This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid
The Kaiser Commission on Medicaid and the Uninsured, October 2013
The expansion of Medicaid, effective in January 2014, fills in historical gaps in Medicaid eligibility for low-income adults and has the potential to extend health coverage to millions of currently uninsured individuals. This expansion essentially sets a national Medicaid income eligibility level of 138% of poverty (about $27,000 for a family of three) for adults. The expansion was intended to be national and to be the vehicle for covering low-income individuals, with premium tax credits for Marketplace coverage serving as the vehicle for covering people with higher incomes. However, the June 2012 Supreme Court ruling made the expansion of Medicaid optional for states, and as of September 2013, 26 states did not plan to implement the expansion.
In states that do not expand Medicaid, over five million poor uninsured adults (5.2 million people) have incomes above Medicaid eligibility levels but below poverty and may fall into a “coverage gap” of earning too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits. Most of these people have very limited coverage options and are likely to remain uninsured.
The ACA envisioned people below 138% of poverty receiving Medicaid and thus does not provide premium tax credits for the lowest income. As a result, individuals below poverty are not eligible for Marketplace tax credits, even if Medicaid coverage is not available to them. Individuals with incomes above 100% of poverty in states that do not expand may be eligible to purchase subsidized coverage through the Marketplaces; however, only about a third of uninsured adults (3.2 million people) who could have been eligible for Medicaid if their state expanded fall into this income range. Thus, there will be a large gap in coverage for adults in states that do not expand Medicaid.
According to this report, “Nationally, over five million poor uninsured adults will fall into the ‘coverage gap’ that results from state decisions not to expand Medicaid, meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits.” That is, they are not eligible for Medicaid, and at an income below 138% of the federal poverty level, they are not eligible for subsidies and therefore cannot possibly afford to purchase private plans. They will remain uninsured, even though they have the least ability to pay out-of-pocket for health care.
These individuals falling into the coverage gap represent about one-sixth of the total number of individuals who will remain uninsured (31 million). Supposedly the Affordable Care Act was designed to make health care affordable for everyone, with an emphasis on Medicaid or private plan subsidies for those who could least afford to pay for coverage. By this standard, ACA can be considered a dud.
Let’s do it right. Let’s enact a single payer national health program that provides health care for everyone while separating the funding by moving it to the tax system. That would eliminate any connection between receiving health care and having to pay for it. Needing health care is bad enough without being assessed charges (in essence financial penalties) for obtaining that care.
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Out of Network, Out of Luck
By Theresa Brown
The New York Times, October 12, 2013
For several hundred patients at the University of Pittsburgh Medical Center, it started with a certified letter informing them that they were no longer allowed to see their physicians. The reason? They were unlucky enough to have insurance called Community Blue, which is offered by a rival hospital system. Astoundingly, they were barred even if they could pay for the care themselves.
One patient, in the middle of treatment for lung cancer, said at a hearing before a State House of Representatives committee that she was prohibited from seeing her U.P.M.C. oncologist. Another, with the debilitating autoimmune disease scleroderma, said she was dismissed from the U.P.M.C. Arthritic and Autoimmune Center. A third, a five-year breast cancer survivor who needs follow-up care every six months, was cut off from the doctor who had been with her since she was first given her diagnosis.
Community Blue is sold by a company called Highmark. Like U.P.M.C., it is both a hospital system and an insurance provider, part of a growing trend toward vertical consolidation in the two industries. These and other companies insist that such consolidation streamlines the caregiving system and thus benefits the patient. But in the short term, they are waging a vicious war over patients — and as the experience in Pittsburgh shows, it’s often the patients who are losing.
Historically, U.P.M.C. was the biggest health care provider in Pittsburgh and Highmark the largest insurer. U.P.M.C., though, has been selling its own brand of insurance for over a decade, and Highmark recently affiliated with a local multisite hospital system, now known as the Allegheny Health Network.
