Category Archives: Health Care

Young Adults and Obamacare

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We've all heard our fill about Obamacare, but because it is so complex most of us don't have a clue what's going to happen as its implementation kicks into gear next year. That's beginning to change as all kinds of research is being done and reports on the results of that research starts to hit the news.

Earlier this week we saw plenty of coverage of the Rand Corporation's analysis of the 14 states that have opted not to implement the Medicaid expansions called for in Obamacare, and the projections aren't good for those states which include North Carolina. Now comes this fascinating interview with the executive director of Young Invincibles, a group that studies young adults' role in health reform. The interview is about how young adults view health insurance and the likelihood that they will opt in to Obamacare, which everyone seems to agree is a critical factor in the success of the program. Here are the most interesting tidbits:

About 19 million young adults 18 to 34 lack health insurance. Our polling shows that less than 5 percent of young people choose not to have it. The number one reason they don’t have it is the cost. Most young people don’t qualify for Medicaid right now even if they have very low incomes because most states just don’t give childless adults Medicaid. That’s one of the biggest changes under Obamacare. If every state expanded Medicaid, about 8 million would qualify for Medicaid. Another 9 million would qualify for subsidies because they make less than 400 percent of poverty.

So then 17 of the 19 million uninsured young people are, in theory, eligible for either subsidies or Medicaid under Obamacare?

That’s right. It’s a pretty phenomenal percentage. So if we do our jobs right, young people will be one of the biggest winners in the health-care law…

 But the cost does matter. So is Obamacare actually going to make insurance affordable for this group? Or will it make insurance more expensive for young, healthy people by making it easier for sicker, older people to buy insurance without getting discriminated against? 

The first important point is the huge percentage of unemployed young people who get access to either subsidies or Medicaid. So you saw in California that many young people will end up having insurance options that cost them less than $100 or less than $50 simply because their income is low enough to qualify for subsidies. For someone making $20,000 a year, they’re going to have to pay $40 a month for health insurance. That’s a very good deal. And in a state like California, there are also millions of young people who qualify for Medicaid.

Now we’ve identified a population between 300 percent and 400 percent of the federal poverty level that’s going to have more problems. The subsidies aren’t that rich for them, and so whether to buy is a tougher question. They’ll have financial strain. They have financial strain now. That’s why they’re uninsured. If you’re just getting by, then $200 a month can be a lot. That’s where education can be key. It can still make good financial sense to be covered because there are real risks. But I think, in general, it will be a good enough deal to sign up. We saw that in Massachusetts where youth uninsurance dropped in half in the first year…

So given all the issues of implementation and the political opposition to the law and the difficulties in various states and the early information about premiums, where do you think this will end up in 2014 and 2015? Do you think young people will sign up or stay away?

I’m pretty hopeful, in part because the experience in Massachusetts showed this model can work. But it will play out differently in different states. A state like California is following the playbook. They’ll do a big promotional campaign. They’re investing in on-the-ground outreach and education. They’re expanding Medicaid so really low-income folks will qualify for health insurance. So I could see it being a huge success in a state like that. But not every state will do that. An important point for young people is that some of the states with the highest rates of youth uninsurance are in the south and some of those states aren’t expanding Medicaid or building their own exchanges. My fear is what happens in those states. So I could see some states coming out and looking much better than other states.

As a father of three children a couple of years away from entering the working world and as a resident of North Carolina, one of those southern states not "following the playbook", that last paragraph truly worries me.

The Unfortunate 14

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North Carolina is one of 14 states that has opted out of the new Medicaid funds linked to Obamacare. What does that mean? According to a new Rand Corporation study it means those states are sailing into a stiff healthcare wind:

The study, by the Rand corporation, looks at the 14 states that have said they will opt out of the new Medicaid funds. It finds that the result will be they get $8.4 billion less in federal funding, have to spend an extra $1 billion in uncompensated care, and end up with about 3.6 million fewer insured residents.

So then, the math works out like this: States rejecting the expansion will spend much more, get much, much less, and leave millions of their residents uninsured. That’s a lot of self-inflicted pain to make a political point.

It’s a truism of health-care politics that the uninsured are impossible to organize. But Obamacare creates an extraordinarily unusual situation. The Affordable Care Act will implemented in states that reject Medicaid. There will be huge mobilization efforts in those states, too, as well as lots of press coverage of the new law. The campaign to tell people making between 133 and 400 percent of poverty that they can get some help buying insurance will catch quite a few people making less than that in its net. And then those people will be told that they would get health insurance entirely for free but for an act of their governor and/or state legislature.

