Friday, December 23, 2011

A bad month for Virginia's Republican leadership, a good month for the PPACA

(This was originally posted on the National Physicians Alliance Virginia Local Action Network blog site December 18, 2011)

Ever since the Patient Protection and Affordable Care Act (PPACA) healthcare reform law was under debate, Virginia has been at the forefront of its opponents.  In March 2010, before the PPACA was passed and signed into law, Virginia passed a law that would make it illegal for the government to require Virginians to have health insurance.  After the PPACA was signed into law, Virginia Attorney General Ken Cuccinelli sued to overturn the law on the grounds that it violated the United States' Constitution's "commerce cause".  Cuccinelli has continued to be vocal in his opposition to the PPACA's reforms, including writing a legal article earlier this year attacking the law's legal foundation.

At the same time that Cuccinelli has taken an ideologically pure approach to attacking the PPACA, Governor Bob McDonnell has taken a more practical approach to the law.  Although McDonnell has opposed the PPACA's reforms from the moment it was signed into law--and he still opposes the law--he chose to set up a Virginia health reform council to discuss how the law's reforms would affect Virginia as well as to review other options to reform health care in Virginia.

Given their political positions (and possible future plans regarding elected office), this has been a difficult Fall for Cuccinelli and McDonald.  First, in September the 4th Circuit Court of Appeals denied Virginia's lawsuit against the PPACA, stating that the state lacked standing to sue until 2014 at the earliest.  Then, November provided two major political blows to Virginia's state leadership: first, when the United States Supreme Court chose to hear legal challenges to the PPACA, it did not include Virginia's legal challenge among the cases it will review.

Then, at the end of the month, the Health Reform Initiative Advisory Council McDonnell appointed filed its report on how Virginia could respond to the PPACA.  Per the ThinkProgress blog, the report indicated that, "[R]oughly half of the uninsured in Virginia will gain coverage, a little more than 520,000 people, and that 420,000 of them will gain Medicaid coverage. A little over 100,000 Virginians would gain private coverage, and more than 60 percent of them will be in group as opposed to non-group markets…[A]lmost 400,000 of those who gain coverage are in households with incomes less than two times the federal poverty level, though 70,000 of the formerly uninsured earn more than three times poverty today." [emphasis in original blog article]  ThinkProgress also reports that the PPACA is expected to reduce the burden of uninsured medical care by approximately 50%.  McDonnell has not yet indicated whether he will recommend formation of a Virginia-run health insurance exchange, but the commission's report suggests that Virginia should run this exchange/marketplace in order to maintain maximum flexibility.

These two developments make November a month that Virginia's Republican leadership would prefer to forget.  On the one hand, the Supreme Court has let stand the Appeals Court decision that Virginia lacks standing to sue to overturn the PPACA.  On the other hand, the Governor's own health care reform commission has found that the state--and it's citizens--stand to benefit notably from the healthcare reform law, and that the state should move forward to enact it.

These same developments support the positions held by the PPACA's supporters: the first being that the the law is constitutional and that the state cannot exempt Virginia from following federal law, and the second being that he law will have tangible and meaningful benefits for Virginians.

This does not end the fight over the law and its constitutionality, and it does not mean that Virginia's General Assembly (now controlled by Republicans in both houses) will work to enact a healthcare exchange.  However, the law's supporters in Virginia can take heart in these recent events as we work to spread the word about the law's benefits--both for Virginia, and for the nation.

Thursday, December 22, 2011

An unbalanced, unfair system--a case study (N=1)

(This post was originally published on the Occupy Healthcare website, December 22, 2011)


About six weeks ago, while in clinic, I developed pain in my stomach--specifically, in my right upper quadrant, just below the ribs.  I had experienced this a few times before, but this time it seemed more persistent than usual.  Following the rule that physicians make the worst patients, I kept working through it until my nurse told me I looked poorly, and made me see my own primary care doc.  This led to an ultrasound that afternoon, a diagnosis of gallstones with mild acute cholecystitis (inflammation of the gallbladder).  I was in the surgeon's office the next week, and in the OR a week after that.  Fortunately, I had an uncomplicated laparoscopic surgery, and was home within 24 hours.

