Health Reform and Medicare for All…Seniors

One of my favorite movies is “White Christmas,” which starred Bing Crosby and Rose Mary Clooney. In one scene, Rose Mary Clooney’s character sings a song in a nightclub about her unhappiness with Bing Crosby’s character. She sings, “Love you didn’t do right by me. . . you planned romance that just hadn’t a chance and I am through.”

In a fashion similar to that Irving Berlin song, after years of touting private health insurance by helping to create the Healthy and Well Kids in Iowa (HAWK-I)—Iowa’s CHIP program, and working with Co-Opportunity Health—Iowa’s health care CO-OP that went bankrupt, I have come to the conclusion that the private health insurance market under the Accountable Care Act (known as the ACA or Obamacare) has not done “right by me.” More importantly, it has not “done right”  the citizens of the country. For reasons that I will clarify later, I now support expanding Medicare to individuals 55 years of age in a graduated, voluntary enrollment process.

First, we must examine the current insurance market. It is drowning under 20 to 40 percent annual premium increases; outrageous and morally reprehensible drug prices; poor insurance enrollment; deductibles ranging from $6,000 to $10,000 and sometimes more, that make having insurance still mean not having access to affordable health care; a significant number of private insurers leaving the exchanges, and more than 20 states that have not accepted Medicaid expansion even though it would not cost state governments. Overall, millions of Americans endure not having health care access because they have no insurance, no Medicaid, or are underinsured, which is the equivalent of having no health insurance.

I fully acknowledge the more than 20 million Americans who have health care access under the ACA and I am thankful for that. I also believe under different circumstances, Congress would have made technical changes which would have improved the ACA in meaningful ways. One of the most significant changes to the ACA made by Congress was withholding money destined to help sustain health care CO-OP’s like Co-Opportunity Health. The non-CO-OP private insurers instigated that theft.That was another “did me wrong” moment.

My proposal is that Medicare allows individuals from 60 to 65 years of age to buy into the Medicare system with premiums determined by income based on a sliding scale and no premiums for Medicaid income level individuals. Additionally, every year the age limit of 60 goes down one year until age 50 with the idea that if monitoring enrollment indicates a need to suspend further age decreases below 55 years of age so that 55 becomes the floor. Also, Medicare for its entire population will begin to negotiate prices with pharmaceutical companies for their medications and those deductibles greater than $2,000 per year be banned for health insurance policies sold to individuals with incomes less than 250     percent of the Federal Poverty Limit (FPL). These parameters would be up for some thoughtful and reasonable negotiation.

Why expand Medicare as a buy-in option? Several reasons: first and foremost, the most vulnerable group in this pre-Medicare population has diabetes and hypertension. They smoke, use illegal drugs and/or excessive alcohol. They also have significant mental health issues. Under this proposal, these individuals would have actual, legitimate access to good medical care now and as they age into the current Medicare program for individuals 65 years and older. They know that they need health care. That is why they represent the largest group of insurance buyers on the exchange. The second reason is that Medicare expansion for this high-risk and high-cost age group might make private insurance more affordable for the rest of the population with the elimination of this age group in the insurance risk pool. Finally, because Medicare is a federal program, it would allow states that have not expanded Medicaid to have their 55 to 65-year old low-income patients have full access to health care. A side benefit would be that Medicare expansion would allow more individuals to retire earlier because their health insurance is covered, opening up jobs in the economy. Current figures are not available on the number of Americans age 55 to 65 who continue to work past retirement age simply to maintain their health care coverage.

Two side notes: One, I am impressed that Medicare is taking action through Accountable Care Organizations (ACOs) to lower the cost of health care. My Medicare ACO with the University of Iowa Alliance which follows 75,000 Medicare-covered-people is making great strides in improving quality and lowering cost. I am chair of its Clinical Operations Committee. Two, Iowa Governor Branstad signed the Medicaid Oversight legislation which will improve the oversight of Medicaid by for-profit Managed Care Organizations (MCOs).I have hopes of reasonable oversight because this legislation will have to assure the care of all Medicaid patients in Iowa.

Finally, at church Sunday morning, I noticed a significant number of small children present with their parents and grandparents, which coincides with a birthday party yesterday for my 2-year-old granddaughter.Her birth was noted on this blog at the time.

