Posts Tagged 'healthcare reform'

Healthcare Crisis: Not Enough Specialists For The Poor, but Calif to Cut Medi-Cal Spending

Healthcare Crisis: Not Enough Specialists For The Poor

LA Times, December 15, 2012

With months-long waits for Medi-Cal patients to see specialists, some turn to emergency rooms — exactly what healthcare reform is banking on avoiding.

By Anna Gorman, Los Angeles Times

The blurry vision began early last year. Roy Lawrence ignored it as long as he could. But after falling off a ladder at his construction job, he knew he had to see a doctor.

He went to a community health clinic in South Los Angeles, where doctors determined he had diabetes and cataracts. The clinic could manage his illness but referred him early this year to the county health system for eye surgery.

Nearly a year later, Lawrence, a Jamaican immigrant without insurance, still is waiting for the operation. His vision has deteriorated so much he is considered legally blind.

PHOTOS: Waiting in vain to be seen

“I want to see again,” he said. “I’ve been waiting a long time.”

Lawrence, 49, and patients like him are posing a critical challenge for the planned overhaul of the nation’s healthcare system. Federal officials are investing billions in community health centers like the To Help Everyone (T.H.E.) Clinic, where Lawrence’s problem was diagnosed, with the hope that they can keep more patients out of high-cost emergency rooms.

But a dearth of specialists available to low-income patients presents one of the bigger hurdles facing the country as it tries to bring spiraling healthcare costs under control. Doctors say meeting new government mandates to keep patients healthy and out of hospitals — a linchpin in reducing medical spending — will be virtually impossible without the ability to make timely patient appointments with specialists.

By the end of the decade, the nation will be short more than 46,000 surgeons and specialists, a nearly tenfold increase from 2010, according to the Assn. of American Medical Colleges. Healthcare reform is expected to worsen the problem as more patients — many with complex and deferred health needs — become insured and seek specialized treatment.

Many of the newly insured will receive Medi-Cal, the government plan for the needy as administered through the state of California. Clinics already struggle to get private specialists to see Medicaid patients because of the low payments to doctors. Last week, an appellate court decision that authorized the state to move forward with 10% cuts in Medi-Cal reimbursement, which could make finding doctors for those patients even more difficult.

“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” said Mark Dressner, a Long Beach clinic doctor and president-elect of the California Academy of Family Physicians. “We’re really disappointed and concerned what it’s going to do for patient access.”

The healthcare overhaul includes initiatives aimed at reducing shortages of general medicine professionals but does little to increase the availability of specialists.

In Los Angeles County, the sheer volume of poor or uninsured patients needing specialist services has long overwhelmed the public health system, creating costly inefficiencies and appointment delays that can stretch as long as a year and half.

Patients’ conditions often must be dire for them to see a neurologist, cardiologist or other specialist quickly. Community clinics try to bypass the backed-up formal government referral system by pleading, cajoling and negotiating to get less critically ill patients like Lawrence moved up on waiting lists.

“Where needs are absolutely critical, we are able to work out special arrangements,” said Rise Phillips, chief executive of T.H.E. Clinic. “That is not the norm. That is, rather, the exception.”

At times, clinic staff members are forced to work against one of their key missions by sending patients to emergency rooms to increase the odds of their seeing a specialist more quickly.

The challenge can be seen in Belinda De Leon’s cubicle in a small, windowless back corner of T.H.E. Clinic. A referral specialist, De Leon spends her days trying to speed up appointments for the center’s clients — and fielding calls from patients wanting to know how much longer they have to wait. At any given time, she’s juggling more than 1,000 pending referrals.

One involves uninsured housekeeper Juana Barrera. Barrera, 45, has been waiting since April 2011 to see a gastroenterologist and get a colonoscopy. She has had bleeding off and on and recently started having pain in her stomach.

On a recent visit, she told De Leon she is scared to wait any longer. But she can’t afford to pay for the test out of pocket. “I’m hoping it’s not anything like cancer,” she said.

De Leon promised to update Barrera’s referral paperwork to indicate she is experiencing pain. “Hopefully that will help,” she said.

Waits for specialist appointments vary dramatically, depending on the type of specialist needed. Patients willing and able to travel across L.A. County to specialty clinics may be able to see a doctor within a month or two. Others who lack transportation and must go to a nearby facility can wait up to a year for a dermatologist or neurologist and up to 18 months for a cardiologist or ophthalmologist.

The county is trying to make the system more efficient, reduce wait times and ensure that those who don’t need more advanced care don’t overburden the system, said Mitch Katz, head of the L.A. County Department of Health Services. County officials risk losing newly insured patients, along with government funding, if they can’t find ways to reduce the bottleneck.

One focus is using technology to improve communication and better screen patients. A pilot program, for example, is allowing primary care doctors at community and public clinics to quickly transmit patients’ medical information via computer to a public health specialist for a consultation.

The electronic consults are streamlining referrals and helping clinic doctors make better treatment choices, said Louise McCarthy, executive director of the Community Clinic Assn. of Los Angeles County.

During an August visit to T.H.E. Clinic, Lawrence saw nurse practitioner Sandeep Lehil for the first time. He told her he was controlling his diabetes with medication and a modified diet. But his vision wasn’t getting any better.

“My eyes are really bad,” he told Lehil. “I can barely see.”

Lawrence’s medical record showed that he wouldn’t be seeing an ophthalmologist for many months.

“That’s a long time to live with blurry vision,” Lehil said.

“By that time, I’ll be blind maybe,” Lawrence responded.

Lawrence, who has a soft voice, an accent and a lanky frame, arrived in the U.S. nearly 20 years ago to pick apples, and overstayed his visa. He can’t work or drive, and he relies on others to cook meals to avoid burning himself. His immigration status prevents him from getting health insurance or unemployment benefits. He lives with a friend, spending most days listening to a television he can barely see. When the phone rings, he lifts it almost to his nose to see who is calling.

In mid-October, Lawrence was back at the clinic and saw a different, fill-in doctor who knew nothing about his situation, nor when his surgery would be scheduled. “You haven’t received any notice?” asked physician David Hwang. “No, not yet,” Lawrence answered, adding that he checks his mailbox every day.

