Category Archives: Medicaid

It’s A National Emergency, we think…

Since his attempt to revive Nancy Reagan’s “Just Say No” campaign in the face of a crisis in the increased addiction to opioid drugs in this country fell flat,  Dear Leader appeared to suggest the problem is a matter of law enforcement — a major mistake.  The genesis of the issue comes from the over-prescribing and over use of opioid medication once advertised as “virtually addiction free.”  Indeed, Purdue Pharma is still facing litigation from the state of New Hampshire over its advertising of Oxycontin. This, in addition to the 2007 guilty plea from the corporation for mislabeling the drug, and the payment of  $634.5 million to resolve a DoJ investigation.  Meanwhile, Nevada holds its unfortunate position in the top ten states when counting opioid death rates.  There were 224 overdose deaths in 2014, another 259 in 2015 [CDC] related to natural and semi-synthetic opioids; Nevada’s statistics were more bleak citing some 465 opioid related deaths in 2015.

Since we probably can’t arrest our way out of this mess, in Nevada or anywhere else, the answer in the long run is prevention (better guidance for physicians and tracking, combined with better public education on the nature of opioid addiction) and treatment.  And, for treatment, people have to have a way to afford it.

Medicaid has been a Godsend for many suffering through an opioid addiction.

“The authors of the report (Urban Institute) draw a parallel between the Affordable Care Act’s Medicaid expansion and spending on addiction medications, saying it has brought addiction treatment to previously underserved populations.

“What we saw was this gigantic, rapid, ongoing expansion in treatment,” says co-author Lisa Clemans-Cope. “It was particularly fast after 2014 when the big Medicaid expansion came into play. There’s definitely an effect of people getting access to treatment. That’s the primary driver of growth of spending.”

So, Medicaid spent more on treatment after 2014 – because more people were in a position to afford the treatment programs available to them.  Therefore, the next time a Republican politician stands before us with plans to slash Medicaid spending, and turn the Medicaid program into a block grant lottery for the states, we might well ask:  What does your proposal do to assist the states, like Nevada, deal with the treatment expenses of individuals trying to cope with opioid addiction and who are seeking assistance to make that treatment affordable.

Gee, the states are supposed to “benefit” from greater flexibility?  Would that be the flexibility to choose between supporting special education children with speech and physical therapy and opiate addicts?  Or choosing between the needs of the families of opiate addicts and the severely disabled?  Or choosing between the needs of opiate addicts seeking treatment and women seeking mammograms and other cancer screenings?  Santa doesn’t come without some expense.

Somehow the Republicans have managed to entangle themselves in their own rhetoric.  We can cut taxes, expand the military, all by cutting social safety net programs, and still have money for fighting opioid addiction in this country!  Santa will bring us tax cuts and another Santa will keep Granny in the skilled nursing facility, help cousin Elwood find a job in a new industry, make sure the family can get immunizations, cancer screenings, treatment for acute and chronic medical conditions, and insure that the Interstate Highway System is continually maintained.

It’s Jude Wanniski’s Two Santa Theory — a position only definable as something coming from an opiate induced delusion:

“Unfortunately, Mr. Wanniski opened Pandora’s box when he let loose the two-Santa theory. Republicans are now bound to it, whether they know it or not. As Keynes once put it, “Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back.”

**For more information: See the following excellent articles in the Nevada Independent — “Another side of the opioid heroin crisis,” “For Many Governors…” “As Out of Control opioid epidemic rages..”

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Filed under Economy, health insurance, Medicaid, nevada health, Nevada politics, Politics

Rest and Repair: Going Forward With The ACA

Breathe, regroup, and re-enlist in the movement to #Resist the egregious GOP agenda to dismantle the 20th century.  The health insurance bill was the first fight, but it won’t be the last.

First, expect the GOP to repeat ad nauseam all the old talking points about the Affordable Care Act, and to keep working in the background to eliminate key elements of health care assistance, and we need to be prepared to counter them.