This post offers a mechanism that provides adequate health care access for the grandparents and non-grandparents of this country who are age 50 to 65 while at the same time, stabilizing health care insurance for these children and their parents.

You should note that I continue to give private health insurance companies a “piece of the action” to insure individuals in businesses and individuals younger than 50. I hope that I will not soon be replaying that old, forlorn love song once sung in a movie set nightclub by Rose Mary Clooney.









Health Care Reform and Confusion

It should be so easy: a patient should receive his or her needed and entitled health care.  Medicaid should be the conduit that connects the patient and the physician, and then pays the physicin or other health care provider for services rendered.

Furthermore, if Medicaid contracts with a for-profit Managed Care Organization (MCO) to provide care to patients, there should be adequate state oversight to ensure the safety and well-being of these patients. As the 2016 Conference Report for the Health and Human Services, passed this week by the Iowa House and Senate, states, “the primary focus of the general assembly in moving to Medicaid managed care is to improve the quality of care and outcomes for Medicaid members.”

Instead of being easy, the transition to Medicaid managed care has been confusing in both negative and positive ways. As I said in the first post on this blog this year, I will spend this year highlighting my experience with how Medicaid managed care works with my patients in my family medicine practice.

Medicaid managed care in Iowa started April 1, 2016, when 550,000 patients assigned to three for-profit MCOs began to have their care provided by these MCOs.

Two patients: Mindy (fictional name) is a young adult with a chronic, inherited intestinal illness which requires periodic visits for medication and IV fluids. She has been through several major medical workups and no medical regime has been found to correct her condition. She has been to multiple medical facilities including the Mayo Clinic. She has been treated so many times that she has no peripheral veins available in which to place intravenous lines. She recently had a port,  which is a site underneath her skin, placed in her chest. The port allows for intravenous access. Mindy has been on Medicaid but often becomes confused about the need for the required reporting necessary to continue her Medicaid status. She received a letter from the Iowa Department of Human Services which said, “Confirmation of your MCO Coverage-Beginning April 1, 2016.” The letter also said that she, her son, and husband had been placed in a named Medicaid MCO. Mindy was seen this week in my clinic with her usual gastrointestinal symptoms and sought medication and IV fluids. Unfortunately, my clinic could not verify her Medicaid status and subsequently, found out that she does not currently have Medicaid. According to the Iowa Department of Human Services, over a thousand individuals were erroneously notified that they had Medicaid when, in truth, they did not have Medicaid coverage. This was a confusing and costly mistake for both my patient and my clinic.

My second patient is Joan (fictional name) who has chronic passage of kidney stones and sees me at least once a week for that reason. She goes to the Mayo Clinic yearly for follow-up of her condition. She is on disability for this condition and has Medicaid coverage. Despite published reports that none of the MCOs had contracts with the Mayo Clinic, Joan, through a prior authorization process, was able to obtain an appointment with her Mayo Clinic specialist. This was a confusing but positive development.

Regarding ombudsmen to hear complaints from Medicaid patients, I have now learned that regular Medicaid patients can access ombudsman services in the office of the long-term care Medicaid ombudsman. Confusing? Yes. The good news is that the bill passed in the legislature increased the number of ombudsmen that will be available to assist Medicaid patients if Governor Branstad does not line item veto this increase.

Finally, my very able head nurse has been severely stressed with the prior authorization requirements of all three MCOs. Referencing the judicial system, the phrase, “Justice delayed is justice denied” is used. In medicine it is accurate to say, “Medical care delayed (by prior authorization complications) can be life denied.” The complicated prior authorization processes  need to be fully evaluated by entities designated by the Iowa Legislature for Medicaid managed care oversight such as the Medicaid Assistance Advisory Council (MAAC) of which I am a member. In the 2016 Conference Report that I referenced previously, I am pleased to report that the MAAC will be one of the entities, which “shall submit executive summaries of pertinent information regarding their deliberations during the prior year relating to Medicaid managed care…no later than November 15, annually”…if Governor Branstad does not line item veto this part of the bill.

We will continue to watch this too often confusing process unfold. My goal will now be the phrase used by the General Assembly of Iowa: “to improve the quality of care and outcomes for the Medicaid members.” For me, they will always be considered patients, not “members,” especially when the MAAC presents its executive summary on November 15 each year.