U.P.M.C. responded to the formation of the Allegheny Health Network by labeling Highmark a competitor and a threat to its financial sustainability. It has also announced that its current contract with Highmark will not be renewed, meaning that in December 2014 almost all U.P.M.C. hospitals will be open to Highmark customers only at out-of-network rates, which are among the highest in the country.
At the same time, U.P.M.C. is running an aggressive ad campaign for its own health insurance plan, and Highmark subscribers with Community Blue have been denied access to their U.P.M.C. physicians.
More health systems nationally are following the lead of U.P.M.C. and Highmark, combining health insurance with the provision of care itself.
The worry is that integration will yield not better care but higher profits achieved through monopolistic consolidations and self-serving business practices.
Integrating health care is a great concept that theoretically should improve coordination of care, reduce duplication, provide incentives to meet quality and outcome targets, improve access to appropriate specialized care – in general, improving quality while reducing costs. That is the idea behind the Accountable Care Organizations established by the Affordable Care Act. How is it working out in the real world?
We’ve watched as insurers have consolidated. Although they tout that they are providing higher quality at lower costs through managed care, in fact they have used their oligopolistic leverage to limit patient access to their selected network providers. Although they contend that they are selecting the highest quality providers, in fact, they are excluding quality institutions such as academic medical centers and going with the cheapest contracts they can extract from the health care community.
In response, we are witnessing an explosion in consolidation of health care providers – hospitals and physician groups – often into single entities. Obviously this results in “must have” groups that in turn have leveraged their oligopolistic negotiating power in dealing with the insurers.
Not to be outdone, we are now seeing insurers and consolidated health care systems joining together to increase their control of markets, and thereby share in the spoils. When you see patients with lung cancer, breast cancer, and scleroderma being cut off from their care strictly on the basis of realignment of the health care business models, you can dismiss the concept that these changes are changes that are designed to benefit patients. The ugly competition that is taking place between Physician-hospital-insurer entities (Phi) is cutthroat and certainly not in the patients’ best interests. (Phi seems to be an appropriate symbol for these entities since, in Lacanian psychoanalysis, it is the symbol for “the phallic function.”)
The Affordable Care Act very specifically was designed to keep control in the private sector. Private sector business models will always do what they are designed to do – anything to make more money. If we really do want a system designed to provide the best care possible with our available resources, we need to dismiss the private insurers and put our own public stewards in charge. They would have the responsibility of answering to us.
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
By Don McCanne, qotd editor
Quote of the Day Editorial, October 11, 2013
Yesterday, my wife Sandy and I had the pleasure of joining a group from our local chapter of the League of Women Voters in viewing the new documentary, Inequality for All, featuring former Labor Secretary Robert Reich. The lesson of the film did not escape those attending. The last couple of decades have left low- and middle-income people behind while all of the workers’ gains in productivity have moved up to the very wealthiest.
This is an important issue for those who support single payer reform – improved Medicare for all. The average health care costs for the typical working family of four are now over $22,000 while the median household income is $50,000. If everyone is going to have the health care that they need, some of that wealth flowing upwards needs to be redirected to health care, and to other social needs as well.
Some of the wealthy one-percenters do understand this. Featured in the documentary was entrepreneur and venture capitalist Nick Hanauer. The following link is to a six minute TED video in which Nick explains the phenomenon and why it is important to us. (For political reasons, TED removed this video from its website, but it is still available through YouTube.)
In our dinner discussion after viewing Inequality for All, some commented that, though the film explained the problem well, it seemed to leave off any plan for action. It does not require much intuitiveness to think of what actions we might take, though the website for the film does help us by discussing six categories for action:
* Raise the minimum wage
* Strengthen workers’ voices
* Invest in education
* Reform Wall Street
* Fix the tax system
* Get big money out of politics
Inequality for All: http://inequalityforall.com
For those who would like to learn more, Berkeley Professor Emmanuel Saez, who was also featured in the documentary, has published extensively on this topic. Many of his papers – several co-authored by Thomas Piketty – can be downloaded from his website:
Where To Compete In A Post-Reform World
By Shubham Singhal, senior partner in McKinsey’s Detroit office
Health Affairs Blog, September 30, 2013
The power of “where-to-compete” decisions, particularly in an industry in as much flux as US health insurance, is enormous. Our analyses suggest that the bottom-line performance differential between a payor who selects a market-average portfolio across businesses and geographies and an identical payor who instead selects a top-quartile portfolio is likely to be almost twofold. Across industries, McKinsey research shows that the majority of the performance differential among corporations results from their alignment with “rising tide” markets rather than from share gain within less attractive markets.