De Leon, the referral clerk, later gave Lawrence unwelcome news: The wait to see an ophthalmologist at the county’s Harbor-UCLA Medical Center was still about a year. She said she was trying to get him an appointment elsewhere sooner.

Weeks later, Lawrence took matters into his own hands. With the help of a friend, he took three buses to reach the emergency room at Los Angeles County/USC Medical Center northeast of downtown. He waited several hours but finally saw an emergency room physician, who managed to get him an appointment the next day with an eye doctor.

“You have to do what you have to do,” Lawrence said.

At the medical center’s specialty clinic, ophthalmologist Simon Bababeygy told Lawrence his cataracts probably were caused by his diabetes, high blood pressure and high cholesterol.

He described the surgery he would perform, on one eye at a time. And he spoke the words Lawrence had been waiting for: He should be seeing much more clearly by the end of the year.

Preparing for the surgery, doctors got an abnormal result on a heart test. Now, Lawrence has to wait to see a county cardiologist before going back to Bababeygy to schedule the eye operation. He has no idea how long that could take.

“Every time, it’s something else,” he said. “My eyes are getting worse. And now it’s my heart.”

anna.gorman@latimes.com

Times staff writer Anna Gorman reported aspects of this story while participating in the California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School of Journalism.

Copyright © 2012, Los Angeles Times

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LA Times, December 13, 2012

Court Ruling Could Cut California Spending On Medi-Cal

A 9th Circuit appeals panel decides California can reduce its Medi-Cal reimbursements to doctors, pharmacies and others. Providers say the doctor shortage will worsen.

By Maura Dolan and Chris Megerian, Los Angeles Times

SAN FRANCISCO — In a potential windfall for the state, a federal appeals court decided unanimously Thursday that California may cut reimbursements to doctors, pharmacies and others who serve the poor under Medi-Cal.

A three-judge panel of the 9th Circuit U.S. Court of Appeals overturned injunctions blocking the state from implementing a 2011 law that slashed Medi-Cal reimbursements by 10%. Medi-Cal, a version of Medicaid, serves low-income Californians.

The ruling could make it harder to find doctors for as many as 2 million new patients who could become eligible for Medi-Cal under President Obama’s healthcare law — a possible 25% expansion of the program. California already provides one of the lowest rates of reimbursement in the nation for medical services to the poor, and there is a shortage of doctors to serve those patients.

Lynn S. Carman, an attorney for a group of pharmacies, said the decision would be costly for providers, worsen the doctor shortage and would be appealed.

“If this decision stands it will not only destroy the Medicaid program in California, but it will destroy the Obamacare program for millions of Americans who are now being shoved into the Medicaid program under the Affordable Care Act,” Carman said.

“They will not be able to obtain quality healthcare or access to services because providers cannot provide services at less than what it costs to furnish them,” Carman said.

The ruling could make it considerably easier for the state to close its budget gap.

The state is facing a $1.9-billion deficit next year, although Proposition 30’s temporary tax hike and an improving economy are projected to shift the state back into surpluses in the near future.

Medical providers said Thursday that the cutback should be lifted now that the state’s fiscal outlook has improved. The ruling can be applied retroactively to June 1, 2011.

“Now that the state has money, it would be like Scrooge for Gov. Brown not to pass a bill to eliminate at least the retroactivity part of it,” Carman said.

For the governor, Medi-Cal cuts could serve one policy aim at the expense of another.

Balancing the budget has been Brown’s first priority since taking office, and cutting healthcare — the state’s second-biggest cost after education — has been key to his fiscal goal.

But at the same time, he has wanted California to be out front in healthcare reform, and lead the country in efforts to put the federal law into place.

A spokesman for Gov. Brown released a statement Thursday that implied that Brown was inclined to put his budget priorities first, and was not likely to rescind the cuts.

“Today’s decision allows California to continue providing quality care for people on Medi-Cal while saving the state millions of dollars in unnecessary costs,” the spokesman wrote.

In a ruling written by Judge Stephen S. Trott, appointed by President Reagan, the panel said the lower court injunctions were unwarranted because the federal government had approved the cuts.

“Neither the State nor the federal government ‘promised, explicitly or implicitly,’ that provider reimbursement rates would never change,” Trott wrote.

California has estimated that the 10% cut to medical providers and pharmacies would save the state $50 million a month.

Medi-Cal typically covers families and disabled Californians. The federal law will extend its coverage to single, childless adults beginning in 2014.

The California Medical Assn., which joined dentists, pharmacists, medical suppliers and medical response companies in trying to block the cutbacks, urged Brown to repeal them.

Dr. Paul R. Phinney, president of the doctors’ association, said the cuts shrink the number of providers who could afford to serve both existing Medi-Cal patients and the new ones who could become eligible for coverage in 2014.

“We need to ensure that health insurance isn’t just an empty promise for these patients,” Phinney said.

According to the California HealthCare Foundation, Medi-Cal patients already have difficulty finding doctors.

A foundation study published in July 2010 said 25% of physicians provided care to 80% of Medi-Cal patients.

Although 90% of physicians told the foundation they were accepting new patients, only 57% said they were taking on new Medi-Cal patients.

Dr. Ted Mazer, a San Diego ear, nose and throat surgeon, said he had to stop taking fee-for-service Medi-Cal patients several years ago because the reimbursements didn’t cover his costs and Medi-Cal patients were inundating his practice.

“So few doctors will see Medi-Cal patients that I was seeing them from the Mexican border to Riverside County to Orange County,” said Mazer, an officer of the California Medical Assn. “The reimbursement costs are so poor they don’t even cover costs, let alone pay for the administrative hassle. I can only see so many until I go under.”

Chris Perrone, deputy director of the foundation, said Thursday’s ruling will make it harder to block rate cuts in the future.

“The hurdles for people who want to block these rate cuts are little higher,” said Perrone.

maura.dolan@latimes.com

chris.megerian@latimes.com

Dolan reported from San Francisco and Megerian from Sacramento.

Times staff writer Anna Gorman contributed to this report.

