Medicaid Block Grants = Unconstitutional Coercion?

 

Professors Sara Rosenbaum and Timothy Westmoreland have an interesting opinion piece in the New England Journal of Medicine with a curious response to the proposal that federal Medicaid funding should be re-structured as block grants (via the Patient CARE Act, proposed by some Congressional Republicans).

It is a pretty well established Republican proposal. It falls short of NCPA’s proposal to convert federal subsidies for health care into refundable tax credits. Nevertheless, it removes the perverse incentive for states to ramp up Medicaid spending beyond what is necessary to pull down more federal funds. In the current system, a state that spends one more dollar on Medicaid will attract between one and nine more federal dollars. This causes states to spend themselves into penury to recover federal dollars.

Ms. Rosenbaum and Mr. Westmoreland suggest that the same Supreme Court that ruled Obamacare’s expansion of Medicaid unconstitutional would do the same for block grants:

Naturopaths Beat Real Doctors in Online Reviews

 

If it quacks like a duck……

A study of more than 28,000 online reviews of doctors suggests that American healthcare consumers are fondest of naturopaths, audiologists, oncologists and osteopathic physicians among healthcare specialists, and are least satisfied with care given by psychiatrists, dermatologists, orthopedists and family-medicine doctors.

Ironically, the analysis indicates that generally as a doctor’s level of education and training increases, patient satisfaction actually decreases. (Vanguard Communcations)

Maybe people have a higher bar of expectations for physicians than naturopaths? I hope that is what this survey is telling us.

Why Would Health Insurers Learn From Life or Auto Insurers?

 

Businessman Sitting at His DeskDori Zweig at FierceHealthPayer has written a good article with examples of how life and auto insurers provide excellent customer service, and encouraging health insurers to do the same. It would be a great idea and there are no shortage of consultants providing advice on health insurers to do exactly that. There are entire conferences dedicated to the topic.

Unfortunately, there are significant differences between health, life, and auto insurance that mitigate health plans’ interest in replicating the excellent service we’ve seen from other types of insurer:

Is Patient Scheduling Software Valuable to Doctors?

 

I am a huge fan of entrepreneurs who want to make medical care more productive and consumer friendly. I wish all of them the best of success. Unfortunately, I am concerned that one of the trends attracting venture capital is chasing a shrinking market. That trend is patient-scheduling software in physicians’ offices.

I was at an angel investor pitch off in Arlington, Virginia, yesterday where one such firm was seeking investors. Two great incubator/accelerators, StartUp Health in New York and Rock Health in San Francisco (and, now, New York) have invested in Arsenal Health, inventor of Smart Scheduling.

Firms like this promise algorithms that use data to predict cancellations and no-shows. I suppose this is the flipside of ZocDoc, the remarkably successful business that doctors use to find new patients to fill appointments that have been cancelled.

These are all great ideas. I am just not sure they make sense in the future environment, where there will be surplus of patients and a shortage of doctors. A few years from now, when the U.S. has Canadian-style waiting lists to see specialists, why would a physician invest in technology to manage cancellations and no-shows?

Such technology would be very valuable where there is a surplus of doctors competing for a limited number of patients. But I don’t think anyone anticipates that for U.S. health care. I hope I am wrong.

Churn: Data Lacking on Critical Question

 

The media and most health policy wonks focus only on the number of insured versus uninsured people. They don’t really care if people are enrolled in Medicaid, Medicare, Obamacare plans, employer-based benefits, or whatever. As long as the percentage insured goes up, they are satisfied.

One of the problems this disguises is “churn” – people moving between different types of coverage, which leads to disrupted care. It is something that Obamacare surely makes worse, by introducing a new type of coverage for people within a certain range of income.

However, the people in charge of the new system are almost completely ignoring this problem, according to Modern Healthcare:

Experts say churn can be disruptive to people’s continuity of benefits and healthcare, particularly if they have medical conditions for which they are receiving treatment. In addition, it can be harder for people to access healthcare providers, particularly specialists, if they switch to Medicaid, which often pays lower rates.

“For a patient under a physician’s care for a condition like cancer or renal failure, changing providers in the midst of chemotherapy or dialysis can be incredibly disruptive,” said Chris Stenrud, executive director of government relations at Kaiser Permanente.

A CMS spokesman said no data on churning between private plans and Medicaid were available for the nearly three dozen states using the federal marketplace. But a committee of health plans selling products on the federal exchange that has been tracking the trend has noted a small but steady exodus from exchange plans. The committee, however, could not determine whether the people exiting the exchange plans were transitioned to Medicaid or employer coverage or became uninsured.

