Category Archives: Healthcare

Measuring Success

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There are many ways to measure success and/or failure, and it’s important to keep that in mind when you assess hot-button issues. For instance, this article in the Greensboro News & Record about Obamacare’s affect on insurance coverage in North Carolina:

In North Carolina, 16.7 percent of residents are now uninsured, compared with 19.6 percent before the onset of the ACA, according to a study conducted by the social network WalletHub.

 

North Carolina ranked 33 among states for its number of uninsured residents.

The Tar Heel state also ranked fourth among states with the most net new private insurance enrollees per capita.

WalletHub used data from the Kaiser Family Foundation, the Centers for Medicare & Medicaid Services, the U.S. Department of Health and Human Services and the Census Bureau to make its projections.

Those who supported Obamacare will likely tout this statistic as proof that Obamacare is working. On the other hand, those opposed to Obamacare can ask the question, “But at what cost?” That’s the crux of the issue: we can all probably agree that more people having health insurance is a good thing, but we’d probably have lots of heated debate over how much to pay for it, how to pay for it and how to structure the program. Does the phrase “socialized health care” ring any bells.

Quite frankly I think it’s far too early in the process to declare Obamacare a success or failure, but I’d say these numbers show a positive trend towards getting more people health insurance coverage. Long term who knows whether or not Obamacare will be a net success, but at a minimum we’ve seen thousands of North Carolinians moved off the roles of the uninsured and that’s a step in the right direction.

 

Health Care Rights

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Have you heard about the SCOTUS decision in the Hobby Lobby case? If you live in American and haven’t heard about it then you might live in a cave, but here’s the gist of it:

The U.S. Supreme Court has upheld a decision whereby closely-held companies can request exemptions the Patient Protection and Affordable Care Act (ACA) coverage provision for some contraceptives because of the corporations’ founding family’s religious beliefs…

Much of the controversy over today’s decision derives from the fact that Hobby Lobby and Conestoga are not in the business of conducting religious services or overseas humanitarian missions as their primary business. They are for-profit companies. The ruling allows the corporations to refuse coverage because of the religious beliefs of individual leaders.

Beyond selectively singling-out women’s reproductive care, the decision raises the question of whether corporate leadership elsewhere might refuse coverage of other drugs due to religious beliefs.

A lot of the reaction I’ve seen online has focused on a couple of points: the weirdness of bestowing religious rights on closely held corporations using the argument that the corporation is an extension of the owners (that’s simplistic but I think gets to the heart of it); that the religious rights of the corporation/owners trumps the reproductive rights of their female employees.

I’d like to focus on the second point for a minute because I think the argument is a bit off and, quite frankly, misses the larger point. While it is regrettable that employers like Hobby Lobby would refuse to pay for insurance that covers all of their female employees’ contraceptive choices it doesn’t mean that those same employees can’t go out and get those contraceptives if they’re willing to pay for it themselves. Thus they aren’t denying them anything, they’re just not paying for it. That might seem like semantics, but I think it’s important because what it exposes is that corporate health insurance in this country is not a right for anyone.

Health insurance as we know it came into being in the World War II era as an incentive companies used to attract and retain employees who were in short supply at the time. As such, health insurance was never a “right” but was a benefit that came to be so commonplace that most employees started to view it as a right. Then something funny happened – companies realized they could shift the cost of health insurance back to employees and not suffer too many dire consequences and so they starting jacking up premiums and co-pays or simply doing away with health insurance all together. The result is a growing percentage of our population without access to health insurance, which means they forego preventive care and rely on ERs when they get sick, helping drive up health care costs for everyone.

The Clinton administration’s effort to deal with the rising health care problem twenty years ago was a notorious failure. ObamaCare started out as an ambitious plan to provide health care coverage for everyone, fought the “socialized medicine” stigma, went through a negotiation phase involving the health insurance cabal that resulted in the imperfect system being fought out in the courts today. You’d be hard pressed to find anyone happy with the system, except maybe for the millions of people who had NO access to health insurance pre-Obamacare and now at least have the option to buy it.