Furthermore, we have found that there are three “macro” approaches that can enable companies to thrive during major industry disruptions: refocus their portfolio on more attractive businesses, build one or two large new businesses, or radically transform their business model. The first two rely squarely on where-to-compete decisions. The last approach is not for the faint of heart.
Thus, today’s payors must carefully choose which markets they want to concentrate their resources on to win. The choices made will be critical not only within the payors’ core health-plan business but also in adjacent areas within the healthcare value chain.
Given the disruptive changes in the healthcare industry, payors that want to thrive over the next few years will need to develop the discipline to make and act on where-to-compete decisions. They will need insights into where growth and margin will be earned, the foresight to determine when inflections points in the market might happen, a clear view of their own competitive advantages and capabilities (which would give them the ability to win and earn a superior return), the fortitude to make tough resource-allocation decisions, and the agility to alter their course as the market shifts. Acquiring the needed discipline is challenging but necessary. The upside from getting where-to-compete decisions right is substantial enough to demand top management’s attention — and the downside is potentially fatal.
Marketplace Plans Vary Widely In Costs, Within Counties And Across The Country
By Jordan Rau and Julie Appleby
Kaiser Health News, October 4, 2013
Consumers shopping in the new health insurance marketplaces will face a bewildering array of competing plans in some counties and sparse options in other places, with people in some areas of the country having to pay much more for the identical level of coverage than consumers elsewhere.
Nationwide, 18 percent of counties have only one insurer offering plans and 33 percent of counties have only two insurers competing, the KHN analysis found.
Private insurers are a totally different animal than public health coverage programs, and this “where-to-compete” industry advice typifies that difference.
Public programs, such as Medicare, make every effort to deliver health care to those that need it. Private insurers make every effort to ensure the success of their business model.
Mimicking Willie Sutton’s famous strategy to rob banks because that is where the money is, private insurers “carefully choose which markets they want to concentrate their resources on to win.” The Kaiser analysis shows that one-third of counties have only one or two insurers offering plans. According to the McKinsey advice, for the insurers covering those counties, the decision is “potentially fatal.”
The Affordable care Act has put the wrong people in charge. We can change that. Fix Medicare and then provide it for everyone. Let’s replace “where-to-compete” with “where-to-provide-care.”
Note: This rather wonkish article is much easier to read on the website (link below) since it includes a series of graphs that helps to visualize the concepts presented.
Inequality Is At The Core Of High Health Care Spending: A View From The OECD
By Richard “Buz” Cooper
Health Affairs Blog, October 9, 2013
It is commonly said that the US spends more than twice as much on health care as other developed countries, yet its outcomes are worse. The inference is that too much care is provided, to no good end.
Such international comparisons are drawn from the Organization of Economic Cooperation and Development (OECD), a group of 34 developed countries. Analyzing these data is a multi-step process, like peeling an onion, and the truth resides deep within its core.
The process starts by adjusting health care spending for “purchasing power parity” (PPP) and expressing it in US dollars. By that measure, per capita spending in the US is 160 percent more than the OECD mean, and this is the basis for the notion that the US spends more than twice as much. But it is only the first layer.
The second layer is the economy. The US spends more principally because it is wealthier, but even in proportion to its gross domestic product (GDP), the US spends more, about 60 percent more. But that is only the second layer.