“Premiums have skyrocketed”Counter: While there are some states in which premiums for health care insurance have increased dramatically, there are others like Indiana and Rhode Island in which premiums have actually decreased. Nevada’s increase was a modest 8% when compared to pre-ACA rate increases.  [See KFF chart for all 50 states.]  Counter: Premiums are only part of the consumer costs.  If an insurance policy offers low premiums, but includes higher co-payments and deductibles then it really isn’t “cheaper.”

“Democrats want to bail out the Health Insurance Corporations.”  The Republicans used this line when attacking the legislation to get ourselves out of the Great Recession, the product of unfettered financialism on the part of investment banks. This line has served them well, and Senator Dean Heller (R-NV) utilized it almost constantly to impress Nevada voters with his “independence” when bragging about how he voted against “bank bailouts” in the Dodd Frank Act, legislation which applied common sense regulation to investment bank practices.

A much better frame for this argument from the pro-ACA side would be that we want to stabilize the insurance markets.  Including a re-insurance element to the ACA would be helpful.  There is a way to introduce these topics without resorting to protracted arcane discussions about the nuances of the insurance market:  Explain the Three R’s.  Risk Adjustment. Reinsurance. Risk Corridors.

Government is forcing people to buy insurance they don’t want.”  I’m fond of hauling out my auto insurance — even though I’m fully aware of the fact that this is far from a good analogy.  I have one vehicle which works and one that doesn’t.  For the one that works I have a comprehensive policy, and for the one that doesn’t I have a basic policy.  What the ACA does is require a “basic policy.”  The old rig isn’t going to hit anyone or anything unless a tornado picks it up and moves it — but I still have some liability insurance for it. The policy pools all car owners, and basic is basic, so there’s liability insurance on a vehicle that isn’t moving and isn’t going to without a tow truck.  (Please don’t ask why I still have it…the answer is irrational.)

Individual mandates and employer mandates aren’t popular.  That’s fairly irrefutable. However, those mandates are an essential part of creating a widening POOL of policy holders, which in fact serves to help contain health care cost increases.

But everyone has access to health care…in the emergency room.”  No, all this means is that everyone has access to EMERGENCY health treatment, which, as we all know is the most expensive place to receive care.  Further, “having access” is not the same as being able to pay for it — thus the pre-ACA misery of personal bankruptcies and hospitals with disturbing amounts of uncompensated care on their books.

Secondly, have a plan.  A plan to address specific needs for specific problems.  If health care costs are rising faster than other consumer needs, then address this directly.  (1) Allow the government to negotiate prescription drug prices for Medicare the same way the VA negotiates prices for veterans’ medication. (2) Incentivize prescription drug research while limiting excessively high prices.  This sounds impossible, but really isn’t.  A paper from the Brookings Institution (pdf) explains how this might be accomplished.   If about $1 out of every $6 spent on health care is related to prescription drugs, holding the line in this realm would be helpful.  (3) Allow the importation, or re-importation, of medication.  This probably isn’t as efficacious as some of the other proposals, but it, too, could be helpful.

(4) Encourage practices which yield better health care outcomes.  Thus far we have a system which pays for services rendered — as it should — however, efforts to study and promote best practices.  This is a component of the ACA and one that should be publicized more effectively.  (5)  Emphasize preventive medicine.  This, too, is an element incorporated into the ACA, and deserves more attention.  It’s far better for all concerned to promote annual health check ups, healthy lifestyle and nutrition programs, and vaccinations than it is to cover the costs of heart attacks and preventable diseases.  The insurance corporation doesn’t have to pay out the claims for the heart attack, the hospital doesn’t risk providing uncompensated care, the physician doesn’t run that same risk, and the person who avoided the heart attack in the first place is working and continues being a productive member of society.

