The US health system was already falling short. Then Covid-19 happened.
https://www.vox.com/policy-and-politics/22555949/us-health-care-system-ranking-covid-19-pandemic
Tag: healthcare
Covid-19 made America’s long-term care crisis impossible to ignore
“The vast majority of Americans want to age in their home and community, spending their twilight years in a familiar and comfortable setting. But the choice is not always their own.
The US long-term care system — such as it is — is broken. Hundreds of thousands of Americans are on waiting lists for home-based care. More than 40 million people report that they have cared for a loved one over 50 without any pay in the last year. The United States ranks near the bottom of developed economies in the number of older adults who receive long-term care at home. Meanwhile, America’s nursing homes are staffed by overwhelmed and underpaid workers, and for-profit takeovers of those facilities have led to worse care for patients.
Covid-19 has made this long-term care crisis impossible to ignore. More than 130,000 nursing home residents have died in the pandemic, accounting for nearly one in four US deaths. Residents of large institutions died at higher rates than those who live in the community.
In America, aging people who need care — in a nursing facility or at home — either must be wealthy enough to pay for it themselves or must deplete their income and assets enough that they qualify for Medicaid. Almost by accident, the health insurance program for low-income Americans has become the main payer for nursing home and home-based care. Experts describe long-term care in the US with a sense of disbelief.
“If you were starting from scratch, you would never design a system this way,” David Grabowski, a Harvard professor who studies the economics of long-term care, told me.
Tricia Neuman, who studies long-term care at the Kaiser Family Foundation, put it even more baldly: “We do not have a system of long-term care in our country.”
America has been struggling for decades to figure out a balance between having people age in long-term care facilities and age at home. President Joe Biden has proposed a massive infusion of federal spending on home-based care. Experts say it should start to address these structural problems — but it’s only a start.”
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“More than three in four people over the age of 50 said in a 2018 AARP survey they want to stay in their community as long they can. But fewer than half thought that would be possible — and many of them may end up being right, as the long waiting lists for home- and community-based services attest. As of February 2020, more than 820,000 Americans were stuck on their state Medicaid program’s waiting list for home- and community-based services, according to the Kaiser Family Foundation, and their average wait time is longer than three years.
Even for those lucky enough to be able to afford in-home care, the US long-term care system hasn’t done them any favors. Virginia Veliz, a 70-year-old in Santa Clarita, California, has been coordinating care for her 90-year-old mother, who has Lewy body dementia and Parkison’s disease, for the past five years.
“You really have to treat it like a job,” she said.”
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“There are some people for whom institutional care makes sense — those with severe cognitive decline, for example. Others might simply prefer to live in a nursing home with other people instead of living alone at home.
But the idea is that it should be the patient’s choice. The US still has not found a way to put that decision entirely in the patient’s hands.”
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“Prioritizing home-based care appears to be the preferred solution for both patients and policymakers. But it will cost money. The Netherlands, Norway, and Sweden are considered global leaders in providing community-based services, but they also spend a substantially higher share of their GDPs on long-term care (around 3 percent) than the US (0.5 percent).”
What Free Market Health Care Would Actually Look Like
The public option is now a reality in 3 states
“Washington state first approved its public option in 2019 and made it available to consumers for enrollment in 2020. The state now has a year of experience getting the Cascade Care program up and running, and it’s already starting to tinker with the policy design. It’s also offering lessons for Colorado and Nevada (the other state to pass a public option this year, one week before Colorado).
As these states have drawn up their plans, one thing has become clear: The potential value of a public option is in keeping health care costs in check by keeping rates lower than those of private insurance plans. But it still remains to be seen whether a public option can expand health coverage to more people.”
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“None of the states offer a “public” option like the one Congress contemplated in 2009, where the government sets up and administers its own health insurance plan.
“None of them are true public options in that sense,” says Katie Keith, who writes about insurance reform for Health Affairs and consulted with states as they developed public option legislation.