The third layer is price. Health care prices are inordinately high in the US and inordinately low in many other countries, particularly those that exercise price controls. Therefore, to understand how much care is given, comparisons of health care spending must be adjusted for the purchasing power parity of health care (HC-ppp). When so adjusted, spending in the US is still higher relative to its GDP, but by only 31 percent. This represents the core difference in services. Some are administrative, but most are health care services.
What explains this 31 percent? A large body of evidence suggests that it results from poverty and income inequality, which are more prevalent in the US than in any other OECD country except Chile, Mexico and Turkey. And poverty is associated with substantial increments in spending. For example, the poorest decile of Medicare beneficiaries spends 30-40 percent more than the wealthiest; overall hospital utilization rates in large urban areas are 25-35 percent more than in their wealthiest Zip codes; and hospital readmissions are most prevalent from poor neighborhoods and in safety-net hospitals.
Much of this relates to chronic illness, which is most prevalent among the poor. And chronic illness rates are higher in the US than in most other OECD countries, higher than Canada or England and higher than the average of France, Germany, Italy, Japan, Spain and the UK. Similarly, obesity, which is most common among the poor, is most prevalent in US. And the rates of infant, maternal and preventable mortality, which are often taken as measures of health care effectiveness but are actually markers of poverty and the burden of disease, are all higher in the US than in any other advanced economy.
The Gini coefficient is a measure of income inequality. To estimate the impact of income inequality on health care spending, it was applied to the spending level in each of the OECD countries. So doing erased the difference between the price-adjusted level expected from GDP and the actual expenditures in the US. Thus, while the US spends more than twice as much on health care than the mean of other OECD countries, its greater GDP and higher prices explain most of it, and income inequality offers an explanation for the rest.
But there is more, and it is the core of the core. The OECD measures a host of spending categories in addition to health care. In most, spending in the US is proportional to its GDP. Health care, which exceeds the OECD norm, is one exception. A second is social spending, and it deviates in the opposite direction. Social spending in the US is 33 percent less than predicted from GDP. And recent trends are constraining it further by limiting funds for food stamps, housing subsidies, and programs that serve youth, the elderly, and the homeless.
It is difficult not to connect the dots from inadequate social spending to excess poverty and income inequality to more chronic illness and higher health care spending. These dots reside in the core of the OECD onion, and the failure to cope with them is placing an unsustainable burden on our health care system.
In this article, Richard “Buz” Cooper develops the theme that income inequality and excess poverty along with our inadequate compensatory social spending are the primary reasons that our health care spending is so high. Others might prefer to frame the reasons in different terms, but that does not change the fact that it is imperative that we establish policies to cope with these societal deficiencies.
As an aside, he does mention that some of the core differences in U.S. services are administrative, but then does not mention that much of that administrative waste could be recovered by establishing a more effective and efficient health care financing system (i.e., single payer).
Buz Cooper’s Health Affairs biography states, “He has rediscovered the essential role of professionalism in health care and the central importance of poverty in the growth of health care spending.” Let’s see what we can do to help the rest of the policy community and our politicians make the same discovery.
Majority of Washington’s Health Benefit Exchange Insurance Plans Fail to Cover Care at Seattle Children’s; Hospital Sues Seeking Adequate Network Coverage for Children and Families
Seattle Children’s Hospital, October 4, 2013
Today, Seattle Children’s Hospital filed suit citing the failure of Washington state’s Office of the Insurance Commissioner (OIC) to ensure adequate network coverage in several Washington’s Health Benefit Exchange (Exchange) plans. We believe strongly that the OIC and the majority of plans on the Exchange have failed to meet their mandate, as they do not currently cover care provided at Children’s.
Children’s is the only pediatric hospital in King County and the preeminent provider of many pediatric specialty services in the Northwest. Some of these specialized services not available elsewhere in our area or region include acute cancer care, level IV neonatal intensive care and heart, liver and intestinal transplantation.
