Summer on the Amish farm

Over the past 11 months, I have interviewed dozens of people and had rewarding opportunities to speak with community audiences about healthcare.  As I have spoken with groups about this issue, I have been amazed that when we connect as citizens the media noise and the political rhetoric disintegrates.  Healthcare is an issue we all care about and we all want clear answers.  Therefore, for the next few weeks I will be doing a series called “Concerns from the Community”.  These are questions and concerns raised to me by people I have met through speaking engagements, e-mails, phone calls and my Facebook page. 

This week's concern came from a woman from Pennsylvania's Amish community.

Artwork by Merrill Coffin

   

The humidity of a summer’s afternoon gave way to the relief of a westward moving storm that rolled over the fields of the Pennsylvania country side as I sipped mint tea on Charlotte’s front porch.  As two women from two very different cultures, we came together to discuss something that we all share as common concern-the health and wellbeing of our families and community.

Pennsylvania is blessed with a rich culture that is deeply routed in tradition, our Amish neighbors are a testament to this.  With a lifestyle that has remained unaltered for generations behind the backdrop of a rapidly changing world around them, it goes without saying that a national dialogue on healthcare is a concern to this community and the impact it will have on their way of life.

In our discussion, I alleviated her concerns that under the PPACA, the Amish religion is exempt from the individual responsibility clause (AKA: The Mandate) for the same reason they are exempt from paying and receiving Social Security.  As a self-sustaining culture, a major factor in their religious belief is to depend primarily on their tightly knit community.  Their religious belief calls them to take care of their community and I soon found that the one really learning about healthcare on this day was me.

Charlotte, an Amish woman with a chronic health condition that utilizes modern medical equipment and treatment, explained that as a culture they do not “reject” modern technology and innovation, as many wrongly believe, but embrace it selectively as it becomes life dependent.  Like the cistern that provides them indoor plumbing and the water wheel in the creek that delivers them hydro-power, their healthcare insurance system is self-sustaining and powered from within the Amish community.  Essentially, they “self insure” their community.

She explains that at the age of 18 each Amish adult pays $125 a month (premium) to their district health fund.  They receive treatment from modern physicians and hospitals as needed and are individually responsible for the first $2000 in bills (deductible).  They do have negotiated contract prices with area physicians and hospitals because the providers know that they will receive payment immediately and in cash, whereas with insurance companies they have to wait and may not get reimbursed.  When an individual meets their $2000 or has a serious medical need, they turn to the district health fund.  If the condition calls for care beyond the allowance of the district health fund, they turn to “free will” (charity from the community and neighboring districts).  Above all, their system is non-profit.  Funds are not lost to administrative costs and profit margins.  Furthermore, because the system of this community covers their medical expenses, they therefore do not contribute to the “uncompensated care” that has burdened our healthcare system for decades and increased the cost of care for everyone.   

As I came to understand their system, I also saw that the exemption for this religious group goes beyond religion.  This community is already taking responsibility for its citizens and is not a burden on the system.  Within this small, homogeneous microcosm-it works.  

The late day storm began to subside and carried with it the suffocating heat of the July day.  While the winds began to settle, so did a sense of peace within me.  Like the relief provided by the storm, I too felt refreshed by an open and civil dialogue about healthcare and relished in the opportunity to escape the hostility that surrounds this topic in our national news outlets.  If only our national landscape could be more like 2 women sipping mint tea on the porch of a Pennsylvania farm house.  

Mary's Question

Over the past 11 months, I have interviewed dozens of people and had rewarding opportunities to speak with community audiences about healthcare.  As I have spoken with groups about this issue, I have been amazed that when we connect as citizens the media noise and the political rhetoric disintegrates.  Healthcare is an issue we all care about and we all want clear answers.  Therefore, for the next few weeks I will be doing a series called “Concerns from the Community”.  These are questions and concerns raised to me by people I have met through speaking engagements, e-mails, phone calls and my Facebook page.  

This week's question is from Mary in Southeastern Pennsylvania.

Oil on Canvas:  "The Birthday Party" by Skip Rohde

In 2011 the infamous “Baby Boomers” officially retired.  While we are seeing a growing population of seniors, this is also coupled with the fact that American’s life expectancy has increased 1.4 years over the past decade, according to the Center’s for Disease Control.  As our population is aging and this aging population is growing larger, we are seeing an unusual trend.