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Bipartisan plan to gut Medicare: Vouchers, Premium Support, and Competition

Bipartisan plan to gut Medicare: Vouchers, Premium Support, and Competition

Democrat Ron Weiden and Republican Paul Ryan are pushing a plan to send the Medicare we know into a death spiral.  Medicare would become voucher system, with recipients receiving checks based on the premiums of the second-cheapest Medicare-HMO in an area.  Annual voucher increases would be limited to Gross National Product  growth plus one percent, far less than the historical growth rates of Medicare costs.  Medicare’s premiums would be higher than HMOs premiums, because Medicare would be forced to accept sicker, more expensive patients, who would not survive under HMOs managed care.  Medicare recipients would have to pay the difference between Medicare’s higher premiums and the vouchers based on the 2nd-cheapest-HMO plan, out of their own pockets, which would steadily drive healthier patients out of Medicare.  Medicare would fall into a death spiral of higher premiums, fewer, sicker patients, and less funding.  This plan was also promoted in the 2003 Medicare Modernization Act.  See http://tinyurl.com/7enm8eo .

New York Times, December 14, 2011

Lawmakers Offer Bipartisan Plan to Overhaul Medicare

By ROBERT PEAR

WASHINGTON — A Democratic senator, Ron Wyden of Oregon, and a Republican member of the House, Paul D. Ryan of Wisconsin, unveiled a bipartisan plan on Wednesday to revamp Medicare and make a fixed federal contribution to the cost of coverage for each beneficiary.

The lawmakers aim to reshape the debate over the giant health insurance program by addressing concerns that have provoked fierce opposition to similar ideas in the past.

Just as important as the details of their proposal was the fact that the two were working together on an issue that both parties have exploited for political advantage.

In 2010, many Republicans won House seats — and the support of older voters — by arguing that President Obama’s health care law would damage Medicare. Democrats are hoping to retake the House by arguing that Mr. Ryan and other House Republicans are pushing for the privatization of Medicare, which they say could greatly increase costs for beneficiaries.

The new Wyden-Ryan proposal, by blurring the contrast between the parties on this issue, could make it more difficult for Democrats to win the argument.

The proposal would make major structural changes in Medicare and limit the government’s open-ended financial commitment to the program.

Under the proposal, known as premium support, Medicare would subsidize premiums charged by private insurers that care for beneficiaries under contract with the government.

Congress would establish an insurance exchange for Medicare beneficiaries. Private plans would compete with the traditional Medicare program and would have to provide benefits of the same or greater value. The federal contribution in each region would be based on the cost of the second-cheapest option, whether that was a private plan or traditional Medicare.

In addition, the growth of Medicare would be capped. In general, spending would not be allowed to increase more than the growth of the economy, plus one percentage point — a slower rate of increase than Medicare has historically experienced.

To stay under the limit, Congress could cut payments to providers and suppliers responsible for the overspending and could increase Medicare premiums for high-income beneficiaries, the lawmakers said.

The proposal is sure to come under fire from beneficiaries and Democratic lawmakers who see themselves as the pre-eminent defenders of Medicare.

For his part, Mr. Wyden said: “Medicare is the most important fiber in the social safety net. I would never do anything to shred it, weaken it or harm it in any way. Our proposal places traditional Medicare, long supported by progressives, alongside a menu of private alternatives that provide the choice and competition long supported by conservatives.”

Unlike the Ryan budget blueprint approved by the House in April, Mr. Ryan said, the new proposal would preserve the traditional fee-for-service Medicare program as an option for all beneficiaries. “Our proposal harnesses the power of competition to address the root cause of medical inflation,” said Mr. Ryan, the chairman of the House Budget Committee.

Democrats expressed concerns about the proposal based on policy and politics. A senior Democratic Congressional aide said, “This plan gives bipartisan political cover to Ryan and other Republicans against whom we have been waging a very successful political offensive.”

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Severe, Long-Term Medicare and Medicaid Cuts Planned Will Impact Jobs Picture

The New York Times says cutbacks in healthcare planned in future years are so severe that the resulting layoffs and hiring freezes will  worsen the nation’s unemployment.   We need to take this very seriously. Half the Obama’s health plan is funded by scaling back $575 billion in planned increases in Medicare spending over the next decade, money intended to care for baby-boomers as they age into Medicare. Democrats and Republicans alike are calling for hundreds of billions in additional Medicare cuts.  All of these Medicare cuts are aimed at the doctors, hospitals, nursing homes, rehab facilities serving Medicare patients.  The cuts will result in many of these providers either dropping out of Medicare or giving dangerous care because of short-staffing.  Read more at http://wp.me/p3xLR-pJ . Proposed cuts to Medicaid providers, and cuts in Medicaid enrollment and services are even worse.

Capping and even cutting Medicaid and Medicare spending while allowing costs to rise to accommodate insurance, drug, and hospital profits means that government and its corporate partners are tossing away the notion of equal care for seniors, children, people with disabilities, and low-income workers.

New York Times, Thursday, August 18, 2011

Cuts in Health Care May Undermine Role in Labor Market

By REED ABELSON and KATIE THOMAS

Even during months of stubborn unemployment, the health care industry has provided a solid underpinning, reliably adding jobs in an otherwise dismal environment.

For example, hospitals, nursing homes and the like added about 430,000 jobs during the recession, as the country shed 7.5 million jobs. With the latest government reports showing a meager overall gain of 117,000 jobs in July, health care remained a significant contributor with an additional 31,000 jobs for the month, a tad higher than an average monthly addition of 25,000 health jobs in the last year. Hospitals, which had a slight decline in June, added 14,000 jobs in July.

While few experts can predict how the stock market’s gyrations and government cutbacks this month will affect the health industry, several health industry analysts warn that the sector is showing signs of economic sluggishness that has long kept other business sectors beleaguered.

The situation has led many in the health industry to caution that it cannot be relied upon to keep hiring workers. “It’s not realistic to believe that we’re going to continue to generate job growth when you’re speaking about Medicare and Medicaid reductions in the hundreds of billions of dollars over the next few years,” said Daniel Sisto, president of the Healthcare Association of New York, which represents the state’s hospitals and health systems.

Companies that rely on government spending have been bracing for deeper reductions, and President Obama recently alluded to another round of belt-tightening from one of the industry’s bedrock payers — Medicare.

Signs of a gloomier outlook have been surfacing in various spots, from a slowing in new construction plans to falling share prices of nursing home companies to announced layoffs among hospital support staff.“Nobody is sure what will happen,” said Alan M. Garber, a physician and health policy expert at Stanford. The cuts in government programs like Medicare and Medicaid, and pressure to reduce costs, are thwarting health care employers in trying to meet the rising demand for their services.