Instead, she compares them with public-private partnerships. States are contracting with private companies to create new insurance options to be overseen, if not run, by the government. States would face practical challenges to doing a “true” public option — namely, building up the financial reserves they’d need to pay out claims — so they’re taking another approach wherein private insurance companies will run the public option under rules set by the government.”
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“The plans will be sold on the ACA marketplaces, alongside ACA-compliant private insurance. Only people who are eligible for ACA coverage through the individual and small-group market can sign up”
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“How much to pay health care providers is the most important issue for any health insurance plan — those prices dictate the premiums charged to customers — and these states are taking divergent approaches in their calculations.”
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“One challenge in trying to set lower provider rates is that doctors and hospitals might simply choose not to accept the public option plan. That was Washington’s experience in its first year: Some hospitals refused to contract with the public plan, and since an adequate provider network isn’t possible without a hospital, the plan has only been available in 19 of the state’s 39 counties.
Washington is trying to correct that issue through recently signed legislation that will, among other things, require hospitals in large systems to participate in at least one public option plan. Nevada and Colorado, having seen Washington’s network-adequacy issues, are setting up their own provider participation requirements from the start.”
What Obamacare achieved — and didn’t
“The Affordable Care Act’s achievements are clear. People who buy insurance in the individual and small-group markets no longer face discrimination for preexisting conditions. Preventive services for Americans with all types of insurance are free. Combine the marketplaces that provide tax subsidies for private coverage and the Medicaid expansions adopted by 38 states (along with a handful of smaller provisions), and the ACA has provided coverage to about 31 million Americans, according to a new estimate from the Biden administration.
After the rocky rollout of HealthCare.gov in 2014 and a few years of soaring premiums, the law’s private marketplaces have stabilized”
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“one of the biggest gaps in the ACA itself: Medicaid. The program’s expansion to cover more low-income adults was supposed to be mandatory for all 50 states, a statutory overreach that was scaled back by the Supreme Court, where two liberal justices joined the conservatives to rule that the expansion must be optional.
As a result, 12 states still refuse to expand Medicaid. An estimated 4 million people who would have been covered by the expansion remain uninsured.”
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“Some people who purchase private insurance through the law can still face high out-of-pocket costs. Some of the health plans sold on the marketplaces have deductibles as high as $6,000 for an individual or $13,000 for a family — and those are usually the cheapest plans available. Until this year, people who made too much money to qualify for the law’s subsidies had to pay the full cost for their insurance, making it unaffordable for some.”
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“one core problem remains: While every other developed country in the world enjoys universal (or near-universal) health coverage, 1 in 10 people living in the United States still don’t have insurance.
That number is lower than it was before 2010, when it was about 17 percent. But it is an embarrassing outlier among our economic peers. Americans also spend more of their own money on their health care than people in almost every other country.”
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“America spends more money on health care for worse outcomes than its peer countries, as researchers have noted time and again. On a global index of health care quality and access, the US trails many more socialized systems. Life expectancy has dipped in recent years, ending decades of progress and dropping the US further behind comparable countries.
There is no denying that the high quality of health care available in the United States — for those who can afford it. The US health care industry can undoubtedly be among the most innovative in the world: It was American science that cured hepatitis-C in the last decade. The success of the country’s Covid-19 vaccine development, production and distribution is undeniable.
But prioritizing innovation above all else creates its own problems, leaving US health policy captive to private interests.”
Medicaid is a hassle for doctors. That’s hurting patients.
“For many low-income people in the US, getting insured isn’t enough to get health care: Patients with Medicaid can struggle to find a doctor willing to take their health insurance.
And this happens in large part because, for doctors and providers, billing Medicaid is a pain.
A recent study by researchers from the US Bureau of Economic Analysis, the University of Chicago, and the Federal Reserve Bank in San Francisco found providers run into more obstacles when trying to bill Medicaid than they do with other insurers, and that these administrative hurdles explain the access problems experienced by Medicaid patients as much as the program’s payment rates.”