North Carolina is already seeing political activism spearheaded by the state's NAACP chapter against policies of the Republican legislature. Just yesterday the NAACP's ongoing "Moral Monday" campaign led to more than 150 arrests at the state capitol. Quite frankly that action is easy for a lot of people to dismiss as just more of the same from a group trying to justify its existence (when doesn't the NAACP protest?), but if people who normally sit on the sidelines are suddenly spurred to action because their government denied them the opportunity for cheaper (or free!) health coverage then things could get very interesting for the next election cycle here in the Tarheel state.

(h/t to Fec for the link to the story).

Hidden Costs

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One of the interesting changes we're seeing in the US is the different behavior of health care consumers when they are actually allowed to act like consumers. From the Wall Street Journal:

Last fall, two big employers embarked on a radical new approach to employee health benefits, offering workers a sum of money and allowing them to choose their health plans on an online marketplace. Now, the first results are in: Many workers were willing to choose lower-priced plans that required them to pay more out of their pockets for health care.

The new online marketplace, operated by consulting firm Aon AON -0.29% Hewitt, a unit of Aon PLC, was used by more than 100,000 employees of  SearsHoldings Corp.  SHLD -0.86%  and Darden Restaurants Inc.,  DRI +0.43% as well as Aon itself, to pick plans for 2013. The employers gave workers a set contribution to use toward health benefits, and they could opt to pay more each month to get richer plans, or choose cheaper ones that might have bigger out-of-pocket fees, such as higher deductibles.

"When people are spending their own money, they tend to be more consumeristic," said Ken Sperling, Aon Hewitt's national health exchange strategy leader.

Go figure. When people are given pricing options and asked to consciously weigh costs/benefits and risks/rewards they make "consumeristic" decisions. Forget for a moment all the details about "Obamacare" and your feelings towards it, and instead ask yourself these questions: Can any health care reform program succeed if it doesn't allow people to behave like a logical consumer? How can a logical consumer exist in a market where pricing is obscured? To that end, the next time you go to the doctor's office try this exercise: ask them what your appointment is going to cost before they do anything. They likely won't be able to tell you because they simply don't know – the cost depends on what kind of insurance you have and the rates your insurer has negotiated with the doctor's network. Craziness, huh?

Changing gears, but sticking to the hidden costs theme, have you ever wondered why we it's been so difficult for people to grasp the true costs of the wars in Afghanistan and Iraq? It's because the bill has shown up in the form of an exploding deficit and not a "War Tax." Deficits are like credit card debt: you know they're bad and that they can be a drag on your financial well being, they are hard to get overly excited about because your daily life doesn't change much until you run out of credit and the bills come due. On the other hand if you're paying cash – or a War Tax – the cost of your action is immediately clear and you're far less likely to be so sanguine about whatever you're doing. 

So here's a rule of thumb we need to teach our children: if the cost of something is hidden, or if you aren't asked to pay for it up front, it is likely much higher than you think so you should really think hard before making that purchase decision. There should also be a corollary: if it's a politician doing the selling then you should probably just walk away or be ready to spend 100x whatever you think the cost is (see War, Iraq).

Health Care Frustration

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The video below was emailed to me by my mother. It offers up a vision of the health care industry being revolutionized by information technology. Hopefully that vision will be realized, but pardon me if I'm skeptical. As I told my mom in reply to her email, I can remember being a member of the Kaiser Permanente HMO in the DC area twenty years ago. They had an integrated computer network that allowed me or any member of my family to walk into any one of their centers and have our records accessed immediately by a doctor or nurse. No carting charts from one doctor to another! This, I thought, was the very near future of medicine. Twenty years later it still hasn't happened for the most part and I remain skeptical that the vested interests in health care will allow the changes needed to improve health care delivery in this country.

After watching this piece I truly hope I'm being overly pessimistic:

Priorities

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The Affordable Care Act (ACA), a.k.a. Obamacare, is starting to kick into gear and states are having to make decisions about how they are going to participate. Here in North Carolina the state legislature is considering opting-out of the expansion of Medicaid called for by the ACA:

Legislation is moving forward in the General Assembly to opt out of the Medicaid expansion under the Affordable Care Act. The expansion would provide health insurance to people living in households with incomes below 133 percent of the poverty line. The federal government would cover 100 percent of the costs for the first three years and 90 percent of the costs thereafter.

Besides extending coverage to about 400,000 poor NC residents who wouldn't get health insurance otherwise, the expansion would bring in $40 billion on net (about $50 billion in total spending), which would jolt the economy and create jobs.

A new report by Regional Economic Models, Inc. forecasts that the expansion would add nearly 6,000 jobs to the NC economy in the first year of the expansion, as participation in Medicaid starts to grow, and 20,000 to 25,000 jobs in subsequent years, as participation stabilizes at a higher level.

