Category Archives: Health care

History and health care

Health care, Politics

By Steve Brawner
© 2017 by Steve Brawner Communications, Inc.

History repeats itself, and, as we’re seeing with health care, that includes recent history.

In 1993, newly elected President Bill Clinton put the first lady in charge of fixing health care, and the next year the Republicans took over the House and Senate and gained 10 governorships. In 2009-10, newly elected President Obama and the Democrats passed the Affordable Care Act, and then Republicans gained control of government in Arkansas and virtually everywhere else except cities and the big blue states.

Now, newly elected President Trump and Republicans in Congress are trying to pass a health care bill – without any support from Democrats, who are salivating at the prospect of that issue sinking Republicans the way it previously sank them.

The latest Senate effort to repeal and replace Obamacare is called the Better Care Reconciliation Act, but you’d better believe that Democrats are calling it Trumpcare. That effort got some bad news Monday when the Congressional Budget Office said its passage would lead to an increase of 22 million uninsured Americans by 2026. That’s about the same as the American Health Care Act earlier passed by the House – the one that only 16 percent of Americans called a good idea in a recent NBC News/Wall Street Journal poll.

Because Democrats are an automatic no, the Senate version cannot survive if more than two Republicans vote against it. Things can change quickly in politics, but as of this writing more than two are expressing serious misgivings. Even Arkansas’ Sen. Tom Cotton, one of 13 senators who helped draft the bill in secret, hasn’t said if he’s definitely for it, and neither has Sen. John Boozman, though it’s hard to see either bucking the party in the end. If it does pass the Senate, it still has to be reconciled with the House version.

Just looking at the politics, you might wonder why elected officials don’t just ignore the issue. Unfortunately, health care is too big to do that. It’s 18 percent of the economy and growing faster than inflation. Premiums are rising, and insurers are pulling out of markets. Costs have risen so much for so long that policymakers vaguely pledge to “bend the cost curve” because it’s too much of a reach to say “spend less.”

In other words, health care is so big that elected officials must at least pretend to try to solve it, and when they do, they’re probably going to get punished for it. That’s because they cannot provide what voters expect – unlimited care for everyone with no bad outcomes at a negligible price and with no effort on our parts beyond taking a pill, which had better go down easy. Americans expect health care to be cheap if not free, but they don’t want the government to run it, and they don’t particularly like the insurance companies, either. You know the old saying, “Everybody wants to go to heaven, but nobody wants to die”? It’s just as accurate to say, “Everybody wants great health care, but nobody wants to pay for it.”

Meanwhile, the problem of exploding costs could be lessened if Americans simply made healthier choices. A recent Arkansas Center for Health Improvement study of 69,000 state and school employees found insurance plans spent far less in 2015 when employees were not obese or exercised regularly. In fact, the plans spent almost twice as much for employees who said they exercised fewer than 20 minutes per week – $6,043 each – as those who exercised moderately three times a week or vigorously once a week. Those employees cost their health plans only $3,345.

Health care won’t be “fixed” by any bill hatched in secret at the U.S. Capitol – not by Republicans, and not by Democrats. But one potential bright spot in the House and Senate bills is that they offer more flexibility to the states, which offer 50 laboratories to experiment with partial solutions. One such experiment, begun in 2013 and now called Arkansas Works, uses taxpayer dollars to buy insurance for poor people rather than enrolling them in a government program. It insures 300,000 people – more than were expected, so now Governor Asa Hutchinson is seeking to modify the program by adding a work requirement and lowering the income eligibility threshold.

Experiments like Arkansas Works should be encouraged. Good or bad, someday they will be the history others can learn from.

Can work be added to Arkansas Works?

Health care, Legislature, Politics, State government
Cindy Gillespie is director of the Department of Human Services.

By Steve Brawner
© 2017 by Steve Brawner Communications, Inc.

Next week, legislators will meet in special session to change the Arkansas Works program to encourage its recipients to work for their benefits and, eventually, no longer need them.

Changing the program will be reasonably easy. Changing the recipients will be much harder.

Arkansas Works, formerly known as the private option, uses federal Medicaid dollars to buy private insurance for 311,000 Arkansans with incomes up to 138 percent of the federal poverty level, or about $17,000 for an individual. The state pays 5 percent of the program’s cost this year and 10 percent by 2020. The federal government pays the rest.

It was created through the Affordable Care Act, otherwise known as Obamacare, which expanded Medicaid. Many Republican-leaning states declined to participate. Arkansas instead obtained a waiver from the Obama administration allowing it to buy private insurance rather than simply enroll recipients in Medicaid.

It has allowed Arkansas to be a national leader in reducing its uninsured population. But it is a government program that has grown bigger than expected, which happens a lot.