Things are fine now.  I was back at work within a few days, and was fortunate to have received prompt and effective care.  However, I realize that my experiences are not typical.  I am a physician, and my primary care physician is one of my partners: I was seen the same day because I was part of the "family" of docs with whom I work.  The ultrasound was arranged two hours after my doc saw me.  My surgery was scheduled so quickly in part because someone else's elective procedure was bumped to make room for me.  If I had been an average person calling my primary care doc for belly pain (or presenting to the ER with the same complaints) I doubt this process would have been this efficient.  I was fortunate to have privilege on my side: the privilege of being a healthcare professional, in his own system, knowledgeable about how to make the system work to my advantage.

This highlights the fact that our system is not fair.  Why should I get these special considerations?  Obviously, the easy answer is that I work in the health system where I received my care: much of what happened could be considered a form of professional courtesy where I was extended opportunities not available to patients not employed by the system.  But at the heart of health care, shouldn't this sort of care be available to everyone?  Why should it be so difficult for an average, non-medical person to be treated in just this way?  Some systems (likely some of the top systems in the nation) work to make easy and prompt access available to all comers, but they are the exception to the rule.

We need to fix our system to make sure that meaningful, necessary, and prompt access will be available to all, whenever they need it.  The system needs to be truly patient-centered.

Over the course of the next few weeks, I began to get my explanation of benefits (EOB) forms from my insurance.  These EOB forms highlight how much the hospital charged, what my insurance wrote off (or "discounted"), and what I needed to pay.  I am unable to list the costs here due to our system's insurance contracts, concerns about anti-competitive activities, etc. This is unfortunate, because they expose another area where our system is unfair and unbalanced: if you are uninsured, you will be expected to pay more than if you are insured.  This is because insurance companies negotiate with hospitals on their patients' behalf, and reduce the costs for which patients are responsible.  If you are uninsured, and if you don't know how to seek financial assistance, you pay the full (non-discounted cost) of your medical services.  That cost is usually set high enough to ensure your healthcare provider will get the maximum payment possible from the uninsured face the full burden of this increased cost.

It is not unusual for insurance companies to negotiate deep discounts for medical services.  Discounts of up to 40% are not uncommon.  This means that if a hospital charges $1,000 for a given procedure, the insurance company will only be required to pay $600 of this--because they have negotiated a discount.  This $600 will then be shared by the insurance company and the patient, who might have a required co-pay or deductible.  If you are uninsured, you do not have access to this discount and you are responsible for the full $1,000.  The $1,000 price will be set because this is the level the hospital needs to set in order to recover all available payment.  Different hospitals and healthcare systems will have mechanisms for patient assistance, but this programs exist at the decision of the system, and levels of assistance will vary greatly.

So: if I were uninsured, I would be required to pay more than any insurance company pays...and my increased liability would be the result of other peoples' insurance companies negotiating discounts for their patients.

This is crazy.  Why do we have healthcare systems that charge so much?  Because they feel they need to in order to be able to accommodate insurance companies' demands for discounted services and still turn a profit--if systems charged the actual cost of the procedure, then they would take a "discount" on that amount and end up losing money.  Why do insurance companies expect/demand discounts?  Because it helps justify their existence: if that "discount" were the actual price people were charged, there might be less need for insurance.  Why was my co-pay a small fraction of the total charges?  Because I am fortunate to have really good insurance coverage.

Presumably people who lack health insurance lack it for a reason.  Most people who are uninsured are not doing so because they like to live on the edge or save money, but rather because they cannot afford it.  What rationale is there, then, to charge them 40% more than those who are insured?
If you have ever wondered whether healthcare costs are really that bad and whether they can bankrupt people, here is your answer.  This is a one-person survey (N=1, to use a medical inside joke), so I can't claim these costs are representative of others' experiences.  But, here in Richmond, if I was uninsured and did not have enough in savings to cover the bill, then I would be scrambling to find a way to pay this sudden medical debt.

It is unfair and unjust that people are exposed to back-breaking medical costs for illnesses that are beyond their control.  We can argue about the individual responsibility patients have for diabetes or high blood pressure, though I would suggest it is less than many claim.  But how much individual responsibility is present if someone has gallstones?  Appendicitis?  Retinal detachment?  Breast cancer?  Why does our system penalize the uninsured if they have the bad luck to actually get sick?

