Tuesday, May 16, 2017

Now, it’s the “Undeserving Sick” who don’t deserve health care

It’s been a long-held truism among conservatives that many of those who live in poverty in the United States are undeserving of help, because, well, it’s their own fault.  If they lived more virtuous lifestyles, studied and worked harder, and of course got a good paying job, they wouldn’t be poor. And if they don’t do these things, the thinking goes, then there is no obligation for “virtuous” taxpayers (well-off people with good jobs) to help support them through publicly funded poverty and income-transfer programs. 

(Never mind that people can be poor because there aren’t good schools where they live, or that well-paying factory and other semi-skilled jobs are a thing of the past, or that there isn’t accessible and affordable transportation to where the jobs are located, or that we’ve had decades of income stagnation, or that minimum wages have not kept pace with costs, or that their housing is substandard and their drinking water unsafe, or that labor unions are no longer around to negotiate for better wages and benefits, or that their parents and their parents before them were poor, so they likely will be as well—it’s all their fault, tough luck.   Or that the so-called virtuous and well-off people with good jobs and incomes have benefited from decades of income transfers from the poor to the rich, from living in good and safe communities with good schools and good jobs, from having nice cars to get them around  from their very nice houses to their very nice offices, even if it means sitting in traffic for 45 minutes, or that their parents were well-off people who gave them every advantage to get ahead—it’s all because of their virtue and hard-work, no luck involved). 

As offensive and factually wrong the “undeserving poor” narrative is, there is a variation of it that is now coming to the fore in the health care debate that may be even more offensive and wrong-headed, if that’s even possible, which is that people are sick because of their own bad choices and shouldn’t expect to get taxpayer-funded health care.  This undeserving sick narrative was used by President Trump’s budget director, Mick Mulvaney, to defend the American Health Care Act (AHCA) against late night TV host Jimmy Kimmel’s charge that the AHCA would deny care to children, like his own newborn, born with a congenital heart defect:

“The phrase ‘Jimmy Kimmel test’ was coined by Sen. Bill Cassidy, R-La., after Kimmel delivered a monologue last week in which he shared difficult circumstances about his son's birth and pleaded for politicians to keep Obamacare's guarantee for coverage of people with pre-existing illnesses. Cassidy said he would vote for a healthcare bill only if it met that test, and Mulvaney was asked by a member of the audience at the Light Forum at Stanford University in Palo Alto, Calif., if he agreed with that standard.

"‘I do think it should meet that test,’ Mulvaney said. ‘We have plenty of money to deal with that. We have plenty of money to provide that safety net so that if you get cancer you don't end up broke…that is not the question. The question is, who is responsible for your ordinary healthcare? You or somebody else?’

He said the debate centered on whether others should pay the burden of paying for someone's healthcare.  "That doesn't mean we should take care of the person who sits at home, eats poorly and gets diabetes. Is that the same thing as Jimmy Kimmel's kid? I don't think that it is.’" [Emphasis added in italics].

Then there is Alabama Republican Rep. Mo Brooks, who justified segregating people with preexisting conditions into underfunded “high risk” pools (where they would likely be faced with staggeringly high premiums, deductible and coverage limits) because, well, it’s the not the responsibility of virtuous people to pay for the health care of people with preexisting conditions who brought it on themselves:

“‘My understanding is that it will allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool,’ said Brooks. ‘That helps offset all these costs, thereby reducing the cost to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy. And right now those are the people—who’ve done things the right way—that are seeing their costs skyrocketing.’”

“I cannot adequately describe how much this enraged me” was physician Aaron Carroll’s poignant response to the “blame-the sick-for-being sick” meme, in an essay I'm sick. It's not my fault. And I shouldn't have to pay more for my health insurance he wrote for Vox.com.   Dr. Carroll recounts his own personal experience with ulcerative colitis, a chronic condition he acquired through no fault of his own, and raises important questions about the whole idea of blaming people for being sick:

There is certainly a case to be made that people have some responsibility for their health. But the lines aren’t clear at all. It’s easy to point at smokers and say they’re doing something harmful and are raising costs for all of us. That’s why we can charge smokers more under the ACA. After that…it gets dicey.

Do you start regulating what people eat? What they drink? If you eat dessert and I don’t, why should I have to pay for your health care? Should we charge people more if they drive cars, which is the number one killer of children? I like to ski. That has risks. So does rock climbing. Or playing contact sports. Should we make them stop, or charge them more? What about people who scuba dive?

Should we start charging more or less to people who have different organs, whether that be male and female reproductive organs or a spectrum of other differences in between?