Gov. Asa Hutchinson, who wasn’t governor when it was created, wants to keep it but shrink it, so he is asking the Trump administration to change the waiver to reduce the maximum income from 138 percent of the federal poverty level to 100 percent, or about $12,000. That will reduce the rolls by 62,000 to about 249,000. Meanwhile, his administration wants to require some beneficiaries to work at least 20 hours a week, train for a job or volunteer. Those changes require legislators to amend some state laws, which they’ll do next week.

Creating those policies is the easy part. The Legislature is expected to approve the changes quickly. The state has been talking to the Trump administration and expects to be approved. The 62,000 Arkansans bumped from Arkansas Works can buy the same insurance they have now with a federal government subsidy. Their contribution will be $13 to $19 a month, about what they are supposed to pay now, though 75 percent of them don’t because the state can’t enforce the rule. Department of Human Services (DHS) officials think most will pay next year when insurance companies can remove their coverage.

The work requirement? Let’s keep our expectations reasonable.

In a briefing with reporters Wednesday, DHS Director Cindy Gillespie said it won’t affect 161,000 of the remaining 249,000 Arkansas Works recipients. They won’t have to work because they are age 50 or above, are “medically frail,” have a minor living at home, etc. Those exemptions mirror the Supplemental Nutrition Assistance Program, formerly known as food stamps, which also serves many Arkansas Works recipients. Some of the remaining 88,000 won’t have to work either if they are students, pregnant or caring for an incapacitated person.

Most of the 88,000 are not working now. More than three-fourths have zero income. Moreover, less than two-thirds of the 62,000 with incomes between 100-138 percent, the ones who will move into private insurance, have jobs. The rest subsist on government benefits and other means.

Most recipients have not taken advantage of a big opportunity they have now. Under Arkansas Works’ current waiver granted by the Obama administration, recipients are referred to the Department of Workforce Services, which can help them get jobs. But of the more than 37,000 individuals referred to DWS in January, only 628 accessed the services or reported a new job after the referral while 703 had done so beforehand.

Changing Arkansas Works will help some people. Given access to health care and an incentive to work, they’ll begin pulling themselves up by their bootstraps.

But some will not. Regardless of whatever liberal or conservative social engineering the state attempts, some people will not be self-sufficient because of lack of skill or will, addictions or very difficult personal circumstances. And then some people will simply choose to work the system and get by.

When they arrive sick and injured at the hospital doors, society must figure out what to do with them. One option: If they can’t pay, turn them away. Another option is the pre-Affordable Care Act method of letting them use the emergency room for free and then hospitals eating the costs or shifting them to the rest of us invisibly so we can pretend they don’t exist.

The state is opting for door number three: Try to provide enough but not too much, and try to get as many off the program as possible, for their own good and the taxpayers’.

Got a better idea? Call your legislators. They meet next week.

Reform instead of repeal and replace

Health care, Politics, U.S. Congress

By Steve Brawner
© 2017 by Steve Brawner Communications, Inc.

After the American Health Care Act failed in the House Friday, Speaker of the House Paul Ryan said this: “I don’t know what else to say other than Obamacare is the law of the land. It’s going to remain the law of the land until it’s replaced. We did not have quite the votes to replace this law, and so, yeah, we’re going to be living with Obamacare for the foreseeable future.”

For seven years, Ryan and other Republicans, including Arkansas’ congressional delegation, have said Obamacare is ruining the health care system – and by extension, the rest of the country. But once they gained control of everything in Washington, they obviously did not have a replacement ready, spent a total of 18 days debating a very bad one, held one vote and then announced their focus will now be on tax reform, though now they’re talking about revisiting health care again.

Because Republicans believe Obamacare is bad for the country but repealing and replacing it is very hard, why not try plan B – reform it? Members of Congress could do what once was done often with major legislation – reach across the aisle, compromise, and produce something that a majority coalition from both parties can support, even if some on both sides are unhappy. That would give shared ownership in the project and therefore less desire by one party to see it fail. Then, later, they could work to change it again.

Naive, I know. In today’s political environment, everything is about total victory and defeating the enemy, once known as “your fellow Americans.” Republicans know if they compromise with Democrats on health care, they’ll be scorned by conservative media sources and attacked by big money. Democrats are hoping the whole effort fails, knowing if it does, they get to be the majority again.

But not so long ago, Congress acted quickly and spent billions on a bipartisan basis to save the banking industry. We’ve been told by Republicans for years that Obamacare is a disaster already happening and a crisis in waiting. Maybe sooner rather than the “foreseeable future” is the best time to act.

