Separate is Not Equal in Education. Or Health Care.

We conclude that, in the field of public education, the doctrine of "separate but equal" has no place.  Separate educational facilities are inherently unequal.

- U.S. Supreme Court in Brown v. Board of Education, May 17, 1954

My office sits about a mile from the Monroe School, an historic, if not well known, place.  Monroe was once one of four segregated African-American elementary schools in Topeka.  Today, it is the location of the Brown v. Board of Education National Historic Site, commemorating the landmark U.S. Supreme Court decision to end racial segregation in public schools. 

As all schoolchildren are now taught, a unanimous court ruled in Brown v. Board that separate is inherently unequal.  Unfortunately, many adults – some who have seats in Congress and the state legislature – have still not learned this lesson. 

The American Health Care Act (AHCA), which has passed the U.S. House and is now being rushed through the Senate, proposes to segregate the sick from the healthy in insurance pools, creating separate and inevitably unequal coverage. 

As we strive to develop a health care system that works for all of us, we should not forget the lessons of Brown v. Board.

Prior to the Affordable Care Act (ACA), individuals with pre-existing conditions could have a difficult time finding health insurance.  Some would have to pay more or buy plans that excluded coverage of their condition.  If they couldn’t afford it, they would often go uninsured. 

Others were locked out altogether.  People who suffered from cancer or other serious conditions could not buy insurance at any price.  For them, many states – including Kansas – created special insurance programs, called high-risk pools, that segregated the sick from the well.

The idea was that sick people drive up costs for everyone else.  By segregating them, insurance premiums for the healthy would be lower. 

The problem was that concentrating those with pre-existing conditions – the people who arguably need health care the most – created insurance ghettos that were enormously expensive.  State subsidies were invariably inadequate and the result was very high premiums and deductibles and low annual coverage limits and lifetime caps.  Few of the uninsured could afford to participate. 

Separate was not equal.

The ACA ended high-risk pools.  It requires insurers to sell policies to everyone and prohibits charging the sick more than the healthy.  As a result, thousands of Kansans with pre-existing conditions have been able to find coverage.  Many now receive treatment for long-standing health issues.  Others are able to receive primary and preventive care, perhaps for the first time.  Lives have been improved.  Some have been saved.

Unfortunately, the AHCA will unravel this coverage guarantee and bring back health care apartheid.  It will allow states to waive protections for people with pre-existing conditions, as long as alternatives, such as high-risk pools, are established.  Predictably, proposed funding for these pools is grossly inadequate. 

You don’t need to be a health care expert – or a Supreme Court justice – to know how this will turn out.  Sky-high premiums and deductibles will make high-risk pools unaffordable for many of the people who are segregated from the insurance market.  They’ll no longer get the care they need.  Their health and well-being will suffer.  Some will die.  We’ve already lived this history.

By overturning the legal basis for segregation, the legacy of Brown v. Board extended far beyond public schools.  It provided energy to the voting rights and civil rights movements.  It inspired the Americans with Disabilities Act.  It continues to inform and encourage us as we work to create a society that offers equal accommodation and equal opportunity for all. 

A visit to the Monroe School quickly demonstrates why it would be unthinkable to bring back segregation in public schools.  It should be equally unthinkable in health care.

This was first published in the Topeka Capital-Journal on June 20, 2017

The AHCA and KanCare: Plan will harm vulnerable Kansans, state budget

The American Health Care Act (AHCA), passed by the U.S. House of Representatives on May 4, 2017, will profoundly change Kansas’ Medicaid program, KanCare. The bill is currently under fast track consideration in the U.S. Senate.

For more than 50 years, Medicaid has been a health coverage safety net to the most vulnerable Americans – mostly low-income children, seniors, and individuals with disabilities. Costs are shared by the federal government and the state government and are based on the needs of patients. Three-quarters of KanCare enrollees are children and families and 70 percent of the program’s dollars are spent on care of seniors and Kansans with disabilities.

The AHCA threatens to change that. It would impose caps on federal spending, shifting the risk for covering growing costs to the state. The federal contribution would increase less each year than the actual cost of care, squeezing the state budget more and more over time. The state will lose the ability to respond aggressively to health crises, cover new breakthrough drugs, and meet other needs that require flexibility and funding.

Nationwide, the AHCA will reduce expected federal spending on Medicaid by $830 billion over the next decade.  At least $1 billion of this cut – or about $100 million per year – will come from Kansas. The state will then face an inevitable choice – raise taxes or shift dollars from other programs to make up the difference. Or most likely, cut eligibility and benefits.

That means fewer kids with health coverage. Pregnant women who can’t get prenatal care. Less funding for seniors in nursing homes. And cuts in services to Kansans with disabilities. Because Medicaid covers the most vulnerable Kansans with the greatest needs, they are the ones who will be hurt when the state is forced to make do with less. In turn, there will be increased pressure on local communities and health care providers to fill in the gaps.

These Medicaid cuts won’t save much money. Instead, they’ll be used to deliver tax cuts to the wealthiest Americans. Tax cuts funded on the backs of low-income children and others who rely on Medicaid.  

The AHCA will harm KanCare and the Kansans who rely on it in other ways, as well. It will create bureaucratic barriers to enrollment and coverage. It will lock in the state’s relatively low program financing. And it specifically prohibits the state of Kansas from expanding KanCare, ensuring that Kansas taxpayers will continue to pay the tab for expansions in 31 other states without being able to bring our federal tax dollars back home.

The AHCA is being rushed through the Senate with no plans to hold hearings or gather testimony and public input. Kansans and all Americans deserve better.


This blog entry was originally posted by the Health Care Foundation of Greater Kansas City:  https://hcfgkc.org/kansans-deserve-better-ahca-offers/

Health Care Truth

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.

Read more here: http://www.kansascity.com/opinion/letters-to-the-editor/article151640477.html#storylink=cpy

Read more here: http://www.kansascity.com/opinion/letters-to-the-editor/article151640477.html#storylink=cpy

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.

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/

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:

• 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.

Many reports, blogs, and other analyses are being written about the direct impact that repeal of the ACA may have on insurance coverage (I may write about that myself).  Popular provisions like prohibiting insurers from denying coverage to those with pre-existing conditions and allowing dependents up to age 26 to remain on parents' insurance policies are at risk.

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.

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.