Maybe the Congress member misspoke and my interpretation of his words is off. But maybe not. Maybe he does believe what he said, that people who did things the right way are the ones who are healthy. If that’s the case, then I have a few questions for him.

What did the baby born prematurely, the one with congenital heart disease, or the toddler with sickle cell disease, or the child with autism, or the little girl with leukemia, or the boy with asthma, or the adolescent with juvenile arthritis, or the young woman with lupus, or the young man with testicular cancer, or the new mother with breast cancer, or the new father with inflammatory bowel disease, or the woman with familial heart disease, or the man with early onset Parkinson’s disease, or the retiring woman with Alzheimer’s disease, or the elderly man with lymphoma — what did they do wrong?

Did they lead bad lives?

Take your time answering. I’ll wait.”

I share Dr. Carroll’s outrage, but would take it a step further.  Most of the examples he cites above are people who are born with a disease, or acquire one through their lifetimes that aren’t necessarily associated with any choices they made, like breast cancer or Alzheimer’s.  Or voluntary choices, like playing a contact sport or skiing.  While I agree with him that they should not be charged more for their health care as a result, I am as concerned about people who are sick with conditions that are associated with things they may or may not have done to stay healthy, like having a poor diet that leads to diabetes, or abusing drugs or alcohol (although I am sure that Dr. Carroll too shares this broader concern).

For one thing, the idea that these are “lifestyle choices”, freely made, is not correct; rather, the evidence suggests that they are due to a confluence of hereditary and environmental factors, trauma, poor education, income inequality and poverty, and other social determinants of health, especially for the poor.  As ACP argues in a new position paper, Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs,  “Substance use disorders have been regarded as a moral failing for centuries, a mindset that has helped establish a harmful and persistent stigma affecting how the medical community confronts addiction. We now know more about the nature of addiction and how it affects brain function, which has led to broader acceptance of the concept that substance use disorder is a disease, like diabetes, that can be treated.”  Many people in poorer communities live in “food deserts” where access to healthful diets is simply not available. 

Of course, many well-off people also engage in activities that may contribute to poor health—they may smoke, drive too fast, drink too much, abuse other prescription and illicit drugs, not exercise regularly,  and favor fast food over healthful diets.  The difference is that they can usually afford good health care insurance and access to the best physicians and hospitals when things go south.  Not so with the poor.

So the narrative that the undeserving sick don’t merit our help is really cut from the same cloth as the undeserving poor narrative: that some people, because they are sick and they are poor (which often go hand-in-hand), don’t deserve compassion, and certainly don’t merit financial help from those who are better off, money- or health-wise.  

Growing up, I was taught that “There but for the grace of God go I.”   We should approach health care policy in the same spirit, with the understanding that any one of us could  be poor or sick or both.  We don’t have the  right to selectively judge who “deserves” health care, and to suggest otherwise is an outrage.

Today's question: what is your reaction to the undeserving sick narrative? 

Thursday, April 27, 2017

How to make a terrible, horrible, no good, very bad bill even worse

It’s BACK—the terrible, horrible, no good, very bad bill to repeal and replace the Affordable Care Act (ACA).  Last month, I blogged about how the bill, called the American Health Care Act, was the worst legislation for health care of any that I have seen in 38 years of advocacy for doctors and patients.  While it was good that this bill was pulled by House Speaker Paul Ryan on March 24 due to a lack of support among Republican lawmakers, he may bring it back for a vote as early as this Friday, April 28. Only, this time, believe it or not, with changes designed to win support from hard-right conservatives that make the original bill even worse for patients.  I guess we will have to call this version the even more terrible, horrible, no good, very bad, bill for patient care. 

On Tuesday, ACP was able to confirm that the House GOP leadership and Trump administration were close to reaching a deal with 20 or so of the most conservative lawmakers, the self-described “Freedom Caucus.” Unfortunately, as explained in a detailed letter that we sent to all members of Congress later that day, the proposed “compromise”  would gut existing law protections for people with preexisting medical conditions and requirements that insurers cover essential benefits by allowing states to opt-out of such requirements.  And today, we joined in a coalition letter with 5 other physician membership organizations, collectively representing over 560,000 physician and medical student members, expressing our combined opposition to the “compromise” bill. 