It's no secret, or a surprise, that the newly empowered Republican majority in the NC legislature is opposed to the ACA. Most conservatives I've talked to would like to see entitlements of all varieties cut rather than expanded, and if you avoid getting all hot and bothered and really listen to them you realize it's not out of meanness. Many of them truly believe that we're robbing an entire generation of any incentive to improve their own lot. Most I've talked to absolutely believe we should help the truly helpless, but defining who the truly helpless are and determining how best to help them can get you into some heated debates faster than you can say Obamacare.

On the flip side most liberals I know truly believe that as a society it's in our best interest to make sure that all people have access to good health care. Most I've talked to view it as a moral issue – we should do it because it's right. 

Here's where I get frustrated: I think there's a middle ground between the two groups. I too think there's a moral obligation to do everything we can to make sure all members of our society have access to health care, but I also think there's a solid "business case" to be made for it. A healthy society by definition will be more efficient than a sick society, and the resources tied up in caring for very sick people could be better spent elsewhere.

Put simply sick people have a hard time working or contributing to society in a meaningful way, and if you want to institute reforms in other areas of our entitlement programs – for instance requiring X hours of community service in return for Y dollars of aid – then you need to make sure they are healthy at a bare minimum. We can debate the details all day long, but in terms of priorities I don't know how you can put health care anywhere below the very top tier.

A Parent’s Nightmare

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Last month I wrote a post titled The Miracles and Limitations of Modern Healthcare that was prompted by my family's experience at Brenner Children's Hospital where our son had a procedure called a cardiac ablation to take care of a heart condition he'd been dealing with for a couple of years. I wrote the post the day after my wife and I had our son safely home following a successful procedure. As you can imagine we were thrilled with the outcome, but that thrill was tempered by some of our experiences in the waiting room. Here's part of what I wrote:

Unfortunately modern medicine also has its limitations. While we were in the waiting room during our son's surgery a doctor came out and met with a mother and grandmother waiting near us. It was very early in the morning and most of the folks in the waiting area were asleep, thus it was pretty quiet. We tried our best not to eavesdrop, but it was impossible not to hear pieces of what the doctor was telling the mother – that her child did indeed have some rare, malignant cancer. It was also impossible not to hear the mother's crying and her mother trying to console her. And quite frankly it was impossible not to break down ourselves once they left – I haven't cried in public since I was a child, and I'm not ashamed to say that I just couldn't hold it together. I can't imagine going through what that family is going through right now.

Right now our country is dealing with a lot of change in our health care system thanks in large part to theAffordable Care Act, aka Obamacare. There's (rightfully) a lot of discussion about how our health care system and the related health insurance industry work. The debate often focuses on cost and on whether or not we're moving towards a system of "socialized" medicine similar to Canada's or the UK's, and if we are, whether that will lead to a stall in medical advances that have led to every day "miracles" like what our family experienced.

Those are all worthy discussion points, but after yesterday all I could think was this: when it's your child in the operating room you really don't care how expensive the procedure is, you just want him to have whatever it takes to make him well. I would gladly live in a cardboard box in order not to have to hear what that poor mother next to us heard. Whatever we do I hope we continue to work towards making sure that fewer and fewer parents have to hear that their child doesn't have a miracle available to them at any price.

Today we learned that a 15 year old student at our son's high school, a boy named Ryan Wood, died today of cancer. His classmates had started a #prayforryan campaign on Twitter, which brought his and his family's ordeal to the attention of the media, celebrities like West Forsyth alumnus Chris Paul, and the community at large. When he passed away today a lot of us in the community heard about it, and that's what is prompting this post.

Ryan was treated at the same hospital – Brenner Children's Hospital – as our son, which means he had access to some of the best treatment available anywhere. When I heard his story I couldn't help but think back to the experience in the waiting room, and I couldn't help but wonder about how Ryan's family can possibly deal with this loss. And I can't help but hope and pray that the capabilities, the miracles,  of modern medicine keep expanding at an ever faster rate so that fewer and fewer families have to discover the absolute devastation that they are feeling with the loss of their son today. 

If you are a religious person please keep the Wood family and all families dealing with tragic loss in your prayers. If you aren't religious please send kind thoughts and reflections their way. 

Here’s a Bone In Your Eye

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If you're considering cosmetic surgery you may want to steer clear of some procedures involving the use of stem cells:

Wu could see that something was wrong: Her eyelid drooped stubbornly, and the area around her eye was somewhat swollen. Six and a half hours of surgery later, he and his colleagues had dug out small chunks of bone from the woman's eyelid and tissue surrounding her eye, which was scratched but largely intact. The clicks she heard were the bone fragments grinding against one another.

About three months earlier the woman had opted for a relatively new kind of cosmetic procedure at a different clinic in Beverly Hills—a face-lift that made use of her ownadult stem cells. First, cosmetic surgeons had removed some the woman's abdominal fat with liposuction and isolated the adult stem cells within—a family of cells that can make many copies of themselves in an immature state and can develop into several different kinds of mature tissue. In this case the doctors extracted mesenchymal stem cells—which can turn into bone, cartilage or fat, among other tissues—and injected those cells back into her face, especially around her eyes. The procedure cost her more than $20,000, Wu recollects. Such face-lifts supposedly rejuvenate the skin because stem cells turn into brand-new tissue and release chemicals that help heal aging cells and stimulate nearby cells to proliferate.

