Category Archives: Health care

Asa’s state of the private option address

Health care, Legislature, Politics, State government

By Steve Brawner
© 2015 by Steve Brawner Communications, Inc.

Gov. Asa Hutchinson’s health care reform speech last Thursday was what the State of the Union address ought to be but rarely is – an accurate definition of a problem respecting both sides, followed by a solution that actually has a chance of being enacted.

Hutchinson spoke last week at UAMS before an auditorium full of legislators, health care policymakers, and other interested listeners. The atmosphere was serious and expectant.

Hutchinson started his speech with a history lesson. One of the provisions of the Affordable Care Act (Obamacare) expanded Medicaid in the states, but the Supreme Court had made that provision optional. Arkansas had created what Hutchinson called an “innovative” approach: using federal dollars to buy private health insurance instead of just pouring more money into Medicaid.

Hutchinson then accurately defined the two opposing viewpoints on the issue. Because of the private option, 200,000 Arkansans have health insurance, and hospitals are providing far less uncompensated care. However, the state will soon be responsible for up to 10 percent of the costs, which could equal $200 million by 2021. Opponents, he said, are “wise” to be concerned about this.

As he pointed out, the private option has paralyzed Arkansas politics. The votes in the two previous legislative sessions have been close enough that health care providers can’t completely rely on it. So many legislators campaigned this past election on ending the private option that its future is very much in doubt, but what about the 200,000 people?

Now for the solution. Hutchinson asked legislators to broaden the debate. Pointing to a single chart beside him, he said most Medicaid spending has nothing to do with the private option, so why argue over one slice of the pie? He asked legislators to approve the private option for two years, and to create a task force that will study health care reform in general for one year. The task force will produce recommendations based on principles such as minimizing the need for more revenues and increasing recipients’ accountability and work requirements.

It will be interesting where this goes. Arkansas is already involved in a promising health care reform process, the Arkansas Health Care Payment Improvement Initiative. Will the task force build on that, produce a different idea, or just tie a pretty ribbon on the private option and rename it so certain legislators can vote yes? We’ll know in a year, assuming the Legislature passes the bill that would create it.

At the end of the speech, Hutchinson remarked good-naturedly that he had not been interrupted by applause, so the audience clapped. The reason that had been the case was that audience members were listening intently – in order to learn important information, not for cues that would tell them to stand or sit in order to make a political point.

Contrast that with the State of the Union address, delivered two days earlier. President Obama’s speech had some good points in that it had a clear theme (middle-class economics) and a call for civil debate. But as is usually the case, it was marked by a list of proposals that had little chance of being enacted. Members of Congress played their expected parts. It was theater, not policymaking. Much of it will be ignored.

Not that there wasn’t some theater in the UAMS auditorium. Part of what Hutchinson was doing was buying time. He’s willing to change the private option, even significantly. But he wants neither to take health insurance from 200,000 people, nor to turn away the $1.3 billion in federal funds the private option will provide the state this fiscal year. After the speech, some legislators opposed to the private option expressed at least mild support because they said Hutchinson’s plan would end the private option in two years. That was not what he said.

But all that’s to be expected. This is politics. Hutchinson’s address changed the tone of the debate and offered a way forward. The legislation to create the task force has been filed, and there are good reasons for it to pass: Supporters don’t want the private option to fail, and Republicans opposed to the private option want their party’s governor to succeed.

Some still will oppose the plan, but what Hutchinson said won’t be ignored. Good speech.

Passing health care reform – and a kidney stone

Elections, Health care, Politics, U.S. Congress

By Steve Brawner
© 2014 by Steve Brawner Communications, Inc.

It was Saturday morning, March 29, and the pain in my lower back was growing more intense. I knew what was happening. It was not my first kidney stone.

If you’ve ever had one, you know the drill: the writhing, the fruitless shifting of positions hoping to find relief, the heaving. When I could take the pain no more, I shakily told my wife to wake the kids and drive me to the emergency room. When we arrived, I begged the admittance clerk to hurry. I underwent a CT scan and was given drugs that, blessedly, took away most of the pain. Surgery removed the stone a week later.

I’m grateful for modern health care, but no consumer product is free. The total out-of-pocket cost for that episode so far is nearing $6,000, including a big hospital bill that recently arrived – six months after the surgery. I’m hoping there will be no more surprises. My insurance company was billed more than $12,000 for the surgery alone and paid about $10,000 of that.

Ask me about health care reform, and I’ll generally say the system doesn’t function enough like a free market. Patients don’t act like consumers, and medical providers don’t act like a business. We must encourage patients to be more price-conscious so they’ll shop around and refuse unnecessary care. That kind of behavior will force medical providers to become more efficient and cheaper.