“Obamacare” has always been a political term meant to fire up the political base, but solving a problem requires first defining it accurately, and Obamacare is not the root of the problem. Yes, the Affordable Care Act made significant changes to the health care system, but the system’s fundamental processes have remained the same. Profit-driven medical providers make more money when Americans are sick than when they are well, while insurance companies and government programs give Americans limited financial incentives to control the costs of their own health care. Meanwhile, the modern American lifestyle is simply too unhealthy to be cheap. We really can’t decide if we want a free market system or not. As a result of all this, health care was really expensive and didn’t insure everybody before Obamacare, and it’s really expensive and doesn’t insure everybody now.

Simply repealing and replacing one law isn’t enough to fix all that. The whole system – really, the culture – needs a reorientation, which the Republican leadership is clearly not ready to do if they can’t pass a single bill through one house of Congress. So if the status quo is unacceptable and radical change proves to be impossible, then the only alternative is incremental change the way the Constitution meant it to occur – through debate and compromise.

I’m not sure if congressional leaders even consider that possibility anymore. Ryan opened his press conference by saying, “Moving from an opposition party to a governing party comes with growing pains,” which would cause George Washington to roll over in his grave. The Constitution does not say anything about opposition parties or governing parties, or even mention parties at all. It’s as if we’ve become a British parliamentary system led by a prime minister and a king, rather than an American constitutional republic.

The system can’t work that way. Health care can’t be “fixed” by one piece of legislation, but it can be made better many small steps at a time. Let’s go back to the drawing board, give everybody a piece of chalk, and keep the eraser handy.

How can an unhealthy nation fix health care?

Health care, Politics, U.S. Congress

By Steve Brawner
© 2017 by Steve Brawner Communications, Inc.

You may have noticed that a while back, a Democratic president and a Democratic-led Congress tried to fix health care, and while more people do have health insurance, health care costs are still rising. You also may have noticed that a Republican president and a Republican-led Congress now promise to fix the fix. It won’t work either.

The truth is that no health care reform can create an affordable system in an unhealthy nation.

Modern American life, in fact, is profoundly unhealthy. Americans eat too much and eat the wrong things: too much sugar, fast “food” and processed conglomerations with unpronounceable ingredients; too few fruits, vegetables and healthy protein sources. We stay up too late bombarding our brains with flashing electronic lights rather than getting the sleep we need. We drive everywhere, take elevators up one flight of stairs, and spend most of our days sitting, which research has shown is very bad for us. We are addicted to all kinds of drugs – caffeine, opiates, alcohol. Then we try to fix all of this, quickly, with short bursts of exercise that often injure us, and with diets we cannot maintain, and with pills that have harmful side effects.

But it’s more than just about what we put into and take out of our bodies. We are disconnected from nature and from the natural rhythms of life. We are replacing healthy personal interactions with shallow distant relationships and unproductive disagreements on social media. We are fueled by a sense of outrage triggered by 24-hour media sources that might as well be plugged into our brains. We seek “more” rather than “enough,” filling our lives with stress and worry, flitting like gnats from responsibility to responsibility, and climbing ladders that are leaning against the wrong buildings.

And then after all of that, we think our members of Congress and a president are going to create an affordable, workable health care system, just because they happen to be members of a certain party?

The costs of our lifestyle were illustrated in a recent report by the Arkansas Center for Health Improvement. As reported by the Arkansas Democrat-Gazette, state and school employees and spouses were given the opportunity to save $75 on their insurance premiums if they completed a survey. More than 69,000 did.

It found that health insurance plans spent $4,302 in 2015 on employees and their spouses who were obese – 43 percent of the respondents – compared to $3,270 on employees who were not. The costs of obesity, in fact, were significantly higher than for those who smoked tobacco, who averaged $3,703. The plans spent an average of $6,043 for employees who exercised fewer than 20 minutes per week, compared to $3,776 for employees who said they exercised moderately at least 20 minutes just once a week. Those who exercised moderately three times a week or vigorously once a week cost their health plans $3,345.

No study tells the whole story, of course. Some people don’t exercise because they already have health problems, perhaps through no fault of their own.

Still, these are large differences in a sample size of more than 69,000 people. The difference in costs between those who exercise very little and those who exercise not that much was almost $2,700 a year. That one habit almost cut health care costs in half.

The United States has by far the most expensive health care system among the industrialized nations. According to the World Bank, the country spent $9,403 in 2014 per person on health care. Health care costs accounted for more than 17 percent of the country’s gross domestic product, compared to an average of 12.3 percent among all high-income nations – a number that we skew upwards.

As the study of 69,000 Arkansans makes clear, healthier lifestyle choices would make us a lot healthier as individuals and significantly reduce the nation’s health care costs, which is the key to increasing access to everyone. Think of what could be done with that extra money now spent on taxes, insurance, and the costs of preventable health problems.

You can’t overcome the actions of 300 million people with a legislative act. Regardless of what elected officials do, if we’re going to reform health care, we’re going to have to reform ourselves.