“The health care industry is facing greater uncertainty than in any time in memory,” Dr. Garber said.

Yet even though economists and other experts still predict increasing demand for health care as the population ages, with an accompanying demand for job growth, health care officials and executives cite a daunting cascade of recent events as reasons to reassess any expansions.

They point to Congress’ intent to reduce spending, economically depressed states struggling to deal with a rash of cuts in Medicaid programs and the continued uncertainty of financial costs that will be imposed by the federal health care law, including contradictory lower court decisions about the constitutionality of various provisions.

A survey by the Conference Board, a business research group, found that help-wanted ads for health care providers and technicians fell by 61,200 listings in July.

In Florida, for example, health care led the state in job gains during the recession — it was the only industry that did not lose jobs during that time. But since September of last year, the leisure and hospitality industry has been adding more jobs, according to a state economist.

The Palo Alto Medical Foundation, a large physician group in Northern California that employs 5,500 people, including 1,000 doctors, says it has no plans to add many more people in the near future. “Really our focus these days is to do more with the assets we have,” said Cecilia Montalvo, the vice president for strategic development for the medical group.

Hospitals also appear to be slowing the pace of building, as projects begun before the recession started are now being completed. The volume of tax-exempt debt for hospitals in the first half of the year has fallen by nearly half from a year ago, said David Johnson, a managing director at BMO Capital Markets. “We’re overinvested in hospitals and hospital beds,” he said.

The University of Michigan Health System, for example, is adding some 560 jobs as a result of new children’s and women’s hospitals it plans to open soon and an expansion of its emergency department. But Doug Strong, who heads the system’s hospitals, said his overall goal is to shrink his work force in future years as he tries to make the system more efficient.

While he expects the demand for health care services to rise, he believes he needs to deliver that care with fewer people at less cost. “I think that is what the nation is asking of all of us,” he said.

The impact of state cuts in Medicaid are already being felt in doctor’s offices, hospitals, nursing homes and home health agencies around the country. Hospitals experienced reductions in Medicaid reimbursement in 37 states for next year’s budgets, according to Lisa Goldstein, an analyst at Moody’s, who predicts further cuts.

At the Elliot Health System in Manchester, N.H., the seemingly abrupt decision by state lawmakers to sharply reduce hospital reimbursements led the hospital to recently lay off 182 people.

“For the last 10 years, we’ve been pretty stable and we’ve been able to grow,” said Elliot’s chief executive, Doug Dean. But faced with the loss of millions of dollars in Medicaid revenue that would wreak havoc on the coming hospital budget, Mr. Dean said he had no choice but to cut jobs. “It was simply because of the economics of Medicaid,” he said. Elliot is among a group of hospitals filing a lawsuit to stop the cuts.

Health care employers are also confronting cuts to the federal Medicare program. In July, nursing home operators learned their reimbursements would be cut by 11 percent in October, and hospitals expect further reductions in what they are paid under the new health care law as well as in future efforts to reduce the federal deficit.

Still, these continue to be boom times in many corners of the industry. Partners in Care, a New York nonprofit provider of home health care services, is hiring so many home health aides that it recently opened a second training center to handle the flood of new employees.

Its staff of aides has grown from close to 5,800 in 2006 to about 9,200 today. In June, the group, which is part of the Visiting Nurse Service of New York, hired 374 new people, the second-biggest month in its history.

Jay Conolly, vice president of human resources at Partners in Care, said his group is benefiting, not just from the growing elderly population, but also from the consolidation of nursing homes and hospitals in the New York area and a heightened interest in low-cost alternatives to inpatient care. The Bureau of Labor Statistics has predicted that jobs will grow faster in the home health care area than in any other section of the health care industry.

“There’s never been enough home health aides, and there never will be,” Mr. Conolly said.

And many expect that when the economy finally does rebound, hiring will, again, take off, especially when more people are expected to be insured under the federal health care law. Geraldine Bednash, chief executive of the American Association of Colleges of Nursing, expects there is pent-up demand for their services, especially for nurse practitioners and nurse midwives, who would work in primary care. “We are going to see this huge onslaught of need for nurses,” she said. “So we’re in a blip, that’s all.”

There are some who wonder whether the country should continue to rely on health care as a stalwart supplier of new jobs. If spending on health care continues at its current pace, it will choke out other vital sectors and end up hurting the rest of the economy, said Joshua Shapiro, chief United States economist at MFR Inc. “I think the path that we’re on now is clearly unsustainable,” he said.

Tom Torok contributed reporting.

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“Everybody In! Nobody out!” Means No Exclusion of Undocumented Immigrants

Since its inception, Single-Payer healthcare’s most enduring rallying theme has been “Everybody In!  Nobody Out!”  This vision, which resonates with our most basic striving for equality, is being challenged now, as progressives and sections of labor rally behind Bernie Sanders’ new single-payer law, S.915, which contains the fatal flaw of excluding undocumented immigrants.  (Section 102, Universal Entitlement)  Single Payer has always been about EQUAL, comprehensive, accessible, affordable, economical healthcare for EVERYONE.  The damage the working class would suffer from passing this bill as is, and splitting us into “legal” and “not legal” groupings, would negate any advances that would be made by getting rid of  insurance companies.

I would like to present a resolution that was submitted to the American Public Health Association in response to the Obama Health Plan’s exclusion of undocumented immigrants.  In the year before the American Public Health Association (APHA) had its 2010 annual meeting on the theme of “Social Justice,” a massive health reform law had passed which totally excluded some 12 million undocumented immigrants. And while immigrants had been hoping for far-reaching reforms and a measure of long-delayed justice, harassment and deportation of undocumented immigrants had markedly increased.  In response, members of the Health-Not-War group at APHA proposed the following resolution to send an unequivocal message that this is intolerable to us as human beings and as public health workers.