Long story short, while it’s easy to get hung up on the reproductive and religious rights arguments raised by the Hobby Lobby case, it would be a mistake to limit the scope of the conversation. The bigger question is why we can spend so much time and energy talking about our religious rights, women’s reproductive rights, our right to bear arms, etc. but we never seem to debate whether we should have a fundamental right to affordable, adequate health care and whether or not relying on private companies to provide it is the best way to approach it.

Four Health System Fixes Neither Party Will Touch

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Here’s an interesting article at Vox that outlines four ways the US health system could be improved, but neither political party will dare touch.  They are:

  1. Let in more immigrant doctors
  2. Curtail pharmaceutical monopolies
  3. Let non-doctors treat patients
  4. All-payer rate setting

Those first three are fairly self-explanatory, but the fourth is a little more complex. This excerpt helps explain it:

In Germany, the Netherlands, and the exotic foreign land known as Maryland they practice what’s calledall-payer rate setting. That means that instead of each insurance company negotiating separately with each hospital group on prices, a government commission sets a price that everyone pays. And it works. Maryland has curtailed cost growth without inducing any noteworthy shortages of health care facilities

Another advantage to all-payer rate setting beyond the simple ability to set low rates is that it would eliminate some of the necessity of doing everything through an insurance company middleman. Right now, one of the services your health insurer provides is a real insurance function that helps you hedge against risk. But for many people, the insurer’s most important practical role is as a negotiator. Since the insurance company has a lot of scale, it can get a good price from a doctor or a hospital. An uninsured person would have to pay at a much higher rate.

Reducing the insurance company’s role as a negotiator would let insurers focus more on the insurance function, and allow routine care to be handled in a more consumer-focused way. And by eliminating some of the advantages to sheer scale on the insurance side, it could also promote more competition in the health insurance industry.

Health Care Offers Huge Investment Opportunity

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Venture investor Fred Wilson sees the digitization of the health care sector as one of the great investment opportunities we’re likely to see:

Mary Meeker’s slide deck addressed this is bit. Here are a few of the big points from it:

  • Healthcare is now $2.8 trillion in the US, which represents 17% of GDP
  • Healthcare is being consumerized
  • Healthcare is being digitized
  • Digital Health Venture Investment was $1.9bn in 2013 (out of a total of $24bn)

We are looking for networks of users, patients, doctors, and other stakeholders in our health care who can transform the way health care is delivered. We only have one game plan at USV and look to play it in every market opportunity we see.

I am pretty certain the intersection of the Internet and mobile, the digitization of the health care system, and a desire for people to take more control over their health is going to be one of the biggest investment opportunities we will see in my lifetime. And its game on.

As we’ve seen here in Winston-Salem the process of digitization won’t always be pretty. We’ve seen a lot of news regarding the problems our large health care networks, particularly Wake Forest Baptist, are experiencing as they try to (finally) catch up with almost every other industry in the use of information technology. While these are very large problems, and people have lost their jobs as a result, they almost certainly have more to do with terrible implementation strategy from executives than with the technology itself. In the long run those providers should realize huge gains in efficiency, and the data they’re accumulating will provide untold numbers of opportunities for entrepreneurial companies to create products and services that benefit providers and consumers alike.

It’s about damn time and it’s great to see that some smart money people are ready to put their money behind some of these initiatives.

Winston-Salem Doc’s Orgasmatron Can’t Get Lift Off

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Following is the true story of a Winston-Salem doctor who has discovered a way to give women an orgasm with the push of a button, but can't get his device to market because of a surprising lack of volunteers and funding:

The doctor who discovered in 2001 that a pain-relief implant could also trigger orgasms is still struggling to raise interest in studying it further.

Stuart Meloy, a surgeon at Piedmont Anesthesia and Pain Consultants in Winston-Salem, North Carolina, was investigating how the device could be used to treat woman who have difficulty achieving orgasm, but we reported in 2003 that volunteers for early tests were proving hard to find.