(6) The slippery slope message is already in the public domain.  “What the Democrats really want is ‘single payer.’” Yes, some do.  The Republican cognitive dissonance hits the surface when some conservatives decry socialized medicine while famously exhibiting their “Get Government Hands Off My Medicare” signs.  However, this argument is both accurate and speculative at the same time.  Some Democrats are, indeed, in favor of single payer. Some are more likely to support a public option where private corporations are reluctant to enter the private health insurance market.  Others would simply prefer to sustain the present health insurance exchange marketplace system under the current provisions of the ACA.  There’s no monolithic, lock step, Democratic position on this issue, which is both a political problem for massing support for a specific proposal, and a political opportunity to let local voters select the candidate who best represents their views.

Third, we need to recognize that “repeal and replace” was never a serious proposal in the first place.  Had it been serious, then surely in the seven years since the passage of the ACA the Republican party would have come up with something more substantial than cutting Medicaid, limiting jury awards for malpractice, defunding Planned Parenthood, and giving tax breaks to the ultra-wealthy among us.  They were perfectly happy to vote in favor of complete repeal of the ACA until the burden shifted to their own backs, then the GOP controlled Senate couldn’t come up with 50 votes for a sham bit of legislation no-one wanted.

Slogans are effective public relations, but they are woefully inadequate policy proposals.  No, the ACA isn’t “socialized medicine.”  If it were then the Heritage Foundation wouldn’t have provided the framework of the plan as a response to Hillary Clinton’s health care proposals back in the ’90s.’  Granted, the Heritage Foundation didn’t include increasing Medicaid coverage, and it did include ‘tort reform,’ but the other similarities are striking even if hard-line Republicans in 1993 opposed the bill based on the framework, and it never came to a floor vote.

The GOP Zombie Bills may be gone, but the fight isn’t over.  And the obese ladies who would do better to follow the advice given by their doctors (covered as part of the ACA mandated insurance) aren’t yet singing.

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Filed under Health Care, health insurance, Medicaid, Nevada politics, Politics

The Moderate Heller Myth: Health Insurance Edition

Senator Dean Heller (R-NV) has cultivated his “moderate” image to the point that this adjective is attached to him with remarkable consistency — when if a person does even a perfunctory piece of research on his actual voting record what emerges is the model of a hard line conservative.  There is a pattern.  The Senator expresses “concerns” with a bill; then announces with ranging degrees of fanfare his opposition to a bill “in its current form,” then when the rubber grinds on the road surface the Senator votes along with the Republican leadership.

Why would anyone seriously believe he would support fixing the Affordable Care Act’s problems and not ultimately support what is now being called the “skinny repeal” version in the Senate based on the following voting record:

In 2007 then Representative Heller voted against the Medicare Prescription Drug Price Negotiation Act (HR 4).  Then on August 1, 2007 he voted against HR 3162, the State Children’s Health Insurance Program reauthorization.  The next day he voted against HR 734, the Prescription Drug Imports bill.  On March 5, 2008 he voted against HR 1424, the Mental Health Coverage bill.  Further into 2008 he voted “no” on HR 5501, the bill to fund programs fighting AIDS, Malaria, and Tuberculosis, and “no” again on the concurrence version of the bill in July.   If he had a ‘flash’ of moderation during this period it happened in the summer of 2008 when he voted in favor of HR 5613 (Medicaid extensions and changes), HR 6631 (Medicare), the latter including a vote to override the President’s veto.  By November 2009 he was back in full Conservative mode.

He voted against HR 3962 (Health Care and Insurance Law amendments) on November 8, 2009, and HR 3961 (Revising Medicare Physician Fee Schedules and re-establishing PAYGO) on November 19, 2009.

In March 2010 Heller voted against HR 4872 (Health Care Reconciliation Act), and HR 3590 (Patient Protection and Affordable Care Act).  He also voted against the concurrence bills.