Without inclusion of Children’s, current and future patients and families who obtain insurance from several plans offered will not be able to access care at Children’s as an in-network provider. This lack of suitable access to pediatric services means that families enrolled in these plans may not receive the most timely, appropriate care, and face larger out-of-pocket amounts.
“Every child should have access to essential healthcare and the intent of the new Exchange is to make it available to all families,” said Thomas Hansen, MD, CEO, Seattle Children’s. “However, we are very concerned about the limited networks being offered by some Exchange insurance plans. Omitting coverage for care at a facility like Children’s prevents families from accessing vital services they may desperately need.”
This press release from Seattle Children’s Hospital presents only one side of the story. Children enrolled in most of the plans to be offered in Washington’s insurance exchange will not have in-network access to the crucial, highly specialized services only offered by Seattle Children’s Hospital. The financial exposure to those families could be enormous. So what is the other side to this story?
There is tremendous pressure on the exchange plans to keep premiums competitive. Although rates generally had been ratcheted down as low as the market will tolerate, they could squeeze a little more out from some providers by negotiating slightly lower rates in exchange for excluding health care competitors. These limited networks are an insurer-driven, cost-containment element of the new ACA exchanges.
Imagine a Seattle child with a major malignancy or with the need for an organ transplant. Is it really reasonable that our “reformed” health care system still exposes that family to severe financial hardship and possibly bankruptcy? This is not what we should have expected from comprehensive health care reform.
We need to go back and do it right – enact a single payer national health program that removes financial barriers to all essential care for everyone. Any child in Seattle that requires the specialized services offered by Seattle Children’s Hospital should have them. No exceptions.
Employers Hold the Line on Health Benefit Cost Per Employee in 2014
Mercer, October 1, 2013
Based on early responses from a major survey conducted annually by Mercer, employers expect health benefit cost per employee will rise by 4.8% on average in 2014
“The recession has been one factor behind slower cost growth, by dampening utilization,” said Beth Umland, Mercer’s director of research for health and benefits. “But employers have made fundamental changes in their health benefit programs in recent years that have put the brakes on unsustainable cost growth.”
Employers estimate that if they made no changes to their current plans, health benefit cost per employee would rise by 7% on average in 2014.
One of the key strategies employers are using to manage cost growth is implementing consumer-directed health plans, which give employees financial incentives and information resources to seek more cost-effective care and are typically paired with an employee-controlled account. Another is health management (or “wellness”) programs focused on improving workforce health. And an emerging trend for 2014 that is expected to accelerate in 2015 is the use of private exchanges, such as Mercer Marketplace, which make it easier for employers to offer a range of medical plan options and voluntary benefits and which can be a tool in cost management.
About a third of all large employer health plan sponsors (those with 500 or more employees) do not currently offer coverage to all employees working 30 or more hours per week, as will be required under the Affordable Care Act (ACA) beginning in 2015. Industries that rely heavily on part-time workers will be the hardest hit by this rule. About half of respondents in retail and hospitality currently do not offer coverage to all employees working 30 or more hours per week.
Some employers will minimize the number of newly eligible employees by cutting back on hours for at least a portion of their workforce – 11% of all large employers say they will do so. But most employers affected by the rule will simply open their plans to all employees working 30 or more hours per week and brace for rising enrollment.
“Rising enrollment will be an even bigger issue in 2015 when the shared responsibility penalty goes into effect,” said Ms. Watts. “While some employers are going ahead with plans to expand eligibility in 2014 despite the delay, most of those with the big part-time populations are holding off and will feel the pinch in 2015.”
Few large employers – just 5% – say it’s likely they will terminate their health plans within the next five years, even though public insurance exchanges will provide another source of health coverage. About a fifth of employers with fewer than 200 employees say it’s likely they will terminate their plans; employers of this size are much less likely to offer coverage to begin with.
Under the ACA, beginning in 2018 employers will pay a 40% tax on the cost of health coverage in excess of $10,200 for an individual or $27,500 for a family. “This tax has been dubbed the ‘Cadillac tax’ but that’s really a misnomer,” said Ms. Watts. “Health coverage can often be expensive without being overly generous.”