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“About 19 percent of the initial claims submitted to Medicaid are not paid in full. For Medicare and for the private insurers, that share is much lower: 8 percent and 5 percent, respectively.
The health care providers then must invest time and money to sort out any rejected or disputed claims.”
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“the study makes a strong case that solving access problems for Medicaid patients does not require jacking up the program’s payment rates, a difficult sell in a time of strained state budgets, in the country already with the world’s highest health care costs.
The researchers instead present this solution to the problem they identified: “To increase access to care, regulators could implement or require a simpler, cheaper administration of payment processes, without raising prices.”
So if we simply made it easier for doctors to receive payment for the services they provide, it could make a big difference for Medicaid patients.”
Why Democrats’ ambitions for health care are shrinking rapidly
“America still has the highest uninsured rate in the developed world and the highest health care costs. So long as the health care industry wields a veto pen over any plan that would cut into its profits to address those problems, little is going to change.”
Biden’s plan to invest $400 billion to make long-term care cheaper is really popular
https://www.vox.com/2021/4/15/22383587/biden-american-jobs-plan-long-term-care
Joe Biden is stretching Obamacare as far as it can go
“We are about to witness, for the first time, the power of a fully operational Affordable Care Act (ACA).
The American Rescue Plan made 3.7 million more people eligible for the ACA’s premium subsidies. The Biden administration had already opened up enrollment after taking office, and 200,000 Americans signed up in the first two weeks. Now the administration is extending enrollment until August 15, backed by millions of dollars in advertising.
Insurers are expanding into new markets, and some who abandoned it long ago in the law’s fraught early years are now reentering. The individual mandate is gone, but, as it turns out, it may not be as important to the law’s long-term viability as originally thought. The law had been weakened since its passage by the Supreme Court and Republican opposition. So this is a new beginning of sorts.
“The ACA is right now much closer to what its advocates hoped it would be from the start,” Larry Levitt, executive vice president at the Kaiser Family Foundation (KFF), told me. “This is a true test of how effective a juiced-up ACA can be at getting us closer to universal coverage.
Taken together, come Labor Day, the country should have the clearest idea yet of how the ACA functions at full strength — and where holes in the US health system remain.”
The GOP’s attack on trans kids’ health care, explained
“Nowadays, doctors recommend taking a humane and affirming approach when a child expresses that their gender may not match their assigned sex at birth. This affirmation includes allowing trans kids to socially transition (i.e., use whichever name, pronouns, and clothing make them comfortable). Medical interventions — like puberty suppression or gender-affirming hormones like estrogen or testosterone — are only recommended for adolescents who have been insistent, persistent, and consistent in their gender identity over long periods.
The affirming model has been recommended by nearly every major American medical association, including the American Academy of Pediatrics, the American Medical Association, the American Psychological Association, the Endocrine Society, the World Professional Association for Transgender Health, the American College of Obstetricians and Gynecologists, and many others.
While the affirming model is often willfully misconstrued as instructing parents to accept a child’s gender identity and rush them off into medical interventions, it’s really more about creating a space for trans kids to explore their own gender expression and more thoroughly understand their dysphoria before deciding on whether to transition or not. Allowing a trans adolescent to go on puberty blockers is a decision most parents don’t take lightly. Transitioning is a slow, deliberative process for minors.
Puberty blockers merely act as a pause on an adolescent’s natal puberty, so that adolescents ages 9 to 14 can be more mentally mature before deciding on the course of their permanent treatment when the time comes”
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“puberty… brings along its own permanent changes, which could only partially be reversed through painful and expensive medical treatments in adulthood. Trans women forced through male puberty would then have to undergo painful and expensive electrolysis to remove facial hair and may be left with a body frame (shoulder and hip width) that would be unchangeable by any surgeries. Trans men would have to have surgery to remove their breasts and, like their trans female counterparts, be forced to live in an unwanted body frame for their entire lives.”