Opposing the Exclusion of Undocumented Immigrants from Health Care Reform

November 5, 2010

The American Public Health Association,

Noting that this March, 2010, Congress passed and the President signed a massive Patient Protection and Affordable Care Act (PPACA), which not only leaves at least 23 million uninsured1, but explicitly excludes ALL undocumented immigrants,1 and,

Noting that the PPACA even forbids undocumented immigrants from using their own money to buy health insurance at discounted prices through the exchanges,2 and,

Noting that, of all groups, undocumented immigrants have arguably the greatest need of having healthcare expanded to them because:

FIRST: Undocumented immigrants are twice as likely to be uninsured as documented immigrants,3 and,

SECOND: Undocumented immigrants are generally excluded from Medicaid and SCHIP by federal law, and state-funded exceptions to this pattern will become rarer as state budgets languish. Moreover, most undocumented immigrants must wait five years after gaining legal residency to apply for Medicaid and SCHIP.4

THIRD: Undocumented immigrants’ future access to healthcare will be more challenging because  (1) increasing raids5 and deportations6, Arizona’s SB 10707, and the Secure Communities Initiative8 are likely to make undocumented immigrants more fearful of registering at health facilities and traveling to them, (2) State and County budget cuts are eliminating health services for  undocumented immigrants9, (3) Anti-immigrant groups are pressing jurisdictions to withdraw health services from undocumented immigrants10, and (4) Legislators are considering withdrawing citizenship from US-born children of undocumented immigrants, compromising their children’s access to healthcare as well as overturning a 150-year old constitutional right,11 and,

FOURTH:  Many of the factors contributing to poor access to healthcare for immigrants in general are worse for undocumented immigrants, such as immigrants’ fears of presenting at health institutions, immigrants’ increasing unemployment rates combined with the higher cost of buying individual insurance, and health institutions’ fear of losing funding for treating immigrants.   Even among the insured, immigrants’ and their children’s access to ambulatory and emergency care is worse than that of citizens,12 and,

FIFTH: Future funds for hospitalization of the uninsured, including undocumented immigrants, will be reduced, as PPACA reduces Medicare and Medicaid Disproportionate Share Hospital payments to hospitals serving the uninsured. Though these hospitals’ burden of uninsured will drop over time, PPACA specifies DSH payments must drop faster13, and Center for Medicare & Medicaid Services Chief Actuary estimated that the combined reductions at $64 billion over ten years.14

SIXTH: Reducing undocumented immigrants’ already poor access to healthcare is particularly dangerous and morally indefensible in light of their increased rates of injury, illness15, and death16 from hazardous  occupations17 and housing18, compounded with their vulnerability to deportation if they report dangerous conditions or seek treatment.

Noting that measures taken to deny healthcare to undocumented immigrants often result in citizens losing healthcare also, as exemplified by the 2004 cancellation of Colorado’s Presumptive (Medicaid) Eligibility program, which had allowed pregnant women to receive prenatal care while their Medicaid applications were being processed. The entire program was eliminated because about half of the women were found to be ineligible by immigration status. Citizen and immigrant women alike were put at risk, as well as their unborn children.19

Noting that  APHA has taken a clear positions against withholding medical care from undocumented immigrants in its resolution 2001-23, which “Urges the President and the Congress to oppose denial of eligibility for programs providing nutritional, prenatal, public health, medical care, and behavioral health benefits and services to any person residing in the United States on the basis of her or his immigration status”;20  its resolution 9501, which “Opposes any mandates and initiatives that would limit access to public health interventions and health services for undocumented and documented immigrants and their children;”21 and its resolution LB04-07, which “Deplores and warns against measures curtailing, eliminating, or disrupting health care to undocumented immigrants.”22

And finally, noting that the recent passage of this massive Health Reform law that explicitly and categorically excludes the grossly underserved undocumented immigrant population presents public health advocates with a grave challenge,

Therefore, the American Public Health Association

1.  Calls on the President, and Congress to end the exclusion of healthcare for undocumented immigrants from Health Reform, and

2.  Calls on the President and Congress to support health reform that provides equal, comprehensive, affordable, accessible healthcare for every person, regardless of their status of health, employment, income, or legalization,  and

3.  Calls on the President and Congress to assure that community health centers receiving $11 billion of dollars of federal aid over the next five years through the PPACA23 continue to give undocumented immigrants comprehensive health care, and

4.  Encourages public health advocates to attend future events on immigration reform (public rallies, demonstrations, press conferences and the like) with the demand of comprehensive, affordable, accessible medical care for all immigrants, regardless of legalization status.

References:

1.  Kaiser Health News. Some Will Remain Uninsured After Reform. Available at: http://www.kaiserhealthnews.org/Stories/2010/March/24/Some-Will-Remain-Uninsured.aspx.   Accessed October 3, 2010.

2.  Lewin Group.  Patient Protection and Affordable Care Act (PPACA): Long Term Costs for Governments, Employers, Families and Providers.   Available at: http://www.lewin.com/content/publications/LewinGroupAnalysis-PatientProtectionandAffordableCareAct2010.pdf.  p. 22.  Accessed October 3, 2010.

3.    Pew Hispanic Center.  Hispanics, Health Insurance and Health Care Access.   Available at: http://pewresearch.org/pubs/1356/hispanics-health-insurance-health-care-access.  Accessed October 3, 2010.

Working Immigrants.  Health uninsured rates among immigrants: far higher.  Available at: http://www.workingimmigrants.com/2009/08/health_uninsured_rates_among_i.html.  Accessed October 3, 2010.

4.   Kaiser Commission on Medicaid and the Uninsured,  Summary: Five Basic Facts on Immigrants and Their Health Care.   Available at: http://www.kff.org/medicaid/upload/7761.pdf.  Accessed October 3, 2010.

5.   Coalicion de Derechos Humanos.  Massive ICE sweep terrorizes Arizona communities following state passage of anti-immigrant profiling law.   Available at: http://www.derechoshumanosaz.net/index.php?option=com_content&task=view&id=166&Itemid=1.  Accessed October 3, 2010.

6.   Common Dreams.  Obama Administration Immigration Deportations Exceed Bush’s Record.   Available at: http://www.commondreams.org/print/56327.  Accessed October 3, 2010.

7.   Arizona Daily Star, National Physician Groups Condemn Arizona SB 1070.  Available at: http://azstarnet.com/news/blogs/health/article_ca3a8c46-62c6-11df-9a0a-001cc4c002e0.html.  Accessed November 3, 2010.

