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Daily Archives: November 17th, 2017

What States Can Learn From One Another on Health Care


By Dhruv Khullar

Nov. 16, 2017
Some have made large improvements in certain areas. What have they done to get better?
We know that where you live matters: There are huge disparities in health and costs across the country.
The uninsured rate in Texas is six times higher than in Massachusetts. You’re four times more likely to be readmitted to the hospital in Maryland or New Jersey than in Hawaii. One-third of low-income adults in Texas forgo medical care because of cost, but only 9 percent in Vermont do. Alaska spends twice as much on health care per person as Utah does.
If all states were to improve to the level of top performers, we’d see gains across the country: 20 million more people insured and 14 million fewer skipping care because of cost; 12 million more adults screened for cancer and 500,000 more children vaccinated; 124,000 fewer hospital readmission and 90,000 fewer premature deaths.
How can we get there? Although it’s important to learn from states at the top, it’s perhaps more instructive to see what states with large improvements are doing, or have done, to get better.
Health care is perhaps the area most consistently recognized as ripe for state-based policy innovation, in keeping with the ideal of states as laboratories of democracy. Nearly all recent health reform proposals, especially from Republicans, focus on granting states greater flexibility to design and manage their health systems.
Seema Verma, the director of the Centers for Medicare and Medicaid Services, has promised to give states an “unprecedented level of flexibility” to devise their Medicaid programs, including the option to impose work requirements. Senators Lamar Alexander and Patty Murray have put forth a plan to make it easier for states to get federal waivers to reshape their health systems.
There are good reasons to pursue such a strategy. States have markedly different populations with varying needs, resources and cultures — and systems that work well in one state may not work well in another. But what do we know about how states use health policy freedom?
Stabilizing Marketplaces and Lowering Premiums
One fundamental challenge in the Obamacare insurance marketplaces is that a few very sick patients can increase premiums for everyone, especially in states with small individual markets. To address this problem, Alaska applied for a Section 1332 waiver to expand its reinsurance program, which brings in federal funds to cover costs for people with particularly expensive conditions.
Alaska thus “reinsures” its insurers for high-cost patients, and prevents those costs from being passed on to healthier people. Because premiums don’t rise as steeply, the federal government pays out less in premium subsidies — keeping the program deficit-neutral. The waiver is expected to lower premiums by 20 percent in 2018, and insure nearly 1,500 additional Alaskans.
Minnesota recently received a similar waiver, and several other states are exploring their own reinsurance programs.
Tackling Health Care Prices
Prices for health care services vary widely across the United States with little relation to quality. The price of an M.R.I., for example, is 12 times higher in the most expensive markets than in the least expensive ones, and can vary by a factor of nine even within the same area.
In 2011, the California Public Employees’ Retirement System (Calpers) changed how it paid for common procedures, a move that drastically reduced prices and saved the state millions. Before the initiative, prices for knee and hip replacements ranged from $15,000 to $100,000 with no difference in quality. That’s when Calpers introduced reference pricing — meaning it set an upper limit on how much it would pay for a given procedure, and patients would pay the rest.
For example, Calpers would pay up to $30,000 for knee or hip surgery at 41 acceptable-quality hospitals, defined by measures like infection and readmission rates. Patients could still go wherever they wanted, but would have to cover the additional cost of a high-priced hospital.
The results were impressive. Referrals to lower-priced hospitals increased by nearly 20 percent. The average price of the procedures dropped to about $26,000 from $35,000 — driven primarily by hospitals not initially included, and hoping to compete. There was no change in how well patients did or how much they paid out of pocket. California saved $5.5 million on knee and hip operations in the first two years. It also saved $7 million on colonoscopies, $1.3 million on cataract operations, and $2.3 million on arthroscopies. Prices fell by about 20 percent for each procedure.
Reducing Infant Mortality
The United States has one of the highest infant mortality rates among wealthy nations — and does worse than even many poorer countries like Cuba and Belarus. Mississippi’s infant mortality rate puts it on par with Botswana and Bahrain. The infant mortality rate in the U.S. is nearly three times higher than in Finland or Japan.
Georgia, which recently had one of the highest infant mortality rates in the country, has had perhaps the largest improvement in the past decade. The state has taken a three-pronged approach to the problem.
First, it began a Safe to Sleep campaign to educate parents and health care providers about putting babies on their backs to sleep, in a separate bed, free of loose bedding or soft objects. The Department of Public Health developed “hot-spot” maps to focus the campaign on six areas with the highest infant mortality.
Second, based on research suggesting that short intervals between births lead to poorer outcomes, Georgia introduced a program to expand access to long-acting reversible contraception (LARC). The state received a Medicaid waiver so it could be reimbursed for LARC insertion immediately after births in the hospital, overcoming a major barrier to broader LARC use among low-income women.
Finally, Georgia aimed to reduce early elective deliveries, which increase the risk of feeding, breathing and developmental problems, by changing its reimbursement policy so that non-medically necessary inductions and cesarean sections before 39 weeks of gestation would no longer be covered.
Back to Basics
There’s much to learn from state-level innovations, but there are also general principles that apply across states. High-performing states have competitive and accessible insurance markets; strategies for data-sharing and health information technology expansion; more value-based purchasing; greater emphasis on primary care; and strong partnerships with community organizations. They also expand Medicaid.
It’s also important to note that many state-level policy changes do not require federal approval, and that states don’t always use their flexibility to improve population health. Proposals that allow states to weaken protections for those with pre-existing conditions, for example, could harm patients and their ability to access care.
Greater flexibility for states is an opportunity, not a solution. The enormous variation in quality, costs and access across the nation should remind us that experiments succeed and experiments fail. Having laboratories is probably a good thing. But it depends on what they cook up.

