This was published as a Letter to the Editor of the KC Star on May 20, 2017 (http://www.kansascity.com/opinion/letters-to-the-editor/article151640477.html)
Rep. Kevin Yoder used banal clichés such as “patients over
bureaucrats” to defend his vote for the American Health Care Act in his
May 10 commentary. (13A, “American Health Care Act will lower costs,
offer choice”). But this bill would take coverage from Kansans and
strain the state budget.
The AHCA would take nearly
$900 billion from Medicaid over the next decade to pay for tax cuts for
the wealthy. Medicaid covers mostly children, seniors and individuals
with disabilities. They would be hurt when the state is inevitably
forced to make do with less.
The AHCA would remove the
guarantee of coverage for those with pre-existing conditions and allow
states to experiment with other approaches. But the bill does not
adequately fund these alternatives. Some, such as high-risk pools, have
been tried in the past and failed.
There’s a reason no prominent health provider or patient organizations
support this legislation. It hurts patients, providers and communities
and takes us backward. Kansans are counting on Pat Roberts and Jerry
Moran and their colleagues in the Senate to do better.
Monday, May 22, 2017
Tuesday, February 28, 2017
Last Week With John Oliver
I can't do it any better than this: https://www.youtube.com/watch?v=YEGpriv2TAc
Repeal, replace, and your father's thong.
Monday, February 20, 2017
Kansans Deserve Better from KanCare
KanCare is in trouble. The state of Kansas’ Medicaid program, which has been run by three Managed Care Organizations (MCOs) since being privatized in 2013, is beset by administrative and operational problems that threaten the health and safety of its beneficiaries, among the most vulnerable Kansans.
Patients, advocates, health care providers, and others engaged with KanCare have been sounding the alarm for years. But it took a series of letters from federal officials detailing the results of in-depth program audits to make much of the public, the media, and Kansas legislators stand up and take notice.
The federal audits, conducted by the Centers for Medicare and Medicaid Services (CMS), detailed a series of pervasive problems, including: failure to properly oversee the MCOs; inadequate coordination and collaboration between state agencies responsible for the program; lack of engagement and adversarial communications with stakeholders and non-responsiveness to their concerns; failure to engage patients in developing plans of care; inadequate verification of the adequacy of provider networks; absence of a comprehensive system for reporting, tracking, and trending critical incidents; etc.
The findings went on for 13 pages.
The conclusions: “Results of our on-site review confirm that Kansas is substantively out of compliance with Federal statutes and regulations, as well as its Medicaid State Plan. Kansas has failed to administer the KanCare program as required…” and “This noncompliance…places the health, welfare, and safety of KanCare beneficiaries at risk and requires immediate action.”
This bombshell was withheld from legislators and the public by state officials until it was exposed by the news media through open records and freedom of information requests. Reporters subsequently uncovered an even earlier CMS letter, also not revealed to legislators and the public, that detailed serious deficiencies with home and community-based services provided to Kansans with disabilities.
Again, federal officials determined that the state fell short of performance metrics and was out of compliance with federal law. And again, these findings came as no surprise to patients and advocates who had been bringing them to the attention of KanCare officials and state legislators for years.
All this comes on top of the ongoing failure of the state to enroll applicants to KanCare in a timely manner. Despite repeated assurances from program officials over the course of more than a year, the state has continually missed self-imposed deadlines to clear an enrollment backlog numbering in the thousands. In the meantime, Kansans do not receive the care they need, or providers deliver care and never get paid.
Amid denials that the problems really exist and accusations that the audits were politically motivated “parting shots” from the Obama administration, the state has submitted plans of correction to the federal government.
But plans are not enough. What beneficiaries and Kansas taxpayers really need are the things that have been lacking since the beginning of KanCare.
First and foremost, a real commitment to judiciously administer the program, reflected in adequate funding, staffing, and oversight. Second, a welcoming of the sunshine and transparency that is necessary in all government programs to ensure that taxpayers’ funds are being spent wisely and appropriate services are provided to the most vulnerable among us. And finally, an assurance that KanCare beneficiaries and their representatives will be included in all discussions about improving the program.
Kansans deserve better.
This blog was first published by the Health Care Foundation of Greater Kansas City: https://hcfgkc.org/kansans-deserve-better-kancare/
Wednesday, January 18, 2017
What's at stake in a repeal of the ACA? Some things you may not have thought of...
The focus of Affordable Care Act is insurance coverage and that's what has been reported about most since the law was passed. But there's much more to the 900 plus pages of the ACA. It also includes many provisions that most people don't associate with "Obamacare."
Here is a list, in no particular order, of some of the provisions not directly related to insurance coverage that are at risk if the ACA is repealed:
But much more is at risk, as well. The ACA has contributed to making the health care system more affordable, more humane, and more transparent. We shouldn't go backwards on these provisions.