8.   San Francisco Immigrant Legal and Education Network.   San Francisco Immigrant Legal And Education Network Opposes The Implementation Of The Dangerous Secure Communities Program In San Francisco.   Available at: http://www.sfimmigrantnetwork.org/comments/sfilen_opposes_implementation_of_secure_communities_program_in_san_francisc, Accessed October 3, 2010.

9.   New York Times.  Reprieve Eases Medical Crisis for Illegal Immigrants.   Available at: http://www.nytimes.com/2010/01/06/us/06grady.html.  Accessed October 3, 2010.

Kaiser Daily Health Policy Report.  Economic Recession Forcing Local Health Departments To Reduce Services to Undocumented Immigrants.   Available at: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=57497.  Accessed October 3, 2010.

New York Times,   Immigrants Facing Deportation by U.S. Hospitals.   Available at: http://www.nytimes.com/2008/08/03/us/03deport.html?_r=1&hp=&pagewanted=all.  Accessed October 3, 2010.

10.   Washington Independent.   Anti-Immigration Activists See Opportunity in Health Care Debate.  Available at: http://washingtonindependent.com/55044/anti-immigration-activists-see-opportunity-in-health-care-debate.   Accessed October 3, 2010.

11.   Newsweek Magazine.  The Next Front on Immigration.   Available at: http://www.newsweek.com/2010/08/01/the-next-front-on-immigration.html.  Accessed October 3, 2010.

Politico.  John McCain backs citizenship hearings.  Available at: http://www.politico.com/news/stories/0810/40589.html.  Accessed October 3, 2010.

12.   Health Affairs.  Left Out: Immigrants’ Access to Health Care and Insurance January/February 2001.   Available at: http://www.projectshine.org/files/shared_images/Left_Out.pdf ,   Accessed October 20, 2010.

13.   The Hospital & Healthcare Association of Pennsylvania.  The Patient Protection and Affordable Care Act

(PPACA) of 2010 and the Health Care and Education Affordability Reconciliation Act (HCEARA) of 2010. Available at: http://www.haponline.org/downloads/HAP_Summary_2010_PPACA_HCEARA_April2010.pdf.  Accessed November 4, 2010.

14.  Centers for Medicare & Medicaid Services. Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” as Amended.  Available at https://www.cms.gov/ActuarialStudies/Downloads/PPACA_2010-04-22.pdf.  Accessed November 4, 2010.

15.  Moure-Eraso R,  Friedman-Jimenez G.  (2004) Occupational health among Latino workers: a needs assessment and recommended interventions.  New Solutions. 14/4:319-47.  Available at: http://www.nap.edu/openbook.php?record_id=10641&page=129.  Accessed November 4, 2010.

16.   Richardson, S. Fatal work injuries among foreign-born Hispanic Workers. Monthly Labor Review, October, 2005.   Available at:  http://www.bls.gov/opub/mlr/2005/10/ressum.pdf.   Accessed on November 4, 2010.

17.   APHA Policy Statement 2005-4: Occupational Health and Safety Protections for Immigrant Workers.  December 14, 2005.  Especially see Richardson S, Ruser J, Suarez P. Hispanic Workers in the United States: An Analysis of Employment Distributions, Fatal Occupational Injuries, and Non-fatal Occupational Injuries and Illnesses in National Research Council: Safety is Seguridad. Washington, D.C., National Academies Press, 2003.  Available at: http://www.nap.edu/openbook.php?record_id=10641&page=48  and http://www.nap.edu/openbook.php?record_id=10641&page=57.  Accessed November 4, 2010.

18.   Robert Wood Johnson Foundation.  Living in America: Challenges Facing New Immigrants and Refugees.  Available at: http://www.rwjf.org/files/publications/other/Immigration_Report.pdf.  Accessed November 4, 2010.

19.   Wall Street Journal.   Prenatal Care Is Latest State Cut In Services for Illegal Immigrants.   Available at: http://www.uniset.ca/naty/maternity/wsj_imm_med.htm.  Accessed October 3, 2010.

20.   APHA Policy Statement 2001-23: Protection of the Health of Resident Immigrants in the United States.  Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=262.   Accessed October 3, 2010.

21.   APHA Policy Statement 9501: Opposition To Anti-Immigrant Statutes.   Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=96.   Accessed October3, 2010.

22.   APHA Policy Statement LB04-07: Responding to Threats to Health Care for Immigrants.  November 9, 2004.

23.   PPACA Health Care Reform Timeline.   Available at: http://stabenow.senate.gov/healthcare/Health_Care_Timeline.pdf.  Accessed October 3, 2010.

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Obama shields states cutting Medicaid doctor payments

Bipartisan attack on Medicaid, healthcare for low-income children, seniors and workers.
  • The GOP’s justly-hated Ryan Plan puts states’ Medicaid programs on an ice floe, because it caps federal payments to states regardless of states’ needs (“block-granting”), and also gives states the rights to cut their Medicaid programs in defiance of federal standards of of who must be eligible and what services must be covered. 
  • But Democrats have also attacked Medicaid, beginning with the Clinton administration, which granted states huge numbers of waivers to the federal requirements.  Now the Obama administration is shielding states that are cutting their Medicaid programs by saying Medicaid patients and doctors cannot sue states for reducing doctor payments, even if such cuts cause a reduction in the number of doctors serving Medicaid patients to the point where patients cannot access care.
  • California has among the lowest Medicaid payments to doctors and pharmacies in the nation, and among lowest Medicaid doctor-to-patient ratios in the country.  Doctors, pharmacies, and patient advocates, including San Francisco and Sacramento Gray Panthers, sued California in response to Schwarzenegger’s 10% cuts to Medi-Cal.  Brown’s budget includes and additional 10% cut.  The suit has worked its way up to the Supreme Court, and it is this context that the Obama administration has submitted a brief saying states cannot be sued for cutting their Medicaid programs.
  • Democrats and Republicans are unified in their determination to cut our programs.  Medicare and Medicaid were won in the in the streets in the 1960s, and that is where they must be defended now.

By Robert Pear

WASHINGTON — Medicaid recipients and health care providers cannot sue state officials to challenge cuts in Medicaid payments, even if such cuts compromise access to health care for poor people, the Obama administration has told the Supreme Court.