After one of my speaking engagements I received a phone call from Mary, an 85 year old senior in assisted living.  She had a question about the provision of long-term care in the PPACA, but it wasn’t for herself.  The question was for her 61 year old daughter, a woman who was also looking to acquire a long-term care facility.  An interesting dynamic is echoing the changing demographics of family:  parent and children living out their “golden years” together!

However, this dynamic also presents an ongoing struggle and financial burden on our healthcare system as we try to provide this much needed long-term care for our aging population.  Under current policy, Medicare will only cover a skilled nursing facility for up to 100 days, after that, it does not cover long term care.  The only alternative for many people is to “spend down” their life savings on long term care until they are deemed impoverished and therefore qualify for medicaid.  Two-thirds of nursing home residents are financed through medicaid, whereas, 7% are financed through private insurance.

It is quite obvious that our current policy is a harsh one:  impoverish our seniors so that they can receive the care they need.  In the original drafting of the PPACA in 2010, there was a provision called The CLASS Program which was scheduled to begin in 2014.  This program would have been a voluntary insurance program established to help people pay for long-term care and services.  It was an attempt on the part of the PPACA to tackle this overwhelming public health issue.

Unfortunately, in response to Mary’s concern, I had to inform her that in October of 2011, Secretary of Health and Human Services, Kathleen Sebelius, announced that the program was deemed unsustainable and therefore repealed.  From the announcement put out by the Secretary, the program was susceptible to a phenomenon known as “Adverse Selection”.  This means that higher risk people and those with already existing disabilities were more likely to enroll in the program as opposed to younger and healthier people.  As a result, more money would be paid out for services than paid in from premiums.

As mentioned before, the PPACA has made a lot of progress towards giving unprecedented access to healthcare for millions and provided much needed consumer protections to others, it is a constant reminder that we still have work to be done.  While the dynamic of mother and daughter sharing their “golden years” together may be a quaint scene, seeing them do so in poverty is not.

To expand or not to expand......

Over the past 11 months, I have interviewed dozens of people and had rewarding opportunities to speak with community audiences about healthcare.  As I have spoken with groups about this issue, I have been amazed that when we connect as citizens the media noise and the political rhetoric disintegrates.  Healthcare is an issue we all care about and we all want clear answers.  Therefore, for the next few weeks I will be doing a series called “Concerns from the Community”.  These are questions and concerns raised to me by people I have met through speaking engagements, e-mails, phone calls and my Facebook page.  

This week’s question for the ongoing series comes from Christine.  Her concern is:

 "What are the next steps for PA in order to effectively implement the PPACA? How does the Supreme Court's decision on the medicaid expansion mean for PA?"

Recently, a study done at the Harvard School of Public Health concluded that when states expand medicaid, they discovered a 6.1% decrease in the percent of deaths in the state.  Of course this is good news for public health and a validation to the recommendation in the PPACA to expand medicaid for individuals up to 133% of the Federal Poverty Level.  However, the questions of cost remain as Pennsylvania and many other states grapple with the Supreme Court’s decision to make the expansion of medicaid optional.  Furthermore, with the Supreme Court’s upholding of the PPACA, Pennsylvania needs to seriously begin the process of implementing the state based insurance exchanges.

The next step for Pennsylvania is to implement the PPACA as it was designed.  According to a 2011 study done by the Robert Wood Johnson Foundation and the Urban Institute, with the implementation of the PPACA states are looking at a $90 Billion cost savings.  In the state of Pennsylvania, the study determined that without the PPACA the state spends $7,098,000 on the uncompensated care of the uninsured.  With implementation of the reform as it was designed, Pennsylvania is looking at reducing its uncompensated care costs to $3,811,000. 

In order to see these savings, states need to expand medicaid and set up the state based exchanges.  By doing this roughly 32 million more people will gain access to health insurance (17 million from the expansion of medicaid) and states will see significant savings from the decrease in the amount of uncompensated care that has been accrued from the uninsured/underinsured.  With the expansion of medicaid, the federal government will pay for 95% until 2019 and 90% in 2020 and beyond.  Even with the reduction in federal money, the study still projects that savings will outweigh costs for the state.  However, with the opening of the exchanges, those currently uninsured that will see the private insurance industry beginning to flip the bill through the new policies they will be purchasing.  Prior to reform, this tab was being picked up by state budgets, providers and increased premium costs ($900 a family in PA) from the insured.