The solution to churn is a refundable, universal tax credit that allows people to buy health insurance of their own choosing, and getting rid of the artificially fragmented market that Obamacare has made worse.

Obamacare Cuts IRS Customer Service

 

According to the New York Times, Obamacare is to blame for the Internal Revenue Service’s decline in customer service:

The IRS’ overloaded phone system hung up on more than 8 million taxpayers this filing season as the agency cut millions of dollars from taxpayer services to help pay to enforce President Barack Obama’s health law.

What is sadly funny about this new disclosure is that when Obamacare opponents pointed out that Obamacare funded new IRS tax inspectors instead of doctors and nurses, its supporters alleged that the new bureaucrats were going to help ensure people who were owed tax credits got them.

Republicans Reach for Redemption on Medicare “Doc Fix”

 

Politico reports that Congressional Republicans might be having second thoughts about the extremely flawed, so-called Medicare “doc fix” legislation that they sent to President Obama a few days ago. One of those flaws was that the spending in the bill was not offset by cuts to other federal spending – which is why almost every Democrat in Congress voted for it too.

Well, they appear to be getting the message that NCPA has been sending them since March 25:

…… one GOP source said negotiators had resolved a sticking point over how to offset a recently enacted bipartisan Medicare overhaul that was not entirely paid for. The source said the agreement is likely to offset the overhaul, often called the “doc fix,” starting next year.

Better late than never. How they will get President Obama to sign any bill that offsets spending that was already committed by his signature on March 15 is unclear. (All they had to do in the original bill was remove two short sentences that exempted the spending from the so-called PAYGO scorecards. Had they done so, they would not have to worry about it today.)

Obamacare Increases Food Stamp Dependency

 

An investigation by the Associated Press has turned up an interesting outcome from Obamacare:

President Barack Obama’s health care law has had a surprising side effect: In some states, it appears to be enticing more Americans to apply for food stamps, even as the economy improves.

New, streamlined application systems built for the health care overhaul seem to be making it easier for people to enroll in government benefit programs, including insurance coverage and food stamps.

An Associated Press analysis finds unforeseen enrollment increases over two years in 11 states, including Illinois, California, Florida, New Jersey and Pennsylvania.

This is really the only, unspoken, reason for having government exchanges. If it were only to enroll in health insurance, there was already an industry of brokers and agents, online and in person, who did that.

I have recently proposed that all federal safety-net funding be bundled into into Opportunity Grants for which states and civic organizations can apply. That’s a long way from just making it easier for people to become dependent on a hodge-podge of government programs.

 

Medicaid Expansion Already Blowing Budgets

 

The Foundation for Government Accountability has examined every Medicaid expansion state with enrollment data available. The report:

discovered a systemic problem of under-projection and over-enrollment. The proponents of expansion have an incentive to keep their projections low when selling the massive welfare expansion to state lawmakers and the public, so the program appears less expensive than it really is.

The five states with the worst differences between projections and actual enrollment:

1) California’s enrollment more than doubled projections at 120 percent above projections.

2) Nevada missed the mark with enrollment, hitting 113 percent above projections.

3) Washington enrolled more than half a million people, exploding projections by 104 percent above projections.

4) Kentucky’s enrollment doubled projections in the first year by 100 percent above projections, costing taxpayers $1.8 billion more in the next fiscal year.

5) Illinois enrolled more than 600,000, exceeding projections by 83 percent above projections, raising the cost to taxpayers by $800 million.

Obamacare Exchanges Still A Bad Consumer Experience

 

The media have cheered the fact that Obamacare exchanges in 2015 operated better than 2014. It is one of the “achievements” that led them do declare “Mission Accomplished” for Obamacare.

Improvement over 2014 is a very low bar. Indeed, it is hard to imagine how the exchanges could possibly have performed worse this year. New research from the Wharton Business School at the University of Pennsylvania concludes that the exchanges are still ineffective:

Wharton

…… when users were provided with non-standardized plans sorted by price, an overwhelming 60% relied on a simple rule of thumb for making their selection: choose the plan with the lowest monthly premium. This emphasis on premium cost defeats the entire purpose of the exchanges.

The portals also came up short in helping consumers understand what they were purchasing. Research has shown that health insurance consumers have only a limited understanding of technical aspects of how health insurance works. In a study by the Penn Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute, only 14% of consumers were able to correctly answer four multiple-choice questions about the most important terms in health care: deductibles, copays, premiums and maximum out of pocket costs