Here is a list, in no particular order, of some of the provisions not directly related to insurance coverage that are at risk if the ACA is repealed:
- Closing the Medicare prescription drug donut hole.
- Calorie counts and nutrition information on chain restaurant menus.
- Privacy rooms and break time at work for nursing mothers.
- Community needs assessments by non-profit hospitals to justify their tax exemptions.
- Online posting of non-profit hospitals' financial assistance policies.
- Ability for women to choose their Ob-Gyn without a referral from another primary care physician.
- The actual cost of insurance coverage appears on large employer W-2 forms.
- Grants to communities to promote healthy lifestyles.
- Grants to small businesses to create workplace wellness programs.
- Grants to states, communities, and nonprofits for disease prevention and health education.
- Expansion of school-based health centers and community clinics.
- Increased rebates to states from pharmaceutical manufacturers.
- Demonstrations and other programs to reduce health care costs, improve quality and delivery of services, and enhance value of care.
- Prohibits rescission, the practice of dropping a patient from insurance coverage when they get sick.
- Programs to detect and deter fraud in Medicare.
- Increased the deduction for qualifying medical expenses from 7.5% to 10% of adjusted gross income for taxpayers under age 65.
- Simplified and streamlined the income determination process for Medicaid eligibility.
- Expanded Medicaid eligibility for foster kids.
- Simplified insurance company explanation of benefits forms and outlawed small print (all print must be at least 12-point font).
- Open reporting by pharmaceutical companies and medical device manufacturers of gifts and other payments to physicians to promote their products.
But much more is at risk, as well. The ACA has contributed to making the health care system more affordable, more humane, and more transparent. We shouldn't go backwards on these provisions.
Wednesday, January 11, 2017
Can a Three-Legged Stool Stand on One Leg?
As Republicans in Congress twist themselves into knots over what to do about the Affordable Care Act (ACA), I thought it would be useful to go back to basics about the pillars of the law. Contrary to the mythology perpetuated by many ACA opponents, it's not just a slapdash collection of requirements designed to boost government authority and crush individual freedom. It actually was constructed in a logical fashion that addresses the reality of how insurance works.
Meet the proverbial "three legged stool."
The first leg is based on one of the most popular provisions of the law, one that even ACA critics have pledged to retain: the prohibition against denying coverage or charging more to those with pre-existing conditions. In insurance jargon this is known as "guaranteed issue."
Before the ACA, companies that provided insurance in the non-group (i.e., non-employer) market were free to pick and choose their customers. Consumers who were considered high risk and likely to incur substantial costs (or sometimes not so substantial) could be denied coverage or charged more. Sometimes they would be offered insurance that excluded coverage of their condition. Illnesses that could block someone from coverage ranged from the serious (e.g., cancer or heart disease) to the commonplace (e.g., acne or asthma).
The ACA's prohibition on discrimination against the sick appeals to people's sense of fairness. But it puts insurance companies at great risk. If an insurer must sell a plan to anyone who applies, what's to stop a consumer from waiting to get sick or injured before buying a policy? Companies that sell homeowners insurance can't survive if they allow customers to buy policies while their houses are on fire. Likewise, health insurers can't afford to sell policies to people who buy them from the back of an ambulance.
So, the second leg of the stool is a mechanism to compel people to buy insurance while they're healthy. In the case of the ACA, it's the individual mandate. It means that with some exceptions, everyone must buy a health insurance policy or pay a fine.
The mandate is the least popular part of the law. Opponents point to it as the provision that most represents government overreach and an attack on personal freedom. Nobody likes the government telling them what to do. But if we want guaranteed issue, we must have healthy people in the insurance risk pool. So the ACA includes a mandate.
But the mandate creates another problem. Health care is expensive, so health insurance is expensive. The mandate requires that nearly everyone purchase a product that very few people can afford.
So, we have the third leg of the stool: financial assistance, in the form of tax credits and subsidies, to help people buy insurance. This financial assistance requires hundreds of millions of federal dollars and is the primary reason for the high cost of the ACA. As a result, it too is unpopular with the public.
Faced with a law that includes both popular and unpopular provisions, President-elect Trump and many in Congress have promised to keep the good parts and get rid of the rest. But that would leave the three-legged stool with only one leg. And even ACA opponents know that such a stool is a couple of legs short.
As a result, every policy proposal that includes guaranteed issue, including those floated by Congressional Republicans, also includes a form of mandate and some level of financial assistance (I'll write about the details of these proposals in a future post). They may not be Obamacare, but they're Obamacare-lite.
Because you can't repeal reality.
Meet the proverbial "three legged stool."