Another overlooked cost savings for states is in the area of mental health.  According to the study, in fiscal year 2008 states spent $16.7 Billion on mental health services.  With mental health services now being one of the essential benefits under the PPACA, private insurance companies that participate on the exchanges will now pick up a significant portion of that cost for those that will acquire insurance on the exchange.  Medicaid expansion will also now cover mental health services instead of other state sources that are currently being used.

Finally, with the improved coordination of services through the use of electronic medical records, our public health programs (medicaid and medicare) will see cost savings with the reduction of duplicated care and catching costly medical errors.  

Mike and The Congressman

Over the past 11 months, I have interviewed dozens of people and had rewarding opportunities to speak with community audiences about healthcare.  As I have spoken with groups about this issue, I have been amazed that when we connect as citizens the media noise and the political rhetoric disintegrates.  Healthcare is an issue we all care about and we all want clear answers.  Therefore, for the next few weeks I will be doing a series called “Concerns from the Community”.  These are questions and concerns raised to me by people I have met through speaking engagements, e-mails, phone calls and my Facebook page.  

Mike of Lebanon County

Mike is a Lebanon County resident that met Congressman Jim Gerlach at a community event at Lebanon Valley Agricultural Center.  The two men were discussing the contributions to the rising cost of healthcare, a reality that we all agree on.  Between 1980 and 2010, healthcare expenditures have ballooned 10 times.  What we don't necessarily agree on is ...WHY?

Congressman Gerlach

 

The Congressman alleged that in order to curtail healthcare costs, we need “tort reform”, curtailing law suits against doctors and therefore causing doctors to practice what has come to be called “defensive medicine”.  This position states that doctors may order extra, and possibly unnecessary, tests in order to prevent being sued.  This was a common statement heard during the healthcare debates that consumed the years 2008-2010.  Mike on the other hand contended that it was overspending on administrative costs (dealing with insurance) that were the primary inflater of healthcare spending.

The reality:  They are both correct.  Mike however, is a little more correct.  According to a study published in Health Affairs in 2010, 2.4% of all healthcare spending can be attributed to liability or tort.  Administrative costs however are larger.  According to the Kaiser Family Foundation, administrative costs are cited as being one of the larger drivers of costs at 7% (1% of which is for government programs and 6% for private insurance).

While this is an important discussion to have between a congressman and citizen, let’s look 

at the most critical drivers of healthcare costs.  These being the impacts of a rapidly aging population, rising rates of chronic disease, rapid development of advanced equipment and the rise in the use of prescription drugs. In other words, we are getting older, sicker and require a lot more expensive healthcare practices than past generations.

The PPACA includes many cost containment measures.  The first addressing Mike’s concern at the consumer level is the Medical Loss Ratio (MLR).  This provision states that 85% of a patient’s healthcare premiums need to go to actual medical care and not administrative costs.  Currently, on the individual insurance market, only 43% of plans meet MLR.  Second, the health insurance exchanges/marketplaces, where individuals who don’t receive employer sponsored insurance as well as small businesses can purchase insurance, will create greater transparency of prices and more competition.  

Finally, many strategies are in place at looking at the ways that doctors are paid.  For example, some strategies look at offering incentives for keeping patients well through more patient centered care, often referred to as a “medical home”.  The basic principle is to focus on wellness, prevention and methods to keep patients out of a costly hospital stay where patients are at a higher rate of complicating conditions by infection.  The idea is to veer away from the "fee for service" model we currently utilize.  TR Reid highlights these measures in his recent documentary US Healthcare: The Good News and illustrates many of the findings from Dartmouth’s infamous Atlas Study.  

While the PPACA has been a big step in improving access to healthcare for millions, offering much needed consumer protections, and takes some steps towards reigning in costs, there is one major factor it does not address.  This is the fact that in the United States we have no price controls on healthcare services and we pay more for almost every major procedure than any other developed nation in the world according to a recent study done by the International Federation of Health Plans.  For example, an MRI in the United States costs $1080 and in France it is under $300.