As of 2014, the massive media interest in the device has not translated into the $6 million that Meloy estimates would be needed to run a full trial…

Meloy stumbled on the idea while performing a routine pain-relief operation. "We implant electrodes into the spine and use electrical pulses to modify the pain signals passing along the nerves," he told New Scientist in 2001. The patient remains conscious during the operation to help the surgeon find the best position for the electrodes. Meloy's breakthrough came one day when he failed to hit the right spot. "I was placing the electrodes and suddenly the woman started exclaiming emphatically," he says. "I asked her what was up and she said, `You're going to have to teach my husband to do that'."

This is an obvious candidate for a Kickstarter campaign.

Health Insurance Cost Calculator

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PuttingPatientsFirst
The National Health Council has created a web-based tool that allows patients figure out which "Obamacare" plans would be most cost effective for them. Unlike the health exchange websites provided by the likes of Blue Cross Blue Shield of North Carolina – which basically just look at the cost variables of premiums, deductibles and coinsurance – the "Putting Patients First" calculator allows people to input information like the number of doctor visits they anticipate having that year, hospitilizations or surgeries they might have and prescriptions they are taking and then gives them guidance on which plans might make the most sense. In other words they don't just take into account the up front costs of plans, but factor in other criteria that might make higher premium plans more sensible.

This is definitely helpful for anyone who's having to shop for his own health insurance. It's tempting to go for the lowest premium plan because it costs the least up front, but if someone has preexisting conditions that causes them to visit the doctor regularly, or take medications on an ongoing basis, then the higher premium plans might make more sense in the long run. The tool provided by NHC is exactly the kind of thing we need so that folks an at least make the best-informed decision possible. As for making our healthcare system more efficient and affordable, well that's a much bigger problem that no web tool will fix.

Mind the Gap

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It will be interesting to see if the Republicans in the states that decided not to expand Medicaid as part of ACA will pay a political price for the outcome. From the Wall Street Journal:

Some GOP-led states are revisiting their decision as complaints pile up over the coverage gap—and its consequences for businesses—in such states as Utah and Florida. The state senate in New Hampshire last week reached a tentative deal to expand Medicaid. In Virginia, newly elected Democratic Gov. Terry McAuliffe hopes to get legislators to reverse his Republican predecessor's stance against expansion.

Lawmakers are also getting a push to boost Medicaid rolls from hospitals that expected a vast new pool of paying customers under the health-care law. Instead, the failure to expand Medicaid coverage by some states not only adds fewer insured patients, it also eliminates the payments hospitals had long received to cover the cost of uninsured people they treat free…

Eugene Steuerle, an Urban Institute economist and former Treasury Department official who served under presidents in both parties, said he couldn't recall a social program that excluded beneficiaries because they earn too little…

Governors in some states that refused to expand Medicaid now say the coverage gap is hard to ignore. "I am not a fan of the Affordable Care Act," Utah Gov. Gary Herbert said in an interview. But, he said, he is working with state legislators on a plan to expand Medicaid after advisers calculated that about 60,000 of his constituents would fall through the gap.

"That is not fair," Mr. Herbert said. "When I say doing nothing is not an option, I'm talking about the 60,000 people in Utah who live below the poverty line and don't have access to health care."

Ripple Effect

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Rex Hammock has 10 Bold Small Business Predictions for 2014 and #9 is dead on:

This is a non-partisan prediction. If you love Obamacare, or hate Obamacare, this prediction doesn’t care. With the bungled launch of the Healthcare.gov online insurance market and the non-stop accusations slinging back and forth between the political parties, it’s been hard for small busines owners to separate fact from vitriol. But here’s one fact: millions of “nonemployee businesses” (a census bureau segment that are independent free lancers, developers, consultants, authors, artisans, etc., who, collectively, account for 4% of all U.S. sales and receipts, but represent the largest number business entities) are now able to obtain healthcare insurance at a competitive price, even if they have pre-existing health condition. Not having access to such insurance has held back lots of employees of lots of big companies from setting up their own shop. Here’s another fact: If a small business has less than 50 employees, the only requirement they have under the Affordable Care Act is to inform employees of the availability of private healthcare insurance sold through marketplaces administered through (depending on the option of a state) federal or state healthcare insurance marketplaces. As Mark Cuban recently told the Wall Street Journal, “As someone who owns chunks of small businesses, the one thing all those companies have in common is [that] buying and providing health care is not a core competency,” he says. “It’s expensive.” By removing the responsibility to provide coverage from these firms and giving it to the government, he says, “You’ve freed up money and time.”