Based on cost data collected in 2011, Mercer estimates that about 40% of employers would have to pay the tax on at least one plan if they made no changes to current plan design. Nearly a third of all large employers say they are taking steps in 2014 to avoid the tax in 2018 – in many cases, by adding a high-deductible consumer-directed health plan or taking steps to increase enrollment in an existing plan.
These preliminary findings just released by Mercer indicate that employers will continue to take steps to reduce their own costs of their health benefit programs, by shifting even more costs to their employees.
One of the more shocking new numbers is that nearly a third of large employers are taking steps in 2014 to avoid the 40 percent excise tax on expensive plans – a tax that will be assessed in 2018. These expensive plans do not have overly generous benefits, but they are expensive only because health care has become so expensive. To avoid the tax, most employers will be offering high-deductible, consumer-directed health plans which expose employees to greater out-of-pocket expenses.
Although only 5 percent of large employers say that they will terminate their plans within the next five years, the deterioration in coverage will surely cause a backlash from those who need care and cannot afford the out-of-pocket expenses. It may be that those who currently feel secure with the plans they get through their work may be the ones who will eventually clamor for single payer once they see how exposed their plan revisions will leave them.
Changes in Health Coverage FAQs
U.S. Office of Personnel Management
Members of Congress and Designated Staff
How will Members of Congress and designated congressional staff obtain health coverage in 2014?
House of Representatives and Senate offices will provide health coverage to Members of Congress and designated staff through the Marketplace. OPM has determined the most appropriate Marketplace is the Small Business Health Options Program (SHOP). SHOPs were established to administer group health benefits to employees of small businesses. Given the location of Congress in Washington D.C., OPM has determined that the DC SHOP, known as the DC Health Link Small Business Market administered by the DC Health Benefit Exchange Authority, is the appropriate SHOP from which Members of Congress and designated congressional staff will purchase health insurance in order to receive a Government contribution.
From which “Metal Level” on the DC SHOP will Members of Congress and designated congressional staff choose their plans?
Members of Congress and designated staff will choose from plans on the Gold Metal Level of the DC SHOP, which currently includes 112 choices. While all plans have the same “essential health benefits” (EHB), plans vary in copays, coinsurance, deductibles, and benefits beyond the EHB. Plans include fee-for-service, HMOs, Point of Service, and HSA-compatible plans.
Supposedly requiring Members of Congress and their staffs to participate in the insurance exchanges established by the Affordable Care Act was to make their coverage comparable to what the rest of us would have (an oversimplification since most of us will not be enrolled in the exchanges). Yet the benchmark plans setting the subsidies in the exchanges are silver tier plans with an actuarial value of 70 percent, and the plans which qualify for Federal Employees Health Benefits (FEHB) premiums for Members of Congress are limited to the gold tier plans with an actuarial value of 80 percent. This is much more significant than it appears to be.
The gold plans for the Members of Congress pay about 80 percent of their health care costs, and about three-fourths of their premiums are paid by the taxpayers. This is comparable to the more traditional employer-sponsored plans that most of us considered to be good insurance coverage. In essence, as members of Congress and their staffs move into the exchanges, they are being assured that they will have coverage very close to that which they now have in the FEHB program.
The standard silver tier for individuals selecting their plans though the exchanges will leave the patient responsible for paying 30 percent of costs out-of-pocket, though lower income individuals will qualify for subsidies that are considered to be inadequate. Also the narrow networks of the exchange plans risk exposing patients to 100 percent of sometimes unavoidable out-of-network costs, with no cap on spending. Further, because of their lower premiums, many will choose the bronze plans at 60 percent actuarial value, risking greater financial hardship should significant health care be required.
This is a huge difference since the 80 percent actuarial value plans for Congress are considered to be standard insurance, whereas the 60 to 70 percent actuarial value plans for the general public are considered to be underinsurance – plans that do not provide adequate financial security in the face of medical need.