The first leg is based on one of the most popular provisions of the law, one that even ACA critics have pledged to retain: the prohibition against denying coverage or charging more to those with pre-existing conditions. In insurance jargon this is known as "guaranteed issue."
Before the ACA, companies that provided insurance in the non-group (i.e., non-employer) market were free to pick and choose their customers. Consumers who were considered high risk and likely to incur substantial costs (or sometimes not so substantial) could be denied coverage or charged more. Sometimes they would be offered insurance that excluded coverage of their condition. Illnesses that could block someone from coverage ranged from the serious (e.g., cancer or heart disease) to the commonplace (e.g., acne or asthma).
The ACA's prohibition on discrimination against the sick appeals to people's sense of fairness. But it puts insurance companies at great risk. If an insurer must sell a plan to anyone who applies, what's to stop a consumer from waiting to get sick or injured before buying a policy? Companies that sell homeowners insurance can't survive if they allow customers to buy policies while their houses are on fire. Likewise, health insurers can't afford to sell policies to people who buy them from the back of an ambulance.
So, the second leg of the stool is a mechanism to compel people to buy insurance while they're healthy. In the case of the ACA, it's the individual mandate. It means that with some exceptions, everyone must buy a health insurance policy or pay a fine.
The mandate is the least popular part of the law. Opponents point to it as the provision that most represents government overreach and an attack on personal freedom. Nobody likes the government telling them what to do. But if we want guaranteed issue, we must have healthy people in the insurance risk pool. So the ACA includes a mandate.
But the mandate creates another problem. Health care is expensive, so health insurance is expensive. The mandate requires that nearly everyone purchase a product that very few people can afford.
So, we have the third leg of the stool: financial assistance, in the form of tax credits and subsidies, to help people buy insurance. This financial assistance requires hundreds of millions of federal dollars and is the primary reason for the high cost of the ACA. As a result, it too is unpopular with the public.
Faced with a law that includes both popular and unpopular provisions, President-elect Trump and many in Congress have promised to keep the good parts and get rid of the rest. But that would leave the three-legged stool with only one leg. And even ACA opponents know that such a stool is a couple of legs short.
As a result, every policy proposal that includes guaranteed issue, including those floated by Congressional Republicans, also includes a form of mandate and some level of financial assistance (I'll write about the details of these proposals in a future post). They may not be Obamacare, but they're Obamacare-lite.
Because you can't repeal reality.
Tuesday, January 10, 2017
Can't Anybody Here Play This Game?
The State of the State is ignorant and uninformed (and seemingly proud of it).
Kansas Governor Sam Brownback gave his State of the State address tonight. It was filled with the usual platitudes about how well things are going here in Kansas (some might have called them delusions). But what caught my attention was the unforced error that demonstrated just how empty Brownback's rhetoric is and how uninformed this administration is about health policy.
Brownback went through the de rigueur criticisms of the Affordable Care Act (or, more accurately "Obamacare;" Brownback would never use the actual name of the law). He patted himself on the back for defying the law and resisting the expansion of the Medicaid program that would cover 150,000 Kansans. And he demonstrated that he knows very little about the law other than how to repeat inaccurate talking points.
Gov. Brownback derided Obamacare by pointing out the failure of most of the 23 state health insurance exchanges established under the law. The problem is that there have never been 23 state exchanges. In his ignorance, he (or his speechwriters) confused state insurance exchanges with CO-OP insurance plans. While it's true that most of the CO-OPs have failed, these start-up insurance plans are very different animals than the state insurance exchanges (or marketplaces) established under the ACA.
This confusion has been showing up in talking points of ACA opponents for several months. That Brownback would simply repeat this blunder, and that nobody on his staff, including Lt. Governor Colyer, a physician and the administration's presumed health policy expert, caught and corrected the mistake should tell you all you need to know.
This is a Governor and an administration that simply doesn't understand health policy and doesn't seem to care. They're adamantly opposed to the ACA, but they clearly know very little about it.
In 1962, manager Casey Stengel responded to the New York Mets historic ineptitude by asking "Can't anybody here play this game?" The same can be asked of the Brownback administration's knowledge of health policy and the ACA.
Kansas Governor Sam Brownback gave his State of the State address tonight. It was filled with the usual platitudes about how well things are going here in Kansas (some might have called them delusions). But what caught my attention was the unforced error that demonstrated just how empty Brownback's rhetoric is and how uninformed this administration is about health policy.
Brownback went through the de rigueur criticisms of the Affordable Care Act (or, more accurately "Obamacare;" Brownback would never use the actual name of the law). He patted himself on the back for defying the law and resisting the expansion of the Medicaid program that would cover 150,000 Kansans. And he demonstrated that he knows very little about the law other than how to repeat inaccurate talking points.