January 19, 2011 he voted in favor of the Repealing the Health Care bill (HR 2).  He also signaled his stance on Planned Parenthood when he voted in favor of H.Amdt. 95 (Prohibiting the use of Federal funds for Planned Parenthood) on February 18, 2011.    He was in favor of repealing the individual mandate (HR 4), of repealing the Prevention and Public Health Fund (HR 1217).  May 4, 2011 he voted to repeal funding of the construction of school based health centers (HR 1214).

There was another “soft” period in some of his initial Senate votes in 2011, especially concerning the importation of medication from Canada (interesting since many prescription drugs are manufactured in other overseas sites).  See S. Amdt 769, S. Amdt 2111, and S. Amdt 2107 in May 2012.  On March 31, 2014 he voted in favor of HR 4302 (Protecting Access to Medicare).

He was back riding the Republican rails in September 2015, supporting an amendment to defund Planned Parenthood, (S. Amdt 2669) which failed a cloture vote.   Then on December 3, 2015 he voted in favor of another ACA repeal bill (HR 3762).    If we’re looking for patterns in this record they aren’t too difficult to discern. (1) Senator Heller can be relied upon to vote in favor of any legislation which deprives Planned Parenthood of funding for health care services, (2) Senator Heller can be relied upon to vote in favor of repealing the Affordable Care Act, and (3) Senator Heller’s voting record, if it illustrates any ‘moderation’ at all, comes in the form of dealing with prescription drug prices, but even that is a mixed bag of votes.

Thus, when he makes comments like the following:

“Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either,” the statement read. “That is why I will vote to move forward and give us a chance to address the unworkable aspects of the law that have left many Nevadans — particularly those living in rural areas — with dwindling or no choices.

“Whether it’s my ideas to protect Nevadans who depend on Medicaid or the Graham-Cassidy proposal that empowers states and repeals the individual and employer mandates, there are commonsense solutions that could improve our health care system and today’s vote gives us the opportunity to fight for them. If the final product isn’t improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it.”

We should examine them with some caution.   If he is referring to rural Nevada voters as ‘victims’ of the Affordable Care Act he might want to note that before the ACA there was one insurer in the northern Nevada rural market and if there is only one now that’s really not much of a change, much less a “nightmare.”  Nor is he mentioning that the proposed cuts to Medicaid will have a profoundly negative effect on rural Nevada hospitals. [DB previous]

That Graham-Cassidy proposal isn’t exactly a winner either:

“The new plan released Thursday morning and written by Republican Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.) would block grant about $500 billion of federal spending to the states over 10 years to either repeal, repair or keep their ObamaCare programs.”

We have no idea if the number is an accurate estimate of what would keep the health care systems of all 50 states afloat — no one seems to want to ‘score’ anything these days.  Additionally, Americans should be aware by now that when Republicans chant “Block Grant” they mean “dump it on the states, wash our hands, and walk away” while the states struggle to keep up with demands to meet needs and provide services, operating on budgets which cannot function on deficits.

Then, there’s that perfectly typical Hellerian comment: “If it is improved, I will support it,” leaving the issue entirely up to Senator Heller’s subjective assessment if “it” has improved his re-election chances enough to go along with it while not upsetting his very conservative base.  Meanwhile, the media persists in repeating the “Moderate Heller” mythology, and we haven’t even begun to speak of his actions to thwart and later repeal any common sense regulations on the financial sector.

 

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Filed under conservatism, Health Care, health insurance, Heller, Medicaid, Medicare, Nevada Test Site, Politics, public health, Republicans, Rural Nevada, SCHIP

It Ain’t Over Until The Fat Golfer Sings

Senator McConnell’s Secret Health Insurance Shop is still working, with the Lobbyists/Elves seeking a way to offer goodies acceptable to the wavering and the wanton.  Keep calling!  and if you’d like more information to substantiate your comments there are some excellent sources.

Kaiser Family Foundation:   Your one stop center for research and analysis on health insurance issues.  Definitely a “bookmark this” recommendation.  Today, KFF notes that before the implementation of the ACA individual insurance plans for health care did not cover delivery and maternity care  in 75% of the policies; 45% of the policies didn’t cover substance abuse treatment; and 38% failed to cover any mental health care services.