That’s Steve the political philosopher talking, and I’m not saying it’s wrong. But what did Steve the kidney stone patient do? Certainly not call the various emergency rooms at 6 a.m. on a Saturday looking for the best combo deal. I went to the only one in my hometown. There I was at the provider’s mercy not only as a patient but also as a consumer. I would have bought whatever service the hospital was selling in order to take away that pain.

Over the course of a week, my kidney was scanned numerous times, including the day before the surgery and the day of. At the hospital, already wearing my gown, I finally asked if it was really necessary to do it again. I was told the doctor liked to see if the stone had moved overnight. What would you do – refuse the scan? Of course I did what the doctor, who is also the seller, told me to do. I had no buying power in that situation.

Health care reform – that’s a hard one. Try as one might, it doesn’t fit neatly into any political ideology, including my fuzzy one. The mandate by the Affordable Care Act (Obamacare) that all Americans must have insurance, which conservatives argue is an unconstitutional edict – it once was a conservative idea. A major issue in this year’s legislative races is the private option, which uses federal dollars to buy private insurance for poor people who make too much money for Medicaid. It was created by Republican legislators and Democrat Gov. Mike Beebe’s administration and now provides insurance to 200,000 people. Other Republicans say it’s just Obamacare by another name.

OK, it is more government, at least on the front end. But uninsured people generally wait until they are very sick to seek care, and then they go to the emergency room, and they can’t afford to pay for their care, so the rest of us pick up the tab. So what’s the easy answer on that one?

No matter how health care is reformed, there will be winners and losers. During Monday’s AETN debate, Sen. Mark Pryor described a church meeting with a diabetic constituent thanking him for voting for the Affordable Care Act. Because it made it illegal for insurance companies to reject his pre-existing condition, the diabetic has coverage for the first time in 15 years. On the other hand, Pryor’s opponent, Rep. Tom Cotton, had his own story: a dentist and his wife lost their insurance because it didn’t comply with all of the act’s mandates. Libertarian Nathan LaFrance said doctors are telling him their attention is now focused on entering computer codes instead of caring for patients.

Take the words “Obama” and “Obamacare” out of the picture. Whose story is more compelling? The diabetic’s, the dentist’s, or the doctors’?

Aren’t they all? Health care reform – that’s a hard one. I don’t know the right answer, but anyone who tells you there’s an easy one is probably wrong.

Is Asa the private option’s better option?

Elections, Health care, Legislature, Politics, State government

By Steve Brawner
© 2014 by Steve Brawner Communications, Inc.

Want the private option to go away? Maybe you should root for the candidate for governor who seems most supportive of it. Want it to survive? Maybe you should root for the candidate who seems most on the fence.

Let’s review the backstory before explaining.

The private option came about because of two provisions in the Affordable Care Act, otherwise known as Obamacare. First, it required states to expand their Medicaid rolls to serve more poor people. Second, because it was doing that, it cut government reimbursements to medical providers for giving uncompensated care to people who don’t have insurance and don’t pay. The thinking was there would be less uncompensated care because more people would have Medicaid.

When the Supreme Court ruled Obamacare constitutional, it also said states didn’t have to expand Medicaid, and many Republican-led states did not. Arkansas legislators – Republicans, actually – along with Gov. Mike Beebe’s administration instead created the private option, which serves the same population by using government dollars to buy private insurance instead of enrolling them in Medicaid.

As a result, about 200,000 Arkansans are benefitting – most through the private option, and the rest because they were routed into Medicaid while trying to enroll in the private option. The federal government is paying for almost all of the private option now; the state will begin kicking in a small share in 2017, eventually paying 10 percent under the program’s current terms.

Supporters say it’s is a rational mechanism for funding health care for 200,000 people. We’ll end up paying for health care for them anyway – often in the emergency room if they don’t have insurance. Smaller hospitals have closed in states that turned down the money. The private option’s mechanisms encourage recipients to behave like health care consumers and be more picky and choosy with their decisions, in theory reducing the cost. So far, it seems to be doing much of what it was intended to do.

Opponents say it’s just Obamacare by another name, inevitably resulting in more government and more debt. Doing business with the federal government is a risky deal, they say. That 10 percent will amount to real money, and at this point, we don’t even know how much it will cost.

The funding mechanism must pass the Legislature with a three-fourths majority every year. Democrats are all for it; Republicans, who likely again will have majorities in both the House and the Senate next year, are split between “yeses,” “no’s,” and “heck no’s.” It barely passed earlier this year, and there will be even more legislative opponents after this year’s elections.

Which brings us to this year’s campaign for governor. Democrat Mike Ross is totally for it. Republican Asa Hutchinson, knowing his party is split, has hedged throughout the campaign. In Tuesday’s televised debate, he referred to its successes but says Arkansas must know the costs before deciding whether or how it should continue.

