zealanders, along with citizens of all other industrialized countries, don’t understand how we Americans tolerate our crazy health care system. Consistently, New Zealanders I spoke with told me they don’t ever really think about health care, and especially not about health insurance. They pointed out that their choice of jobs isn’t tied to health insurance coverage. They have guaranteed basic health care coverage for all citizens, or ‘universal health care,’ through their Ministry of Health. People in New Zealand have the option of purchasing additional private health insurance to help speed up access to things like hip replacement surgeries, but it’s mainly affluent older people who take that option. New Zealand has a centralized national pharmaceutical agency, Pharmac, in order to keep drug costs down. U.S.-based large pharmaceutical companies continue to try and block Pharmac. And they have a national, comprehensive, no-fault personal injury coverage system, the Accident Compensation Corporation (ACC), that covers New Zealand residents as well as visitors. ACC also covers instances of medical malpractice/liability: people in New Zealand cannot sue their health care providers or hospitals.

In terms of life expectancy, in the Health Olympics, New Zealand ranks #16, coming in just after the Netherlands. The U.S. ranks #34 right before Qatar. According to a 2011 Commonwealth Study (The US Health System in Perspective: A Comparison of Twelve Industrialized Nations, by David Squires), New Zealand spends almost one-third less per person on health care than we do in the U.S. ($2,683/person/year versus $7, 538/person/year). Obviously, New Zealand is a much smaller, less diverse country than the U.S., and no health care system is perfect, but their health care system blows ours out of the Pacific waters.

It is interesting to note that the (Republican) Harvard Business professor Michael E. Porter’s new Social Progress Index of overall livability ranks New Zealand No. 1, and the U.S. No.16 (and he ranks the U.S. No. 70 in health). See Nicholas Kristof’s NYT op-ed piece We’re Not No. 1! We’re Not No. 1! (April 2, 2012).

The photo this week is of me on a home visit in Hobbiton, New Zealand. This is a community where hobbits manage to live very long and healthy lives, despite the fact that they have high rates of smoking and drinking and eating of high-fat foods. How do they do that?

Toe Saga Enters Health Insurance Maze

toes
toes (Photo credit: ribarnica)

The first bill of sorts came today for my young not-so-invincible son for his recent torn off big toe (previous post). The letter is in reference to a $17 radiology charge from the emergency department of the university-affiliated hospital where he was seen. I assume this charge was for flipping the switch to warm up the X-ray machine, but it doesn’t specify what it was for.

The letter came from his student health insurance company. They are requesting documentation that my son’s missing toe was not a preexisting condition. Their specific wording: “Has (dearest son of mine) received any medical care or medicine for diagnosis code 729.5–pain in limb (for the three months preceding the X-ray)?”  Like what, he’s been running around for the past three months with his
toe in the refrigerator just waiting for his health insurance to kick in
so he can have his toe reattached?

Do U.S. health insurance companies purposefully hire stupid people so they can spend even more on administrative overhead and pass those charges on to us, the mostly overwhelmed and confused health care consumers? At least 15% of our country’s total healthcare expenditures is spent on this sort of inept health insurance administration. That’s over $360 billion annually just for paper pushing. Medicare’s administrative costs are less than 2% of total Medicare expenditures. Meaning: that paper pushing can be done a lot more efficiently.

As Jeffrey Pfeffer wrote in his Bloomberg Business Week News article (4-10-13), “Because insurers are paid a fixed percentage of the claims they administer, they have no incentive to hold down costs. Worse than that, they have no incentives to do their jobs with even a modicum of competence.”

A good overview of the obstacles to reducing administrative costs within our healthcare system is included in this brief NEJM article. The authors point out that Obamacare/ACA has some provisions to address these problems. Here’s hoping.

Young Invincible Health Insurance Saga

IMG_1227Last night I had to take my ‘young invincible’ son to a local emergency department to have his toe sewn back onto his body. He had heeded my advice to get back to the gym to exercise, and somehow combined ballet with karate and lost a big toe in the process. His ED physician said he’d never seen anything like it in his 33 years of practice. Oh so reassuring. Also unsettling was this physician mug shot on the vending machine in the ED waiting room. He glared at me all night as I tried in vain to figure out what he was doing there, what his message was. Don’t you dare drink these sugary drinks? You’d better have good health insurance if you want to be seen here? I have some bad news: we somehow lost your son’s toe?

Fortuitously (or so I hope), my son listened to me and signed up for student health insurance–the day before his ballet/karate accident. As a mom and a nurse it was taking years off my life to have him ‘going bare’/uninsured. I now know some of what it feels like to live in fear of an accident, injury, or illness that could ruin my son (and by extension, me) financially. Even though he officially has health insurance to cover his expensive ED visit (X-rays, sutures, IV Vancomycin, physician quips) and ortho follow-up, I do not trust it. There are pages upon pages of exclusions to his health insurance plan, including bungee-jumping and intercollegiate sports–neither of which would seem to apply to losing a toe in ballet/karate. But I know how crafty and devious health insurance companies can be in trying to deny medical claims. I would hope that the university where I am employed and teach (and where my son is now a student) would have a decent health insurance plan option for its students. I guess I’m about to find out.

Health Insurance: Good Luck

Insurance
Insurance (Photo credit: Christopher S. Penn)

If anyone ever questioned whether or not US healthcare is political, they should now be convinced that it is. What with the drama of Obamacare, that Texan Tea Partier/Green Eggs and Ham reading/White Castle hamburger loving/Obamacare hating Senator Cruz, and then the looming shutdown of the federal government.  Not to mention Vanderbilt Medical Center’s recent creative administrators’ cost-cutting move to require nursing staff to take over housekeeping duties, for which they invoked the ghost of Nightingale (yes, HER again!) as the rationale behind their decision. Oh Nightingale! Rise up and smite them with a mop!

And then there is the desperate, mostly behind-the-scenes scramble for state health exchanges to be up and working by this coming Tuesday, October 1, when they are all slated to open for business. As described in today’s NYT article, many state exchanges will most likely be delayed. I especially like the article’s photograph of a roomful of intensely-working computer programmers trying to fix things for Oregon’s health exchange. I wonder how many of those workers have health insurance, and if not, how many of them now understand how to shop for and purchase health insurance once the system they’re working on is functional. Many of them do not look healthy.

My son, age 26, recently aged out of my health insurance plan. He was able to stay on my plan thanks to that provision of Obamacare. For the past few months he has been one of the many ‘young invincibles‘ (or ‘young invisibles’ perhaps?) who has no health insurance. Of course, I bug him constantly about this and want him to be insured. He’s now in graduate school at the University of Washington and is now eligible to purchase their student health insurance plan. The annual fee for one student (including 2014 ACA fees/whatever that means) is $2,748. School started this week, the earliest he would qualify for the insurance. I just checked their website and it has a statement marked urgent: “due to a system error some students who registered for Autumn quarter have had their coverage cancelled.”

This is complex stuff. I have a doctorate in health policy, teach, live and breathe health policy, and I can’t figure it out. Our healthcare system, especially the health insurance scene, has always been complicated, but I’m convinced that this specific part of Obamacare is creating more problems than it solves. It adds layers of administrative complexity and a huge burden (time and frustration–heart attacks anyone?) on consumers to ‘shop and pick a plan.’ These add up to a substantial increase of costs and inefficiencies in our already overly costly, inefficient, ineffectual healthcare system.

The best (mostly fully functional that I’ve seen) interactive tool for consumers ‘explaining’ ACA/Obamacare in more or less vernacular (English and Spanish), is Consumer Report’s Healthlaw Helper. Good luck.