Let me be clear why the compromise makes a terrible bill even worse:

It would allow states to obtain “waivers” to opt-out of the ACA’s prohibition on insurers charging more to people with preexisting conditions.  That’s right, the “compromise” would return us to the pre-ACA days when states often allowed insurers to charge whatever they wanted to people with conditions like asthma, diabetes or dozens of other conditions that were considered to be “declinable” by insurers.  As ACP explained in its letter to Congress, “Before the ACA, insurance plans sold in the individual insurance market in all but five states typically maintained lists of so-called "declinable" medical conditions—including asthma, diabetes, arthritis, obesity, stroke, or pregnancy, or having been diagnosed with cancer in the past 10 years. Even if a revised bill would not explicitly repeal the current law’s guaranteed-issue requirement—which requires insurers to offer coverage to persons with pre-existing conditions like these—guaranteed issue without community rating allows insurers to charge as much as they believe a patient’s treatment will cost. The result would be that many patients with pre-existing conditions would be offered coverage that costs them thousands of dollars more for the care that they need, and in the case of patients with expensive conditions like cancer, even hundreds of thousands more.”

The bill does say that states would have to set up or participate in high risk pools for people with preexisting conditions in order to be approved for a waiver.  But we know from experience that underfunded high-risk pools, which were common before the ACA, typically had very high premiums and deductibles, long wait lists, and limited benefits, making the coverage unaffordable for those who need it most. And the amended AHCA does not provide anywhere near the amount of money that could make high risk pools viable, and does not set any standards or funding levels that states must meet to ensure that coverage under the pools are affordable and benefits are adequate.

It would allow states to obtain “waivers” to opt-out of the ACA’s requirement that all insurers cover 10 categories of essential medical care services.   We know from the pre-ACA days what this could mean for patients: in many states, insurers will once again be allowed to decline coverage of needed benefits like physician and hospital visits, maternity care and contraception, mental health and substance use disorder treatments, preventive services, and prescription drugs. “Prior to passage of the ACA, 62% of individual market enrollees did not have coverage of maternity services, 34% did not have substance-use disorder services, 18% did not have mental-health services and 9% did not have coverage for prescription drugs,” ACP wrote to Congress.  “A recent independent analysis found that the AHCA’s repeal of current law required benefits would result in patients on average paying $1,952 more for cancer drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient admission for mental health; $4,555 for inpatient admission for substance use treatment; and $8,501 for maternity care. Such increased costs would make it practically impossible for many patients to avail themselves of the care they need. The result will be delays in getting treatment until their illnesses present at a more advanced, less treatable, and more expensive stage, or not keeping up with life-saving medications prescribed by their physicians.”

And repeal of the essential benefit requirements would mean that insurers would no longer be required to cover substance use disorder treatments.  “Allowing states to eliminate the [Essential Health Benefits] will threaten our nation’s fight against the opioid epidemic,” ACP told Congress. “A study concluded that with repeal of the ACA, ‘approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage.’”

And the “compromise” would even gut the ACA’s ban on insurers imposing annual or lifetime limits on coverage, because under current law insurers are only banned from imposing dollar limits on services that are included in the mandatory essential health benefits package.   If a state, for example, decided that chemotherapy was no longer an essential benefit in your state, there would be nothing stopping insurers from putting a $100,000 lifetime dollar limit (if even that much) on coverage for your cancer treatment.  After that, sorry, you’d be on your own, forcing choices like lose your house, or lose your health care, you decide. 

The bill’s gutting of prohibition on annual and lifetime coverage limits would affect not only people who get coverage  through health plans sold through the ACA’s marketplaces, but also the vast majority of people who get coverage from their employer, as analyst Tim Jost explains today in a Health Affairs blog.  “Since the ACA’s prohibitions of lifetime and annual limits and cap on out-of-pocket expenditures also only apply to essential health benefits, states granted a waiver would be able to define these protections as well. The changes to the lifetime and annual limits and to the out-of-pocket caps could potentially apply as well to large group and self-insured employer plans.” Jost also observes that although the amendment says that “’nothing in this Act shall be construed as permitting insurers to limit access to health coverage for individuals with preexisting conditions,” but that is precisely what health status underwriting [which could return in states that obtain waivers] does. Health status underwriting could effectively make coverage completely unaffordable to people with preexisting conditions.”  

And remember, even before the proposed compromise made the AHCA even worse, the original bill was unacceptable because it cut, capped, and block granted Medicaid, ended funding for Medicaid expansion, and replaced the ACA’s income-based premium and cost-sharing subsidies with regressive age-based ones that would make premiums and deductibles unaffordable for older and sicker patients, resulting in 24 million more uninsured persons, according to the Congressional Budget Office.

So if politicians tell you that people with preexisting conditions are protected by the amended AHCA, don’t believe them.  They are either lying, or more charitably, don’t understand what is being proposed.  And if they say premiums will be lower, keep in mind that while this might be true for some young and healthy people, it would be at the expense of making health care unaffordable for older and sicker patients.