If he’s really against it, he’d say so.

Let’s not ignore the other candidates: Green Party nominee Joshua Drake supports the private option, while Libertarian Frank Gilbert is opposed.

When the Legislature convenes in January, the new governor will have an agenda (along with all 135 legislators), but everything will hinge on the private option. It’s that big and that controversial, and Hutchinson probably gives it a better chance of continuing in some form.

That’s because Hutchinson, the Republican, would have much more pull with the Republican “no’s” than Ross. (No one will flip the “heck no’s.”) Every legislator in Ross’ minority party is already for it. He could use his veto if the Legislature left out the private option, but the Legislature could override that with a simple majority – the same percentage that passed the bill in the first place.

So Ross perhaps would be more eager to fight for the private option, but Hutchinson, the outwardly more reluctant warrior, would have more weapons.

Hutchinson would have his own motivations for saving it. He has plans, including cutting taxes by $100 million during his first year in office – a difficult prospect anyway and an impossible one without the private option’s federal dollars. He does not want to spend his first term reneging on his campaign promise, plugging budget holes, and trying to save endangered hospitals.

The private option may survive, albeit with changes, regardless of who wins. It may die either way. But it probably has a better chance of surviving with help from the candidate for governor who won’t say he supports it.

A drugstore quits cigarettes

Business and economics, Health care

By Steve Brawner
© 2014 by Steve Brawner Communications, Inc.

CVS Pharmacy, a national drugstore chain, stopped selling cigarettes last week. This was big news because it was so unusual. And if anyone is wondering why the United States is spending far too much money paying for health care that isn’t making Americans healthier – those first two sentences should help explain it.

The chain is rebranding itself as “CVS Health” as it empties its shelves of the tobacco products that contribute to one in five American deaths, according to the Centers for Disease Control and Prevention (CDC). The company did not have a sudden epiphany that tobacco is bad for us. It’s trying to find a market niche as a health care provider. Like other pharmaceutical retailers, it also is offering basic medical services such as flu vaccines and blood pressure tests.

This is a welcome change because drugstores – which supposedly sell us products to make us well – are among the unhealthiest retailers in the country. The national chain in my area – I won’t use the name, but it’s new slogan contains the word “healthy” – sells cigarettes, candy and colas behind or near the cashier, who is located only feet from the doorway. Rows upon rows of candy, in fact, are sold in that store, along with chips and other salty snacks. It does sell cereal, and there’s a small refrigerated section that contains juice and milk, along with frozen pizza and ice cream. The gas station that changes my oil sells bananas, oranges and apples. Not so this drugstore, where virtually every grocery item is a processed food. The drugstore does sell bottled water, which, though a waste of money, is at least good for you.

You can’t really blame the drugstores for this. I guess they have every right to sell us what we have every right to buy, and Americans in general and Arkansans in particular buy a lot of tobacco, candy and processed foods. According to the CDC, an estimated 41.1 million Americans, or 18.1 percent of us, smoke cigarettes. In Arkansas, it’s 27 percent, ranking the state 49th, and not in a good way. More than one-third of Americans are obese.

The United States spends about 18 percent of its gross domestic product on health care – far more than other industrial countries. Some say it has the “best health care system in the world,” and if you judge it by one metric – the ability to treat certain serous diseases, that’s true. But it’s burdening us and future generations with unsustainable debt, and was doing so long before Obamacare was created.

The health care system itself is partly to blame. Among its biggest problems is that it rewards all the wrong behaviors. It pays medical providers far more money for treating diseases than it does for curing them and pays them almost nothing for prevention. A pharmacy selling us cigarettes and then selling us drugs (and charging the government for them) to treat the effects of those cigarettes? That’s the American way.

But just as it’s very hard for schools to educate students without parental support, it’s difficult for the health care system to treat patients when we don’t treat ourselves. Americans see “health care” largely as the act of taking a pill, right now, to make us feel better, right now. It’s no wonder drugstores sell cigarettes and candy. They’re drugs. One produces a nicotine high, and one produces a sugar rush.

So while we’re talking about state and national policies, we also have to talk about personal responsibility. In fact, the conversation must start there, even if it’s a little uncomfortable, just as writing this column has been. (Most are.) As Arkansas Surgeon General Dr. Joe Thompson said recently as we discussed various forms of health care reform, “If we don’t get control over our obesity and of our hypertension and our tobacco use, it doesn’t matter how much money we’re spending. We’re going to sink the boat.”

Will a drugstore clearing its shelves of America’s most harmful drug keep that boat afloat? No, but it certainly can’t hurt. It made its choice based on free market principles. Let’s hope the market rewards it, and that others freely follow its lead.