If terms like “risk adjustment,” “re-insurance,” and “risk corridors” seem like something written in Minoan Linear A, the KFF has an excellent summation of these technical terms in easily understood American English.

There are also some analytical pieces on the impact of Republican suggestions for health care insurance “reform” as they relate to rural health care in the following:

Human Rights Watch — Senate Health Care Bill A Swipe At Rural United States.

MSNBC/Scarborough – Rural Health Care Would Be Savaged By This Bill.

There’s a narrative going around that Democrats haven’t brought anything to the table, which depends on whether we’re taking the long or short term view.  In the short term this would be true — because the McConnell Secret Health Insurance Shop didn’t invite any Democratic participation,  for that matter there seems to have been some Republican Senators who were left in darkness.  The longer view would note some of the following:

Senator Franken’s “Rural Health Care Quality Improvement Act of 2016” (pdf) S. 3191 (114th Congress) was introduced in July 2016 and “died” in the Senate Finance Committee.  The bill would have amended two titles of the Social Security Act to improve health care in rural areas of the United States.

There is Representative Jan Shakowsky’s CHOICE Act, H.R. 635, which would establish a public option under the ACA.  See also S. 194, Senator Sheldon Whitehouse’s CHOICE Act.  There’s Rep. Gene Green’s HR 2628 to stabilize Medicaid and the Children’s Insurance program.  Rep. John Conyers introduced his form of “single payer” in his Medicare for All bill, HR 676.  On the topic of making pharmaceuticals more affordable:  Senator Sanders – Affordable and Safe Prescription Drug Importation Act S. 469.  Senator Klobuchar has a bill “… to allow for expedited approval of generic prescription drugs and temporary importation of prescription drugs in the case of noncompetitive drug markets and drug shortages.” S. 183. Rep. Kurt Schrader introduced H.R. 749 to increase competition in the pharmaceutical industry.  Senator Ron Wyden introduced S. 1347, RxCap Act of 2017.

Senator Klobuchar has also introduce a bill supporting Alzheimer’s caregivers in S.311.  Rep. Derek Kilmer’s bill, H.R. 1253, seeks to improve access to treatment for mental health and substance abuse issues.   This is by NO means an exhaustive list of what can be gleaned from Gov.Track, but it does illustrate that the Democrats are not without suggestions — negotiating drug prices for Medicare, stabilizing the current system, public options, single payer — it’s just that these bills won’t get out of Republican controlled committees and they didn’t make it into Senator McConnell’s Secret Shop.

Indulge in no victory dance, we’ve seen this movie before … don’t believe that some minor blandishment won’t be enough to lure Senator Heller from his current position …don’t think that the products of McConnell’s Secret Shop have stopped coming off their assembly line.

Senator Heller can be reached at 202-224-6224;  702-388-6605;  775-686-5770

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Filed under Health Care, health insurance, Medicaid, Medicare, nevada health, Pharmaceuticals, Politics, public health

What Nevada Loses under Trump-Doesn’t-Care

Here’s what Nevada loses under the egregious Trumpcare Bill:

(1)  138,100 citizens in Nevada will lose their health insurance coverage.

(2) 81,000 Nevadans will lose their Medicaid coverage.

(3) 439,000 Nevadans with pre-existing conditions will be put at risk.

(4) The bill cuts funding for care for 125,056 Nevadans with disabilities.

(5) It would raise the average health insurance premium for Nevadans by $677 in 2018.

(6) $288 million in new costs will be added to Nevadans in order to keep their Medicaid expansion.

Not a very good deal for the Silver State!