Our healthcare system is unfair and unbalanced.  Too many lack meaningful access and struggle to afford the care they can get, while a few have easy access and much lower costs.  We need to fix this broken and dysfunctional system.

Sunday, December 18, 2011

How does the public *really* feel about healthcare reform?

(This post was originally posted on the National Physicians Alliance blog December 18, 2011)


Opponents of the Patient Protection and Affordable Care Act (PPACA) are fond of pointing out how much the public opposes the law.  Now, these voices calling for the law's repeal--with the most prominent voices coming from Republicans (including all the current presidential candidates)--usually overlook one important fact: a substantial portion of opposition to the law come from those who feel the law did not go far enough.  Seems like a fairly convenient lapse.

Having said that, I would like to review the current state of the public support for the law's reforms with the help of the most recent Kaiser Family Foundation tracking poll (pdf).  The overall public view of the law still trends unfavorable, but this seems to reflect in large part the public's unhappiness with the current state of politics in Washington, DC.  The chart on page 3 shows that half the poll's respondents would like the law expanded (32%) or kept in place (18%).  Only 24% would like the law repealed, and only 15% favor repeal and replacement with a Republican alternative.  This suggests that Republican alternatives to the PPACA have not gained traction, and that although many Americans prefer stronger reforms there is a willingness to work with the law as it stands. 

The chart on page 4 shows some reason for the public's confused approach to the law (unfavorable overall view, but support to keep the PPACA in place or strengthen the law): the public is still very confused about the law's reforms, but in terms of what is included in the law, and what isn't.  More than half of those polled believe the law includes a public option (it doesn't), while only slightly more than one-third are aware of the law's reforms to the medical loss ratio (requiring insurance companies to spend money paid in premiums on providing care, as opposed to executive pay, administrative costs, etc) or the law's requirement that screening tests such as mammograms and colonoscopies be provided without any patient co-pays.  This lack of understanding is no thanks to the Republican leadership in Washington or conservative pundits, who are so opposed to the law that they are willing to distort and misinform Americans about the law in their efforts to demonize it.

The reasons for the public's opposition to repeal/replace efforts are likely the law's actual reforms: as shown on page 5, the individual elements of the PPACA's reforms remain broadly popular across the political spectrum.  Republicans polled supported major elements of the PPACA, including closing the Medicare Part D donut hole, providing tax credits to small businesses who provide health insurance for their employees, providing subsidy assistance for individuals unable to afford insurance on their own, providing preventive care without any co-pays or patient cost-sharing, and guaranteeing coverage despite preexisting medical conditions.  In fact, of all the reforms Kaiser polled on, only the individual mandate was viewed unfavorably by the public. 

I suspect that the fact that the individual mandate has been the focus of so much discussion around the PPACA also helps explain why the public is ambivalent about the law: if bulk of the media attention is on the only reform viewed unfavorably, then it is natural that the law will be seen unfavorably.  It would be interesting to see what would happen if politicians and media discussed the law's other (positively-viewed) reforms: would this move public opinion more firmly in favor of the PPACA?  The charts on page 6 reinforce this suspicion: few Americans report hearing  any positive coverage.  Much of the negative coverage appears to come from Congressional and Republican Presidential candidates' debates, reinforcing the perception that the law's political opponents are choosing to attack it as opposed to assessing it fairly.

On page 7, the top chart shows that most Americans see that the greatest benefit from the PPACA's reforms will accrue to low-income Americans, those with preexisting conditions, and those who lack insurance.  This is a good thing, as these are the individuals who have been marginalized by our current system and who are most in need of help.

So: more Americans support the law or wish it were strengthened than support repealing/replacing it, the PPACA's reforms are broadly popular, the law's benefits will largely impact those most in need, and the law's opponents and the media are not discussing the law's reforms and benefits honestly.

I think this information leads to two important conclusions:
  1. The law is a net positive, its reforms are popular, and we need to continue discussing its benefits, protections and reforms and ensure that all Americans understand how it will protect us.
  2. We cannot rely on the media or political leaders to make this information available.  We must continue to be resources to our peers, our patients, and our communities.  We must do this, because otherwise we risk losing these important reforms.