This kind of puts the potential risks of botox to shame doesn't it?

The Miracles and Limitations of Modern Health Care

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My wife and I spent yesterday at Brenner Children's Hospital in Winston-Salem with our youngest son. Our son has been dealing with a condition called supraventricular tachycardia (SVT), which in layman's terms means his heart will sometimes beat really fast – like 200 beats-per-minute fast – for extended periods of time even if he's sitting still. He was in the hospital for a procedure called a cardiac ablation which, if successful, would prevent these episodes from happening in the future.

The way the ablation was explained to us is that the doctor would send catheters through major veins in the legs to our son's heart and, depending on where in the heart the problem was, either burn or freeze the part of the heart that was causing it to go into this abnormal rhythm. Our son would be put under general anesthesia for the procedure and it would likely take about four hours. They would provoke his heart into going "wonky" (that's our technical term for it), identify the problem area, treat it and then observe it for a period of time to make sure they got all of it. If they needed to they'd freeze or burn more spots until they had the problem area taken care of.

Here's the really amazing part: if all went as planned we'd have our son back home the same day and he'd be under orders to take it easy for four days, not lift anything heavy for about a week, and then he'd be back to normal. To us this was truly a miracle of modern medicine – our son would have a heart procedure as outpatient surgery!

Thankfully all went as planned and we had our son home last night. Truly amazing.

Unfortunately modern medicine also has its limitations. While we were in the waiting room during our son's surgery a doctor came out and met with a mother and grandmother waiting near us. It was very early in the morning and most of the folks in the waiting area were asleep, thus it was pretty quiet. We tried our best not to eavesdrop, but it was impossible not to hear pieces of what the doctor was telling the mother – that her child did indeed have some rare, malignant cancer. It was also impossible not to hear the mother's crying and her mother trying to console her. And quite frankly it was impossible not to break down ourselves once they left – I haven't cried in public since I was a child, and I'm not ashamed to say that I just couldn't hold it together. I can't imagine going through what that family is going through right now.

Right now our country is dealing with a lot of change in our health care system thanks in large part to the Affordable Care Act, aka Obamacare. There's (rightfully) a lot of discussion about how our health care system and the related health insurance industry work. The debate often focuses on cost and on whether or not we're moving towards a system of "socialized" medicine similar to Canada's or the UK's, and if we are, whether that will lead to a stall in medical advances that have led to every day "miracles" like what our family experienced.

Those are all worthy discussion points, but after yesterday all I could think was this: when it's your child in the operating room you really don't care how expensive the procedure is, you just want him to have whatever it takes to make him well. I would gladly live in a cardboard box in order not to have to hear what that poor mother next to us heard. Whatever we do I hope we continue to work towards making sure that fewer and fewer parents have to hear that their child doesn't have a miracle available to them at any price.

Sapolsky on Depression: Speakers Take Note – This Is How You Do It

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Joe called this "The best presentation I've ever seen. Not even close." I don't know if I'll go that far, but I will say that it's very, very good and it reinforces my belief that the best speakers/presenters forego PowerPoint presentations. Also, chalk boards/white boards are two of the most underrated communication tools in the universe. Finally, great presentations almost always result from a combination of genius, preparation, personality and "it" factor. Technology can enhance these elements, but it can't replace them or hide a speakers 

About the presentation itself: I've never, ever seen anyone take complex, medical/scientific information and break it down into layman's terms as well as Sapolsky does here. Phenomenal, and a must watch for anyone with an interest in depression.

Coverage Gaps

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The Wall Street Journal has an interesting article about large companies in certain industries moving towards employing more part-time workers in reaction to provisions of the Affordable Care Act that will kick in in 2014. What's even more interesting is the graphic that shows the percentage of employees (not including professionals and managers) who are covered by employers' health insurance plans by industry. In other words, the percentage of hourly working stiffs whose employers provide health insurance in different industries. Here's the breakdown:

  • Agriculture: 34% 
  • Services: 41.5%
  • Construction: 46.9%
  • Professional and technical services: 51.4%
  • Wholesale and Retail Trade: 57.9%
  • Health and Social Services: 62.5%
  • Utilities and Transportation: 67.1%
  • Finance: 69.7%
  • Mining and Manufacturing: 71.1%
  • Information Communications and Education: 72.9%
  • Public Administration: 83.9%

That's a lot of working stiffs who don't have even partial coverage from their employers, and a pretty good indication that "Cadillac benefits" are increasingly rare.