Call. Call. Call Senator Dean Heller.  702-388-6605    775-686-5770    202-224-6244

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Filed under health, health insurance, Heller, Medicaid, nevada health, Nevada politics, Politics

Caring for Grandma on the I-80 Corridor

Republican “reforms” of Medicaid, which seem to be composed of stalling funding until the program can be gutted in 2025, could easily have a negative impact on those families trying to find skilled nursing care for elderly relatives along the I-80 corridor in northern Nevada.  As noted in the previous post, health care facilities in northern Nevada have service areas of miles and miles of miles and miles.  The euphemistic term “remote rural” is especially pertinent in this instance.  These may be the “cow counties” but they do include a significant number of individuals over the age of 65.

By The Numbers 

Pershing County (Lovelock) has a total population of 6,560 of which 14.8% are over 65, and 11.1% of those are disabled individuals under the age of 65.  Humboldt County (Winnemucca) population of 16,842 includes 11.9% over 65 and 8.3% under 65 disabled. Lander County (Battle Mountain) has 5,702 people, of whom 13% are over 65 and 6.5% are disabled.  Eureka County (Eureka) is a small entity with 1,917 people of whom 12.9% are over 65, and 6.6% are disabled.  More populous Elko County (Elko) with 52,168 people has an over 65 population of 10.0% and 8.4% disabled individuals.  Churchill County (Fallon) has a population of 24,198 of whom 18.7% are over 65 and 6.5% are disabled.

For the sake of this analysis, let’s assume that the families would like to find skilled nursing facilities for their elderly relatives closer to home than securing similar residences in the Reno/Sparks/Carson City area.  That means finding skilled nursing facilities in the towns listed above.  Elko County has such a unit with room for 110 residents, Fallon has a facility with a capacity for 74 residents.  Lander and Eureka counties are served by a facility in Battle Mountain with a capacity of 18.  Pershing county has one facility with a capacity of 25 residents, and Winnemucca has a skilled nursing facility for up to 26 residents. [Links]  We’re speaking in numbers at present, but it’s important to remember that those numbers are specifically associated with real people, and very real families who are seeking affordable quality care for those individuals.

The cost of skilled nursing care will vary with the level and type of medical or rehabilitative services required, however we can generally assume that the monthly price tag for SNF care in Nevada is about $8,213.  Drilling down a bit deeper, the reported minimum cost per month for Skilled Nursing Care in a semi-private room is about $3,346; the median is $7,128; the maximum is $8,425.  Private rooms come at a minimum of $4,106, a median cost of $8,213, and a maximum cost of $15,452.  [SNF]  At this point another reminder is appropriate — these aren’t price tags, the numbers represent what a family might have to pay for care specific to the needs of their elderly relatives.

And now we return to the numbers.  In the State of Nevada 1 out of every 7 persons over the age of 65 is covered by Medicaid. Medicaid covers 3 out of every 5 nursing home residents. [KFF]  Consider for just a moment what would happen to the fiscal solvency of the residential facilities listed above in the rural counties if Medicaid is cut, then “reformed” into block grants (which can be further cut by Congressional action) and finally all but reformed out of existence by Republican representatives.

Mythology

Let’s work on some of the elements of Republican mythology commonly associated with their efforts to slash the Medicaid program.

(1) It was only originally intended to cover the “really poor.” Republicans have an interesting way of defining “poverty.”  Several reports of recent memory decry the fact that people on various welfare programs have CARS (to get to work) and REFRIGERATORS (which come with most furnished apartments.)  Left to their own devices it’s easy to imagine that unless a person is naked, living rough in the bush, and starved into semi-consciousness the individual wouldn’t qualify as “poor” by some Republican standards.  That said, Medicaid isn’t really a welfare program — it’s essentially a health insurance program.  One way to extend this health insurance coverage was to apply income eligibility standards for publicly subsidized health insurance — for the low income families, for the aged and for the disabled.

(2) The states can do better because they are closer to the problems.   There’s a reason we have a federal system — there are some tasks which the states are not capable of adequately addressing.  Providing health insurance coverage for millions of Americans working at low wage jobs, who have disabled family members, who have aging family members, and have children in need of health care services is one of those objectives best addressed by federal resources.  Imagine if someone said the states can best determine what security is best for them?  Should we block grant the Defense Department budget, send it to the states and let them decide how to fund the elements of their National Guard?  This sounds ridiculous, and doesn’t the Constitution require government prioritization of our mutual defense? Yes, and it also provides that our government provide for our “general welfare.”