States around the country, faced with severe budget problems, have been reducing Medicaid rates for doctors, dentists, hospitals, pharmacies, nursing homes and other providers.

Federal law says Medicaid rates must be “sufficient to enlist enough providers” so that Medicaid recipients have access to care to the same extent as the general population in an area.

In a friend-of-the court brief filed Thursday in the Supreme Court, the Justice Department said that no federal law allowed private individuals to sue states to enforce this standard.

Such lawsuits “would not be compatible” with the means of enforcement envisioned by Congress, which relies on the secretary of health and human services to make sure states comply, the administration said in the brief, by the acting solicitor general, Neal K. Katyal.

In many parts of the country, payment rates are so low that Medicaid recipients have difficulty finding doctors to take them.

But, the Justice Department said, the Medicaid law’s promise of equal access to care is “broad and nonspecific,” and federal health officials are better equipped than judges to balance that goal with other policy objectives, like holding down costs.

The administration expressed its views in a set of cases consolidated under the name Douglas v. Independent Living Center of Southern California, No. 09-958.

In 2008 and 2009, the California Legislature passed several laws reducing Medicaid payment rates. Recipients and providers challenged the cuts in court, arguing that the California plan violated — and was pre-empted by — the federal Medicaid statute.

The law does not explicitly allow such lawsuits. But the United States Court of Appeals for the Ninth Circuit, in San Francisco, said beneficiaries and providers could sue under the supremacy clause of the Constitution, which makes federal law “the supreme law of the land.” In reducing payment rates, the appeals court said, California violated the requirements of federal Medicaid law and threatened access to “much-needed medical care.”

California appealed to the Supreme Court, which is likely to hear oral arguments in the fall, with a decision by next spring.

Consumer advocates were dismayed by the administration’s position, which they said undermined Medicaid recipients’ rights and access to the courts.

“I find it appalling that the solicitor general in a Democratic administration would assert in a Supreme Court brief that businesses can challenge state regulation under the supremacy clause, but that poor recipients of Medicaid cannot challenge state violations of federal law,” said Prof. Timothy S. Jost, an expert on health law at Washington and Lee University, who is usually sympathetic to the administration.

Representative Henry A. Waxman of California, the senior Democrat on the Energy and Commerce Committee and an architect of Medicaid, said the administration’s brief was “wrong on the law and bad policy.”

“I am bitterly disappointed that President Obama would accept the position of the acting solicitor general to file a brief that is contrary to the decades-long practice of giving Medicaid beneficiaries and providers the ability to turn to the courts to enforce their rights under federal law,” Mr. Waxman said. He said that he and other Democratic lawmakers planned to file a brief opposing the administration’s view.

By contrast, many state officials agree with California and the Obama administration.

The National Governors Association and the National Conference of State Legislatures filed a friend-of-the-court brief endorsing California’s position that Medicaid recipients and providers could not sue.

In a separate friend-of-the-court brief, Michigan and 30 other states went further. “Allowing ‘supremacy clause lawsuits’ to enforce federal Medicaid laws will be a financial catastrophe for states,” they said.

Medicaid is financed jointly by the federal government and the states. The number of recipients and the costs increased sharply in the recent recession and will increase further with the expected addition of 16 million people to the rolls under the new federal health care law.

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What is the Fiscal Commission Co-Chairs’ Plan About?

What is the Fiscal Commission Co-Chairs’ Plan About?

Starting in less than a year (Oct. 1, 2011) when unemployment is supposedly back to normal, the Simpson-Bowles plan reduces projected deficits through 2020 by nearly $4 Trillion.  Spending cuts are twice revenue increases. (Extending all Bush tax cuts over same period would do the same deficit reduction.)    Not bailing out banks would have reduced deficit $1.5 trillion.   Discretionary spending under Congress’ control accounts for only 10% of deficit.  This will throttle any chances of lowering unemployment.  Most of deficit is caused by the recession, which the Co-Chairs’ plan will make worse, causing worse deficits.

Here are some of the pieces of the Co-Chairs’ plan:

Permanently Shrinks All Government Services by capping federal revenues at 21 pct of the GDP. The sum of Health, Education, Housing, Jobs Programs, Infrastructure Rebuilding, Social Security, and even military spending could never exceed 21% of GDP. This is less than spending from 1980-2008, when no baby boomers were starting Social Security and Medicare.

No repealing of Bush Tax Cuts for the Rich, no tax on stock or bond transactions, no eliminating the cap on Social Security Payroll taxes, no end of wars.  Instead,

Tax cuts for corporations and the rich; Tax increases for the middle class and the poor. Corporate tax rate is reduced from 35% to 26%.   The Individual rate for the richest is reduced from 10% to 8%.  There is a permanent extension of corporate tax credits for research.   There is a reduction or elimination of Mortgage Interest Deduction (while the housing market is still in disaster), and elimination of deductions for State and Local Taxes paid, contributions to your private retirement account, for charitable contributions,  and elimination of the Child Tax Credit.   Students must pay loans while still in school,   There’s a 15 cent/gallon gas tax, As Krugman says, “”(it) clearly represents a major transfer of income upward, from the middle class to a small minority of wealthy Americans.”

Social Security: Raises Retirement Age, Reduce benefits for middle-income recipients, Reduce Cost-of-Living Raises,  Moves Social Security from a universal plan toward a welfare plan:

  • Payroll tax cap raised to increase covered workers from 86% to 90% of workers by 2050! Even then, the rich don’t pay!

  • Cut benefits of middle-income earners: Half of Social Security recipients, who had earned above ($34,500), would be considered “high-income earners” and would be have their benefits cut from 17-36% depending on income, for example a 25% cut for people who had earned $43,000.

  • Raise Retirement Age: For full benefits, retirement age is raised from 67 to 69, an average 13% benefit cut; that discriminates against poor, who start working earlier and die earlier. To get partial benefits, retirement age is raised from 62 to 64, meaning two more years of poverty for seniors whose bodies are worn out or who can’t find jobs.