So while Mike, The Congressman and the rest of us begin to wrap our heads around the PPACA, keep in mind that this challenge is far from over.  All we can hope is that in the next round we have learned from our experience to turn down the noise and set aside the political games in order to actually get something done.

Spending on Healthcare in the US

"Health on the Horizon" on Summer Break

"Health on the Horizon" will be taking the next week off for a summer break.  I will return on Friday July 27 in order to complete the final sprint to the finish line from my one-year tour around the state of Pennsylvania.  The final weeks will feature a series called "Concerns for the Community".  It will tackle questions and concerns from Pennsylvania citizens regarding the PPACA.  If you would like to have your question featured in this series, e-mail me at: hollygonyeadolan@gmail.com.  Please include your first name and county.  Enjoy your summer!

Exciting News!

Health on the Horizon:  Phase II

Looking for a GUEST SPEAKER on healthcare and The New Healthcare Law?  Contact Holly Dolan.  Through the art of storytelling, Holly takes you on her year-long tour around Pennsylvania with an interactive and informative presentation. CLICK HERE for more information.  

"Health on the Horizon" on Summer Break

"Health on the Horizon" will be taking the next 2 weeks off for a summer break.  I will return on Friday July 27 in order to complete the final sprint to the finish line from my one-year tour around the state of Pennsylvania.  The final weeks will feature a series called "Concerns for the Community".  It will tackle questions and concerns from Pennsylvania citizens regarding the PPACA.  If you would like to have your question featured in this series, e-mail me at: hollygonyeadolan@gmail.com.  Please include your first name and county.  Enjoy your summer!

Exciting News!

Health on the Horizon:  Phase II

Looking for a GUEST SPEAKER on healthcare and The New Healthcare Law?  Contact Holly Dolan.  Through the art of storytelling, Holly takes you on her year-long tour around Pennsylvania with an interactive and informative presentation. CLICK HERE for more information.  

The Hidden Tax

Last week when the Supreme Court ruled that the PPACA was constitutional, they also determined that the “personal responsibility” provision (AKA: The mandate) was also constitutional.  So what does this really mean?

It means that in 2014, if someone does not have health insurance they will have to pay $95.  In 2015 it will be $325.  In 2016 and beyond it becomes $695 or 2.5% of an individuals income.  For families, it is 1/2 the amount for children with a $2,250 annual cap per family.  

There has been a lot of debate as to what to call it: a tax, a penalty, a fine, a mandate.  Whatever you choose to call it, it essentially means that everyone is responsible for carrying health insurance.  The question is why?

To answer this question, we need to look at what is currently going on.  According to 2009 study done by the Center for American Progress and Families USA, whenever someone goes without health insurance, the cost gets shifted to the rest of us.  In other words, when someone can’t pay for care, the cost gets passed along to those that can pay in the form of increased premiums of those that have health insurance.  In Pennsylvania, this “hidden tax” is $320 per person or $900 a family (the national average is $1100 a family).

Looking for a GUEST SPEAKER on healthcare and The New Healthcare Law?  Contact Holly Dolan.  Through the art of storytelling, Holly takes you on her year-long tour around Pennsylvania with an interactive and informative presentation. CLICK HERE for more information.  

Justice (ification) for Public Health

Yesterday’s Supreme Court decision was a victory for public health. In the past few years it has been challenging to sift beyond the political rhetoric, grandstanding and nonsense to see this issue for what it really is, a vital public health crisis. The Supreme Court’s decision yesterday has allowed us to finally be able to move on and deal with the complex and multi-layered problems that lie in American public health

Since the 1960‘s, the United States has fallen from being the 12th in infant mortality to 29th (with #1 being the best).  Infant mortality is always a key indicator for a nation’s overall public health. At the heart of this problem has been lack of access to quality healthcare.  In that time we have seen an incremental increase in the numbers of the uninsured, individuals which have a 25% higher chance of dying than those with health insurance. As a result, 46,000 people die each year because of their inability to access health care, as we saw in the story of Billy Koehler from Pittsburgh.