My long-besieged wife has heard me say this for years – if the health care system in the US was fixed there would be an explosion of entrepreneurialism. It's hard to overstate how many people have been tethered to a deadend job because they needed the benefits. Imagine what they would do if that wasn't hanging over their heads and I'm sure that thought is a big motivator in the fight against health care reform.

America – Home of Bizarro Health Care

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Bizarro World is a fictional planet introduced by DC Comics where things are the opposite of what you expect, where Superman isn't super. That's an apt description for the health care system in the United States, which is likely the only place on Earth where this story in the Wall Street Journal would not be shocking:

A Better LA, a decade-old Los Angeles nonprofit, said last week it was signing up 50 low-income people for health plans in California's health-insurance marketplace. The charity, which said it has the blessing of the state agency overseeing the marketplace, will pay $50 to $100 a month to cover the share of the people's premiums not already financed by federal subsidies.

Those 50 people are at the vanguard of a push that could shift the balance between hospitals and insurers across the nation. Nonprofits, including some hospitals, say paying premiums would ensure coverage for people currently uninsured who can't afford even a small monthly payment for health insurance.

But insurers say they can't make a profit unless the health-insurance exchanges created by the Affordable Care Act draw a balanced mix of healthy and sicker customers. The law's rocky start, many insurers fear, has already skewed the mix toward people in worse health. Help from nonprofits or hospitals could speed the arrival of less healthy customers into the exchanges, outpacing the arrival of younger, healthier people who might not cross paths with hospitals…

But such plans have drawn criticism. "It is a conflict of interest for hospitals and drug companies to pay patients' premiums and cost-sharing for the sole purpose of increasing utilization of their services and products," said Karen Ignagni, head of America's Health Insurance Plans, the health-insurance industry's trade group.

Jesus.

The Red State ACA Donut Holes

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North Carolina, like many states controlled by Republicans, opted out of the Medicaid-expansion component of the Affordable Care Act. A New York Times article explores the practical effect it's having on those states' citizens:

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. The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years.

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.”

We're going to be hearing a LOT about the ACA, aka Obamacare, rollout over the next few months. The program opened for enrollment on Tuesday (Oct 1) with a start date set for January and the traffic to the website was heavy enough that it slowed to a crawl.  Like any new program, especially one of this scale, there will be issues but it will be interesting to see if the overall benefits outweigh the problems enough that people will eventually say "Keep the government's hands off my ACA!"

If that does happen it will be with folks like the self-employed who couldn't get on a regular insurance plan that was anywhere near affordable, the employees working for small employers who stopped offering health insurance long ago because they couldn't afford to provide coverage and weren't legally required to, and the folks with preexisting conditions who couldn't get any coverage no matter how much they were willing to spend. Sadly it seems that a huge chunk of the working poor will fall in the "not poor enough" donut hole created by states' refusal to expand Medicaid and won't have access to a program that was most definitely intended for them.

As you can likely tell I'm one of those who is truly hoping that ACA is a step in the right direction for our country. I don't believe it's a silver bullet or that it truly fixes anything, but I'm hoping that it's a step in the direction of a comprehensive, effective reform of our health care system. It's still way too early to see what the end result of ACA is going to be, but quite frankly it would be hard to go backwards from where we've been in the recent past so I'm pretty confident it will be a net benefit for society. On the other hand I seriously doubt it's enough on its own and I hope we continue to look for ways to make sure the neediest have some form of health coverage without bankrupting the rest of us in the process.