  • Reduce Cost-of-Living Raises: Raises would be based on new “chained CPI” inflation formula, .3% lower than now,  based on our alleged ability to switch to cheaper alternatives for goods and services that get priced beyond our means. What about, healthcare, which rose 4.2% last year while the regular CPI rose 1% .  By 2030, the COLA cuts would be a benefit cuts between 5-20% depending on income.
  • Means Testing, moving toward a welfare model of Social Security: Instead of raising the payroll tax cap so the rich pay the same as us on all their income, the Co-Chairs’ plan raises the payroll tax rate on the small portion of their income that’s taxed.  This undermines widespread support for the current, universal insurance model that has withstood 75 years of attacks.
  • Deficit Commission admits Social Security doesn’t increase deficit, so “savings” aren’t counted toward deficit reduction.  “Cuts are being made for Social Security’s own good.”

Medicare: Accelerate and intensify the cuts to Medicare that are in Obama Health Plan. (Increases in Medicare and Medicaid costs, are of course, the real drivers of increased future government expenses, and  single-payer, improved, expanded Medicare for All, is the only solution.  The Obama Plan greatly increases healthcare costs, and shifts the cost onto working families, particularly on Medicare.)

  • Federal health spending is supposed to be cut one-third by 2040, but no plan given.
  • The “Cadillac Insurance Tax” (a tax on insurance plans without ruinous deductibles or co-pays) would apply to less adequate insurance plans also.
  • Cuts in healthcare for veterans: “Modernize the Tricare health system” to increase premiums and co-pays for healthcare for vets.
  • It speeds up Obama Plan’s cuts to Medicare Advantage plans and charity hospitals that will serve the 23 million remaining uninsured, including all undocumented immigrants.
  • It strengthens the Independent Payment Advisory Board beyond its already-sweeping powers to cut Medicare payments to hospitals, doctors, equipment suppliers etc
  • It pushes Malpractice Reform, “tort reform,” to limit the ability of people to sue for damages in cases of medical malpractice.
  • Federal payments for Medicaid (Medi-Cal in Calif.) would be a fixed amount per year, no matter how much care was needed by poor patients in that state, making states cut their programs.  Old or sick Medicaid patients needing long-term care would have to pay more of costs.

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Health Reform may not be able to cover the uninsurables

The Hill, July 1, 2010

Health law risks turning away sick
By Julian Pecquet – 07/01/10 07:13 PM ET

The Obama administration has not ruled out turning sick people away from an insurance program created by the new healthcare law to provide coverage for the uninsured.

Critics of the $5 billion high-risk pool program insist it will run out of money before Jan. 1, 2014. That’s when the program sunsets and health plans can no longer discriminate against people with pre-existing conditions.

Administration officials insist they can make changes to the program to ensure it lasts until 2014, and that it may not have to turn away sick people. Officials said the administration could also consider reducing benefits under the program, or redistributing funds between state pools. But they acknowledged turning some people away was also a possibility.

“There’s a certain amount of money authorized in the statute, and we will do our best to make sure that that amount of money insures as many people as possible and does as much good as possible,” said Jay Angoff, director of the Office of Consumer Information and Insurance Oversight at the Department of Health and Human Services (HHS). “I think it’s premature to say [what happens] when it’s gone.”

The administration has not discussed asking Congress for more money down the line if the $5 billion runs out before Jan. 1, 2014. Uninsured sick people could start applying for participation in the high-risk insurance pools on Thursday.

Healthcare experts of all stripes warned during the healthcare debate that $5 billion would likely not last until 2014. Millions of Americans cannot find affordable healthcare because of their pre-existing conditions, and that amount would only cover a couple hundred thousand people, according to a recent study by the chief Medicare actuary.

Republicans continued to hammer that point on Thursday, asking HHS officials to brief them about the program.

We are “deeply concerned that these pools may not provide quality coverage or will limit enrollment,” Reps. Joe Barton (R-Texas), John Shimkus (R-Ill.) and Michael Burgess (R-Texas), the ranking members on the Energy and Commerce panel and its health and oversight subcommittees, wrote in a letter to HHS Secretary Kathleen Sebelius.

The letter requests a briefing on high-risk pools by July 15, particularly on three topics: protections and services in place “to make sure that access is efficient and unimpeded; whether HHS believes the program is financially sustainable through 2013; and details about how each state’s pool will be administered and what options they’ll have available.”

Leading health reform advocate Ron Pollack, founding executive director of Families USA, said the pools were a “very imperfect tool that could be implemented quickly” but were the best option available for the interim period before 2014.

“The pools are going to be helpful for a significant number of people,” he told The Hill, “but nobody thought they’re the ultimate answer for helping people with pre-existing conditions.”

Still, he didn’t rule out that Families USA could press lawmakers to allocate more money in a few years if it looks like the program needs it.

Each state has a certain budget allocation for its pool, and the first step to stay under budget would be to shift money around between states that don’t see a lot of applicants and those that do, said Richard Popper, deputy director of the Office of Consumer Information and Insurance Oversight at HHS.

“If we have that situation where we have strong demand in one state and not as strong demand in another state, the secretary of HHS after a year or two has the authority to reallocate the funding,” said Popper, who used to run Maryland’s high-risk pool.

“Along with that, we can work with the states to adjust their benefit structure, the deductibles, the co-pays, the overall plan structure to address some of those cost drivers, again to help the plan make it to 2014, when it will no longer be needed.”

In addition, Popper said, many people won’t be able to afford to participate in the program since premiums will range between about $140 and $900 a month, depending on applicants’ age and where they live. HHS estimates that at least 200,000 people will be in the program at any one time. To be eligible, applicants have to be citizens or nationals of the United States or be lawfully present; have a pre-existing medical condition; and have been uninsured for at least six months before applying for the high-risk pool plan.

“There are going to be meaningful premiums that are going to be required to stay in this plan — premiums in the hundreds of dollars every month,” Popper said. “There are a significant number of people out there with pre-existing conditions who are uninsured, but a significant number of those people … also have limited income. And some of them, while they may need this plan, the premiums may not be something they can afford.

“We have that to think about as well,” he added. “But for those who can afford it, this is going to be a great, great plan.”

If it looks like too many people are signing up — states will get monthly updates on how many people they can cover with the money they have left — there’s always the option of turning people down.

The bill “does give the secretary authority to limit enrollment in the plan … nationally or on a state-by-state basis,” Popper said. “So that is present, but at this point, we’re starting with no one in the plan as of today … so we don’t see that happening anytime soon.”

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