(3) We’re really not cutting anything.  No? When the inflation rate for the medical sector exceeds that of the other sectors of the economy, and budgeting or funding proposals don’t meet or exceed that inflation rate the end result is a cut.  It’s not mathematics, it’s just old fashioned arithmetic.  There’s also something disingenuous about continually clamoring for tax cuts (especially at the state level) and then offering that the states should pick up more of “their share” of program expenses.  Finally, it’s always easier to cut funds from “block grants” than it is from specific program budgets.  Yes, the Republicans intend to cut Medicaid; if it’s done slowly or quickly is beside the point — at some date the result will be the same.   Program cuts will affect those real people in those real skilled nursing facilities, both the staff providing the services and the residents who depend on them.

Senator Dean Heller should be aware of these issues, and if he isn’t perhaps he should receive some phone calls this week.  702-388-6605;  775-686-5770; 202-224-6244.

*And we still haven’t discussed the benefits of Medicaid supported home health care programs!

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Filed under Health Care, health insurance, Heller, Medicaid, nevada health, Nevada politics, Politics

Rural Nevada Health Care and the Great Bamboozle AHCA

The state of Nevada consists of 110,567 square miles of miles and miles and miles.  271,985 people live in those miles and miles and miles out of a total population of  2,940,058.  A quick poke at the calculator shows a state in which 93% of the population is urban, while most of the real estate is rural.   This situation poses some easily apparent problems for health care services and the delivery thereof.

Rural health services must literally cover wide spans of territory in which there is a small population.   There is one hospital in Battle Mountain (Lander County, NV) to serve a total population of 5,702.  There is one hospital in Winnemucca (Humboldt County, NV) serving a total population of 16,528.  There is one hospital in Lovelock (Pershing County, NV) with a total population of 6,753.  There is one hospital in Elko (Elko County, NV) serving a population of 48,818.  Two conclusions can be reasonably drawn from this quick view of the northern tier of rural counties: (1) In none of these areas can a hospital draw upon “economies of scale” in terms of hospital services.  The obvious example may be that an expectant mother will usually require the same obstetric services in Battle Mountain, as in Winnemucca, as in Las Vegas or Reno.  (2) These rural hospitals serve populations which are generally not as affluent as in urban areas;  the rural per capita income lagging slightly behind urban areas. [RH] This places the northern tier of counties in a predicament similar to other western states:

“In the rural West, many farmers, ranchers and other agricultural workers are self-employed, so they can’t get coverage through an employer. Hence, a higher percentage of agricultural employees are covered by Medicaid (11 percent) than in non-agricultural industries (8 percent). Before the ACA was enacted in 2010, workers in the agricultural sector had fewer options, so many remained uninsured. But under the Obama-era plan, many states expanded Medicaid, increasing the percentage of those covered. Under the AHCA, that expansion would be significantly scaled back, according to the Joint Economic Committee report.”

Thus, the National Rural Health Association issued this warning:

“Though most rural residents are in non-expansion states, a higher proportion of rural residents are covered by Medicaid (21% vs. 16%). Congress and the states have long recognized that rural is different and thus requires different programs to succeed. Rural payment programs for hospitals and providers are not ‘bonus’ payments, but rather alternative, cost effective and targeted payment formulas that maintain access to care for millions of rural patients and financial stability for thousands of rural providers across the country. Any federal health care reform must protect a state’s ability to protect its rural safety net providers. The federal government must not abdicate its moral, legal, and financial responsibilities to rural, Medicaid eligible populations by ensuring access to care.”

In short,  cuts to the Medicaid program will disproportionately affect rural health care providers serving rural populations.