Yet Speaker Ryan is counting votes right now in the hope of bringing the bill to a vote by Friday so it can be passed by the House of Representatives during President Trump’s first 100 days.

Don’t let Speaker Ryan and President Trump bring their even more terrible, horrible, no good, very bad bill back from the dead.  Call your member of Congress today, especially if he or she is a moderate Republican or one in a competitive district, at 202-224-3121 and help us put a nail in the AHCA’s coffin.  (And even if you have called before, they need to hear from you again).  Don't put this off, tomorrow could be too late.  Patients are depending on you.

Today’s question: did you make your call to Congress to urge them to vote no on the even more terrible, horrible, no good, very bad AHCA!


Thursday, March 23, 2017

In 38 years advocating for doctors, patients I've never seen a bill that will do more harm to health

When I tweeted this on Monday morning about the House GOP bill to “repeal and replace” the Affordable Care Act, I had no idea that it would result in me appearing on MSNBC’s Last Word with Lawrence O’Donnell or that it and my other tweets would be referenced by NBC News, a New York Times editorial, or for that matter, a retweet from singer-songwriter John Legend!

video

I mention all of this not for reasons of self-promotion, but to share with readers of this blog why I firmly believe that the GOP “repeal and replace” bill, expected to be voted on later today in the House of Representatives, will, if enacted, do more harm to health than any I have seen in nearly four decades of advocacy on behalf of internal medicine.

Here are my reasons:

First, never before I have I seen legislation advanced to the floor of either the House or Senate that would take health insurance coverage and consumer protections away from tens of millions of Americans; not once, not ever.  In fact, I doubt there is any time in history where Congress is being asked to vote to take health care away from so many.  Instead, the trajectory has been to expand health insurance coverage, not take it away: from enactment of Medicare and Medicaid in 1965, to the bipartisan Children’s Health Insurance Program becoming law in 1997; to creation of the Medicare Part D prescription drug program, signed into law by President George W. Bush on December 8, 2003; to the Affordable Care Act becoming law on March 23, 2010, exactly seven years ago.   Up until now, no President of either political party, and no Congress, has championed a measure that would result in a wholesale rollback of coverage and access to care for people who have gained it under prior laws.

Second, and most importantly, the American Health Care Act would do incalculable harm to the health of tens of millions of Americans.  This is not a political assessment, it’s based on what the bill actually proposes to do and evidence (from independent and non-partisan researchers) on how patients will be affected.

  • It makes radical changes to the Medicaid program’s structure and financing; the non-partisan Congressional Budget Office (CBO) estimates that 14 million low-income kids, adolescents and adults will lose their Medicaid coverage as a result. By putting a per-enrollee cap on the federal contribution to Medicaid, or offering states a “block grant” option (both of which means that the states are left having to make up any difference between the federal contribution and the costs of providing benefits to Medical enrollees), and phasing out the higher federal contribution for states that have expanded Medicaid to persons with incomes up to 138% of the Federal Poverty Level (FPL), the CBO found that the total federal contribution would be cut by $890 billion over the next decade, a whopping 25% cut!  Because most states are required by law to balance their budgets, a reduction in and/or a cap on federal matching funds will necessarily require them to greatly reduce benefits and eligibility and/or impose higher cost-sharing for Medicaid enrollees, most of whom cannot afford to pay more out of pocket—or alternatively and concurrently, reduce payments to physicians and hospitals (including rural hospitals that may be forced to close), enact harmful cuts to other state programs or raise taxes.  The phase-out of funding for Medicaid expansion, and the retroactive (to March 1) freeze on providing enhanced funding to any additional states that might have expanded the program, will eliminate one of the most effective programs ever in driving down the uninsured rate to historic lows.  Some Republicans surely recognize the importance of preserving funding for Medicaid expansion in their states: just yesterday, Michigan (GOP) Governor Rick Snyder wrote to the state’s congressional delegation urging them to vote against the AHCA.

  • It would reward states with higher federal funding if they impose punitive work or job search requirements on certain Medicaid enrollees.  If states adopt such requirements, current Medicaid enrollees (or those seeking to enroll) would not be eligible for the program if they are unable to prove to state Medicaid officials they have a job or are in job-training, or that they meet the conditions specified in the statute to be exempted from the requirement.  Medicaid is not a cash assistance or job training program; it is a health insurance program and eligibility should not be contingent on whether or not an individual is employed or looking for work.  While an estimated 80% of Medicaid enrollees are working, or are in working families, there are some who are unable to be employed because they have behavioral and mental health conditions, suffer from substance use disorders, are caregivers for family members, do not have the skills required to fill available positions, or there simply are no suitable jobs available to them.  Skills- or interview-training initiatives, if implemented for the Medicaid population, should be voluntary, not mandatory.  ACP’s Ethics, Professionalism and Human Rights Committee has stated that it is contrary to the medical profession’s commitment to patient advocacy to accept punitive measures, such as work requirements, that would deny access to coverage for people who need it.