Dhruv Khullar, M.D., M.P.P., is a physician at New York-Presbyterian Hospital and a researcher at the Weill Cornell Department of Healthcare Policy and Research. Follow him on Twitter: @DhruvKhullar.

Correction: November 15, 2017
An earlier version of this article misstated the comparison between infant mortality in the United States and two other nations. The infant mortality rate in America is nearly three times higher than in Finland or Japan. Babies born in Finland and Japan are not three times as likely to see their first birthday as those born in the United States.

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The “ME” adminstration


The current administration appears to be all about themselves. The cabinet has several members who can’t pass up a photo op that garners attention on them (and theirs). Considering our TIC there should be no surprise there. Mr. TOTUS uses tweets as attention getters while rolling back rules and regulations on importation of exotic protected species with no regard to the ultimate consequences. There is the push for so called “Tax Reform” which will be accomplished by making changes in the ACA which will ultimately affect the health care of millions yet with this knowledge the neer do wells are still trying to move forward while espousing how good it will be for us. All of this is geared toward next years elections and the unrealistic campaign promises made by them. The wake up call was sounded long ago and many of us missed it or ignored it, the awakening will be rude and possibly devastating. Since TOTUS was elected hate , racism and sexual assault have seemingly become OK. This development has been ignored by our legislators or perhaps their response will wait until after 2018 elections when it’s too late. Now we have the potential gutting of the ACA which with all of it’s faults is working, this action is just to push along a tax reform that will harm as many people as the loss of healthcare. All of these actions are laying the groundwork for 2018 election and maintaining the status quo which is not in favor of the often cited “American people”. How can these folks speak for us when they never ask us? Their information appears to come from select groups rather than a true representation of  the cited “American People”. If you truly believe that your elected official represents you then perhaps you haven’t paid attention to them which they don’t mind at all. As I have stated before “Hitler used the same tactic to convince Germans that Jews and non Aryan’s were the reasons Germany was in such poor shape and not the previous war. Telling the same lies over and over convinced many Germans he was right until the end when Germany was devastated by allied forces and  Hitler took the easy way out. While this administration may not be as radical, they are just as devious.

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What Does the Tax Bill Do for Low-Income Workers?


Steven Greenhouse
November 13, 2017

Imagine a low-wage worker, perhaps one who voted for Donald Trump
Basically, nothing. But will that be sufficient to peel away voters?
This worker is getting nothing from the huge Trump-GOP tax plan. This worker won’t benefit from phasing out the estate tax. Nor will this worker gain from eliminating the Alternate Minimum Tax or from reducing the business pass-through tax from 39.6 percent to 25 percent.  And because working class people can’t afford to invest in stocks or mutual funds, they won’t be among the lucky folks who receive bigger dividend checks after the corporate income tax is cut from 35 percent to 20 percent.
This worker toils hard day after day, juggling two kids and a job that pays just above the minimum wage. She was understandably thrilled to hear that Ivanka Trump was pushing to increase the child tax credit. It’s slated to go to $1,600 per family from the current maximum of $1,000. But this larger child tax credit won’t help her at all even as it is extended for the first time to families making $150,000 to $300,000 a year. The House GOP seems to have gone out of its way to make sure that people like her don’t benefit at all from this expanded credit—they’re refusing to make more than the current $1,000 maximum refundable.
Many people say this worker doesn’t deserve to be helped by the Trump-GOP tax plan because she doesn’t pay any federal income tax. But please don’t forget, despite their meager income, low-wage workers do pay several highly regressive taxes: the federal Social Security tax, the federal Medicare tax, as well as local sales taxes.
And many wealthier Americans mock this worker as a taker, as one of the 46 percent of Americans to be looked down upon. But she feels that she gives and gives and is not a taker, because day after day, she is a loyal worker, giving her all on the job, all for paltry pay. She would be happy to contribute more in taxes if only she were paid more.
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Twenty-five million households—around one fifth of all households in the United States—have annual income of less than $23,000.
This worker feels it’s not fair that so many Americans, especially richer Americans, will benefit from the huge tax cuts while so many low-wage workers will be left out in the cold—and receive nothing from this budget-busting cornucopia. She fears that because the tax cuts will add at least $1.5 trillion to the national debt, those cuts and the resulting higher deficits and debt will ultimately push Congress to chop Medicaid and other programs that help keep low-income Americans like her out of misery. Twenty-five million households—around one fifth of all households in the United States—have annual income of less than $23,000.
This worker feels that the architects of the tax plan are punishing her—punishing her for having poor parents and for having the misfortune of going to a low-performing, segregated schools in a high-poverty neighborhood. She feels she is also being punished for not being in the small minority of students from her high school class who went to college.
This worker was hoping that President Trump and Congress would follow in Ronald Reagan’s footsteps and increase funding for the Earned Income Tax Credit (EITC). But no luck there. President Reagan had championed the EITC as a great program for hard-working, low-income Americans.
This worker wants to make America Great Again for people like her. She wishes that she could donate millions of dollars to political candidates, political action committees and dark money groups so that politicians would pay attention to workers like her—instead of to millionaire and billionaire donors who complain about corporate taxes, the estate tax and the alternative minimum tax.
This worker thinks America is Already Pretty Great for those wealthy donors, and she’s not sure why Congress is rushing to make American Even Greater for them. But then she remembers that the most important thing for many politicians is to keep their big donors happy.

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