But, but, but, sputter the advocates of the Republican offering — We’re Giving People A Choice — you can buy what you want!  Not. So. Fast.

“Though some provisions in the modified AHCA bill improve the base bill, NRHA is concerned that the bill still falls woefully short in making health care affordable and accessible to rural Americans. For example, the modified bill contains a decrease in the Medical Expense Deduction threshold from 10% to 5.8% in an attempt to assist Americans between the ages of 50 and 64 who would see their premiums skyrocket under the current plan. However, this deduction is not a credit and therefore would be of little use to low income seniors that are in very low tax brackets or do not pay income tax at all. Additionally, the new amendments to freeze Medicaid expansion enrollment as of Jan. 1, 2018, and reduce the Medicaid per-capita growth rate will disproportionately harm rural Americans.”

Well, that didn’t go well.  What about that “get what you want argument?”  The first question might well be — What can you afford?  The annual earnings of a farm or ranch owner (manager) in Nevada is reported at an annual mean of $91,970.  However, the range runs from 10th percentile $39,850 to 90th percentile $150,410.  The annual mean wage for a farm or ranch worker is $34,520. [BLS]  Nevada’s reported average annual mean for farm and ranch workers is slightly higher at $36,480. [DETR download] Now we have a problem — 138% of the federal poverty level is $16,374 for a single person or $33,534 for a family of four.   Our hypothetical average annual mean earnings for a farm or ranch worker isn’t eligible for Medicaid expansion enrollment, but has an income well below the Nevada average household income average of $52,431, or 63.96% of the annual average household income level.

How to market an insurance policy this hypothetical average family could afford?  Either offer a comprehensive insurance plan and provide premium assistance to make up the difference between what the premium costs and what the family can reasonably afford — or there’s always the Junk Insurance option.   Consumer Reports offered some excellent advice concerning what constitutes Junk Insurance — aka “affordable plans” —  watch out for fixed benefit indemnity plans, and medical discount cards.  Another Consumer Reports bulletin specified the elements of Junk Insurance, your insurance plan could be very hazardous to your physical and financial health if it contains: Limited benefits; Low overall coverage limits; unrealistic “affordable” premiums; No coverage for important health care services; Ceilings on categories of care; No limits on out of pocket costs; Random catches — like covering hospital care after the second day, when it’s known that the first day is usually the most expensive.

The problem at this juncture for rural Nevadans is that those in the agriculture sector may or may not have earnings allowing them to enroll in Medicaid.  If “yes” then a reduction in Medicaid — whether it happens now or just after the 2020 elections — will have a negative impact on many citizens in the northern tier of “cow counties;” similarly, a return to the Bad Old Days pre-ACA makes those who are certainly less than affluent vulnerable to the offerings of Junk Insurance, which is fine as long as they don’t mind paying for a product which will not cover their medical expenses at the time they actually need it.  Exacerbating this issue is the fact that jobs in agriculture (farming and ranching) are listed by Forbes as the 4th most dangerous occupations in the country.

There’s no way to bestow a bright face to the Republican tax cut disguised as a health insurance ‘reform’ bill in terms of what happens to rural Nevadans and their health care providers.  Those it doesn’t cut out completely it leaves vulnerable to incomplete and almost useless “catastrophic coverage” plans — which for too many policy holders leaves them facing health care costs well beyond their ability to pay for out of pocket.  If there were a recipe for increasing the “uncompensated care” costs for local hospitals and clinics this is definitely IT.  Rural hospitals and clinics, already stretched to meet costs, would be especially at greater risk — and we haven’t even touched on the topics of long term care for the aging or home health care services which prevent individuals from having to reside in more expensive residential care facilities in rural areas.

NOW is the time to contact, and continue to contact, our Senators (Heller and Cortez-Masto) and urge their opposition to this assault on medical care for northern Nevada citizens and their health care providers.

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Filed under Health Care, health insurance, Heller, Medicaid, nevada health, Nevada politics, Politics