It is in the interest of public health to see that everyone is insured. According to the center for American Progress, it costs Pennsylvania families $900 a year more in insurance premiums to cover the uncompensated care of the uninsured, therefore leading more individuals and businesses to forgo insurance or cutback benefits and as a result, jeopardizing personal health. With the highest population of uninsured being those under age 26, as we saw in the story of Eric from Radnor and Teddi from Lebanon County, insuring these young people not only protects them, it protects all of us.

While being able to access healthcare is key to overall public health, ensuring quality is equally as important. As we move forward to open up the state-based exchanges in Pennsylvania, access will be enhanced for currently uninsured individuals and small businesses, therefore alleviating the likelihood of premature death. However, within the exchanges, all policies will be subject to adhering to certain essential benefits in order to ensure a higher quality plan that many in the small group markets are currently unable to access. For example, an essential benefit that consumers on the exchanges will now be able to access is preventive care. As we saw in the story of Micheal and Laura, small business owners from Lebanon County, their small group plan had limited access to cancer preventing procedures such as a colonoscopy. With colon cancer being one of the most preventable forms of cancer, being able to catch it early is a public health victory.

The story of Barbara, a senior from Westmoreland County, illustrates that closing the “donut hole” is in the interest of public health. The Department of Health and Human Services shows that 25% of seniors that fall in the “donut hole” forgo taking their prescription drugs and therefore get sicker and more costly. With 70% of Pennsylvania seniors falling in the “donut hole”, continuing to be able to cover them is a milestone in public health.

With the validation of the high court , it’s time to lower the volume on the cable TV networks and stay focused on ensuring that the tools we have to improve the health of the public are utilized to their highest potential.

Looking for a GUEST SPEAKER on healthcare and The New Healthcare Law?  Contact Holly Dolan.  Through the art of storytelling, Holly takes you on her year-long tour around Pennsylvania with an interactive and informative presentation.  CLICK HERE for more information.  

The Graduate: Teddi's Story

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May 2012
Teddi with her parents at Lebanon Valley College Graduation

When Teddi graduated from Lebanon Valley College in May of 2012, she became a member of the second graduating class to benefit from the provision in the PPACA that allows young adults to stay on their parent’s health insurance until age 26.  The provision went into place September 1, 2010 and in Pennsylvania we have seen 89,000 young adults benefit and 3.1 nationwide according to the Department of Health and Human Services.  This number is an increase from the 2.5 million American youth that benefited when “Health on the Horizon” presented the story of Eric, a member of the first graduating class to benefit from the provision in the PPACA.

While Eric went into the workforce and was covered by his parents plan while he searched for a job and during the 3 month “lapse of coverage” before his employer provided plan became active, Teddi’s situation is different.  In the fall 2012, Teddi will be going to graduate school at Villanova where she will work on a Master’s degree in English.  Her ultimate goal is to earn a PhD in English and become a college professor.  

In fact, all young people, regardless of student status, marital status and state of residence are now eligible to stay on their parent’s health insurance plan until age 26 as long as they are not offered comparable coverage elsewhere (ie: employer).  However, what people continue to question is why this group of individuals are singled out for this provision.  A valid and very important public health question.

When Teddi is in graduate school at Villanova, she will be making $14,000 a year, enough to cover rent and living expenses.  If this provision in the PPACA was not in place Teddi commented that she would not be able to afford a health insurance plan.  Furthermore, she said she would most likely forgo one of her medications, pay out of pocket for the other and just chose to remain uninsured.  A common scenario for many young adults.  

While this may be one individual story, Teddi’s story represents a much larger demographic.  The United States Department of Labor reports that young adults under 26 have the highest rate of being uninsured (over 30%), more than any other age group.  According to a study done by the Commonwealth Fund, over a 3 year period of time, 62% of young adults age 19-23 reported being uninsured at one time.  This is because this age group is more likely to be working part-time jobs, work in low wage jobs that do not offer health benefits, or be a student.

While some argue that this demographic is not in jeopardy because they are generally young and healthy, data shows that they do pose a reasonable amount of risk that results in leaving many young people with lofty medical debts.  The Commonwealth fund states that visits to emergency rooms are more common among this age group.  This age group also comprises 1/3 of all HIV diagnosis, 3.5 million pregnancies each year and this demographic has the fastest rising rate of obesity.  In other words, this group that isn’t as invincible as the critics assume.  