  • Although not final, it’s been widely reported that Speaker of the House Paul Ryan will add to the version of the bill being voted on today a repeal of the ACA requirement that private insurers in the individual insurance market must cover 10 categories of essential services including physician and hospital visits, prescription drugs, cancer screening tests and other preventive services, mental health treatment, and many other services.  Even before this change, the AHCA repeals the requirement that Medicaid programs cover such benefits.  Any reduction in Medicaid coverage for substance use disorder treatments would exacerbate the grave opioid misuse epidemic that is devastating individuals, families and communities across the country.  Women’s access to health care would particularly be at risk, because the AHCA eliminates required coverage for childbirth and maternity and for contraception. 

  • Prior to passage of the ACA, 62% of individual market enrollees did not have coverage of maternity services, 34% did not have substance use disorder services, 18% did not have mental health services and 9% did not have coverage for prescription drugs. A recent independent analysis found that the AHCA’s repeal of current law required benefits would result in patients on average paying $1,952 for cancer drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient admission for mental health; $4,555 for inpatient admission for substance use treatment; and $8,501 for maternity care.  Such increased costs would make it practically impossible for many patients to avail themselves of the care they need.  The result will be delays in getting treatment until their illnesses present at a more advanced, less treatable, and more expensive stage, or not keeping up with life-saving medications prescribed by their physicians.

  • The AHCA’s regressive age-based tax credits, combined with changes that will allow insurers to charge older people much higher premiums than allowed under current law, will make coverage unaffordable for poorer, sicker, and older persons, as well as for persons who live in high health care cost regions. The AHCA replaces the ACA’s income-based and cost-sharing subsidies with age-based advance refundable tax credits worth only $2,000 to $4,000 for an individual.  These subsidies will be inadequate for most people to be able to buy affordable coverage, and would especially put vulnerable persons at risk, including low-income families and children, children and adults with special health care needs, and older persons with chronic illnesses who are not yet eligible for Medicare.  Indeed, a study based on the value of these tax credits determined that only 34% of a beneficiary’s medical costs would be covered. This is much less than the ACA, which ranges from about 60% to 94%, depending on the level of plan. By repealing the current law cost-sharing subsidies for persons with incomes up to 250% of the FPL, the AHCA would make out-of-pocket costs too high, and health care unaffordable, for many poorer patients. Without cost-sharing reductions, enrollees will be exposed to higher deductibles, co-payments and other cost sharing, potentially discouraging patients with limited financial means from seeking medically necessary care.  The AHCA also establishes a set amount for the tax credits per individual, without any adjustment for differences in the cost of care by locality.  This will result in the tax credits being insufficient to make coverage affordable for patients in high health care cost areas, especially older, poorer  and sicker ones.

  • The AHCA discriminates in the awarding of federal grant funds and/or Medicaid and Children’s Health Insurance Program funding to women’s health clinics that are qualified under existing federal law for the provision of evidence‐based services including, but not limited to, provision of contraception, preventive health screenings, sexually transmitted infection testing and treatment, vaccines, counseling, rehabilitation, and referrals.  This provision, targeted at Planned Parenthood, reduces women’s access to evidence‐based services offered through the clinics including, but not limited to, provision of contraception, preventive health screenings, sexually transmitted infection testing and treatment, vaccines, counseling, rehabilitation, and referrals.

  • The AHCA eliminates funding for Prevention and Public Health Fund, which provides billions in dollars to the Centers for Disease Control and Prevention to prevent and control the spread of infectious diseases like flu, Zika, and epidemics and pandemics.  

I could go on and on with other reasons why Congress should vote down the American Health Care Act but I think (hope) you get the point: this bill is a monstrous and unprecedented assault on coverage and access to care for many millions of Americans, and especially, the most vulnerable of our neighbors: those who are older, poorer and sicker.  It is by far the worst piece of health-related legislation I have seen since I first started working for the American Society of Internal Medicine (which merged with ACP in 1998) when Jimmy Carter was president.  It must be stopped, now.

Today’s questions: What do you think of the AHCA, and what are you doing about it?