We didn’t get this right. A gold standard for Congress and a lesser standard for the people? Let’s “Occupy Congress” by replacing those in Congress who don’t seem to get it with legislators who will bring us what we need – a single payer, improved Medicare that covers everyone.
Millions of Poor Are Left Uncovered by Health Law
By Sabrina Tavernise and Robert Gebeloff
The New York Times, October 2, 2013
A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.
Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help.
Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states.
The 26 states that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.
“The irony is that these states that are rejecting Medicaid expansion — many of them Southern — are the very places where the concentration of poverty and lack of health insurance are the most acute,” said Dr. H. Jack Geiger, a founder of the community health center model. “It is their populations that have the highest burden of illness and costs to the entire health care system.”
The disproportionate impact on poor blacks introduces the prickly issue of race into the already politically charged atmosphere around the health care law. Race was rarely, if ever, mentioned in the state-level debates about the Medicaid expansion. But the issue courses just below the surface, civil rights leaders say, pointing to the pattern of exclusion.
Every state in the Deep South, with the exception of Arkansas, has rejected the expansion. Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.
Blacks are disproportionately affected, largely because more of them are poor and living in Southern states. In all, 6 out of 10 blacks live in the states not expanding Medicaid. In Mississippi, 56 percent of all poor and uninsured adults are black, though they account for just 38 percent of the population.
Dr. Aaron Shirley, a physician who has worked for better health care for blacks in Mississippi, said that the history of segregation and violence against blacks still informs the way people see one another, particularly in the South, making some whites reluctant to support programs that they believe benefit blacks.
When the Supreme Court relieved the states of the requirement to expand their Medicaid programs as a condition of continuing to receive federal Medicaid contributions, it was understood that, in those states that did not voluntarily participate, many low-income people who were not eligible for plans to be offered in the exchanges (since they were to have been covered by Medicaid) would now also remain ineligible for Medicaid. Thus the most vulnerable are to be left with no coverage at all. What this New New York Times analysis adds to our understanding is that the sector hardest hit is poor blacks, especially those living in the South.
State politicians must carry much of the blame for this egregious health care injustice. If they agreed to participate, the states eventually would be required to fund only ten percent of this expansion, and none of the costs at the beginning. These politicians fully understood the demographics of the populations they refused to cover. So why did they refuse to authorized the quite modest expenditures that would bring health care to these people? Was it because they are poor? Or is it because they are predominantly black?
Regardless, we can blame not only these politicians, but also the voters who keep them in office. It is heartbreaking to realize that that so much of Martin Luther King’s Dream remains only a dream.
We still desperately need reform that is truly equitable and egalitarian. The Affordable Care Act didn’t get us there.
Health Care for All: Why We Need a New Prescription
By Scott Tucker
Truthdig, October 1, 2013
The right-wing assault on Obamacare is a distraction, but the “progressive” (or rather party line) defense of the Affordable Care Act is also a dead end.
This conversation between one doctor (Don McCanne) and one writer (Scott Tucker), both of us active in the reform of our health care system, is not a detailed map of that terrain, and far less a scripture for those looking for a new religion. Any proposals for public policy must, of course, be discussed before the widest public. Within the secular horizon of the public realm, we must not lose our sense of balance and common sense, nor our sense of right and wrong. The right to health care is a human right, but the political will to win that right as a daily fact of life begins with a moral commitment to care for the poor, the sick and the dying, and for all of us without exception.
The editors of Truthdig strategically selected October 1 to post this article – the day that the insurance exchanges opened for business. It is important to understand where we are headed and where we should be headed instead. This conversation between a writer and a doctor (5 pages) tries to provide perspective on the need for better policies than those in the Affordable Care Act and the need for social activism to achieve those policies.
Comments are welcome on the Truthdig website.
Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.
PNHP Chapters and Activists are invited to post news of their recent speaking engagements, events, Congressional visits and other activities on PNHP’s blog in the “News from Activists” section.