Gov. Brownback derided Obamacare by pointing out the failure of most of the 23 state health insurance exchanges established under the law. The problem is that there have never been 23 state exchanges. In his ignorance, he (or his speechwriters) confused state insurance exchanges with CO-OP insurance plans. While it's true that most of the CO-OPs have failed, these start-up insurance plans are very different animals than the state insurance exchanges (or marketplaces) established under the ACA.
This confusion has been showing up in talking points of ACA opponents for several months. That Brownback would simply repeat this blunder, and that nobody on his staff, including Lt. Governor Colyer, a physician and the administration's presumed health policy expert, caught and corrected the mistake should tell you all you need to know.
This is a Governor and an administration that simply doesn't understand health policy and doesn't seem to care. They're adamantly opposed to the ACA, but they clearly know very little about it.
In 1962, manager Casey Stengel responded to the New York Mets historic ineptitude by asking "Can't anybody here play this game?" The same can be asked of the Brownback administration's knowledge of health policy and the ACA.
Friday, January 6, 2017
Rural Kansas Needs More Physicians. Who's Going to Pay Them?
Kansas Governor Sam Brownback and Lieutenant Governor Jeff Colyer today announced two new programs to bring more doctors to rural Kansas. As in most rural states, the vast majority of Kansas counties are considered medically underserved, with shortages of doctors, dentists, and other health professionals.
Brownback and Colyer proposed the development of a school of osteopathic medicine in Kansas and a new rural medical residency program. Both are admirable goals that could help to produce more physicians who will practice in rural Kansas communities.
But training more doctors is only part of the solution. These doctors also need to be supported after they complete their training and begin to practice. And here, Brownback and Colyer had little to offer.
The ideas for the osteopathic school and the residency program came from the Lt. Governor's Rural Health Task Force, which met over the course of the last year to assess rural health in Kansas and develop solutions to the workforce shortages, underfinancing, and other problems that have plagued rural areas for decades. The back story, however, is that the task force was established so the administration could show it was doing something about rural health as it resisted an obvious answer - expansion of KanCare, the state's Medicaid program.
Accepting federal funding to expand KanCare would bring hundreds of millions of new health care dollars to rural Kansas to cover the uninsured, and at the same time support struggling local hospitals and other providers and create thousands of new jobs (many for all these new physicians). All discussions of KanCare expansion, however, were shut down by Lt. Gov. Colyer during meetings of the task force. We don't want Obamacare here in Kansas.
So the question remains. How are these new rural Kansas physicians going to be paid? Workforce follows financing, not the other way around (i.e., if the money is there, the doctors will follow). Is a young physician interested in rural practice likely to locate in Kansas, where many of her patients are uninsured and will not be able to pay for services, or look next door to Colorado, which has expanded it's Medicaid program?
Enhanced workforce, innovative delivery models, and other common solutions to rural health problems are great, but they only go so far. At the end of the day, we also need money to pay for these programs. It's right in front of us. But Gov. Brownback and Lt. Gov. Colyer refuse to see it.
Brownback and Colyer proposed the development of a school of osteopathic medicine in Kansas and a new rural medical residency program. Both are admirable goals that could help to produce more physicians who will practice in rural Kansas communities.
But training more doctors is only part of the solution. These doctors also need to be supported after they complete their training and begin to practice. And here, Brownback and Colyer had little to offer.
The ideas for the osteopathic school and the residency program came from the Lt. Governor's Rural Health Task Force, which met over the course of the last year to assess rural health in Kansas and develop solutions to the workforce shortages, underfinancing, and other problems that have plagued rural areas for decades. The back story, however, is that the task force was established so the administration could show it was doing something about rural health as it resisted an obvious answer - expansion of KanCare, the state's Medicaid program.
Accepting federal funding to expand KanCare would bring hundreds of millions of new health care dollars to rural Kansas to cover the uninsured, and at the same time support struggling local hospitals and other providers and create thousands of new jobs (many for all these new physicians). All discussions of KanCare expansion, however, were shut down by Lt. Gov. Colyer during meetings of the task force. We don't want Obamacare here in Kansas.
So the question remains. How are these new rural Kansas physicians going to be paid? Workforce follows financing, not the other way around (i.e., if the money is there, the doctors will follow). Is a young physician interested in rural practice likely to locate in Kansas, where many of her patients are uninsured and will not be able to pay for services, or look next door to Colorado, which has expanded it's Medicaid program?
Enhanced workforce, innovative delivery models, and other common solutions to rural health problems are great, but they only go so far. At the end of the day, we also need money to pay for these programs. It's right in front of us. But Gov. Brownback and Lt. Gov. Colyer refuse to see it.
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