While the personal toll of access to healthcare is evident on these young people both physically and financially, there is also a larger societal cost.  According to Families USA, the hidden “tax” to each taxpayer is roughly $1000 a year to cover the uncompensated care of the uninsured.  It benefits all of us when the largest cohort of the uninsured is covered.

There are also other larger societal issues related to ensuring this population has access to healthcare.  It is in our national interest the the youth population, our future workforce, such as Teddi, is able to meet their most basic needs.  In 2010 The Georgetown University Center for Education and Workforce estimated that by 2018, 2/3 of all jobs in the US will require post-secondary education.  Whereas in 1978, this number was less than 1/3 (28%).  In order to compete globally, we need to be investing and ensuring the success of this population.  

Healthcare Poker: Barbara's Story

his is the fifth story in a 5-part series called "Faces from the Frontline".  Join "Health on the Horizon" on Facebook and Twitter.

Barbara:  Berks County, PA

I like games just as much as anyone else.  However, in the past 9 months of my journey across the state of Pennsylvania, there is one game I have come to realize I no longer want to play.  That’s the game of healthcare poker.  Let’s face it, to insurance companies, it’s a game. If you get dealt a bad hand or play your cards wrong, you lose.  I won mine with beginner’s luck, I missed the lapse of coverage by 48 hours.  However, so many people loose in the worst kinds of ways, as we know with the story of Billy Koehler.

Let’s take Barbara Stakes as an  example.  Barbara is a 64 year old Buck’s County resident.  At the age of 42, Barbara discovered she has a seizure disorder called Venous Angioma.  However, to the insurance industry her disorder has another name.  It’s called a “Pre-existing Condition”.  

So what has this meant to Barbara?  Since her condition appeared in the late 1980‘s when she worked as an administrative assistant for a biotech research company, she was covered under a large group employer plan and she had full coverage.  However, when the company closed it’s doors in September of 2002, she lost her health insurance.  Fortunately, she still had a hand in this “game”.   Her 60 year old husband who worked for Amtrak was able to take her on his policy.  

As with all games though, sometimes you loose.  In 2007, Barbara’s husband turned 65 and he was therefore automatically enrolled into Capital Medicare.  She was now uninsured at the age of 59 and had to play a new hand in this sick and twisted game of healthcare poker.  Let’s explore her possible moves:  (1) an unaffordable COBRA plan for $650 a month, (2) gamble with being uninsured and pay $400 a month for prescriptions or (3) call the private insurance companies and try and get a comprehensive policy.

Barbara went with #3.  When she called two large national health insurance companies, a customer service agent leveled with her and said, “go ahead and apply, but you’ll probably get rejected”.  Barbara played the hand anyway, but lost.  One immediately rejected her and in the letter it stated it was due to a “health history that exceeds the allowable limits”.  However, the other accepted her for $835 mo. with a $5000 deductible (Barbara’s pension was $1230 month).  Go ahead and do the math.  Yes, that’s more than her yearly income!  Let’s face it, that was a denial for a “pre-existing condition” too.  

In the end, Barbara had no choice but to choose option #2 and gambled for 3 1/2 years without insurance until the PPACA was passed in 2010.  At that time, PA Faircare began, the high risk pool to assist the uninsured until the state based exchanges open up in 2014.  For now, Barbara is able to manage the $283.20 a month premium with at $1000 deductible.  

This October, Barbara will be eligible for Medicare.  However, according to a recent (April 2012) Government Accountability Report to Congress, on average, 32% of the US population has a pre-existing condition, with this number drastically higher among older populations.  After 2014, the “house” will no longer always win.  Under the PPACA, insurance companies will no longer be able to deny customers due to pre-existing conditions and for those that can not get insurance through an employer, there will be state based exchanges where individuals can go to purchase insurance at a reasonable rate.  All policies are subject to basic patient protections, must provide essential benefits and based on one’s income, individuals may qualify for a premium tax credit.  

Right now we sit at the crossroads of uncertainty while we wait for the Supreme Court to decide the fate of the PPACA.  To those who oppose the PPACA, I ask you this question:  should we continue to play this game of healthcare poker?  As for me, I’ll pass.

Source:  Department of Health and Human Services