Health equity has become one of the pressing issues in our world today. Growing up in India, I have seen pernicious manifestations of health inequity with people I’ve known personally due to lack of basic health care access.
Minnesota consistently ranks in surveys as one of the country's healthiest states, bolstered by strengths like low prevalence of obesity and premature death. But not all Minnesotans share this distinction. Vulnerable populations, which include “disadvantaged racial and ethnic minorities,” often bear the brunt of receiving the worst care and “experience poorer health outcomes than other groups,” according to a 2012 Commonwealth Fund report. African Americans typically have lower life expectancy and higher rates of premature births, according to this and other studies.
Recently, the Minnesota Department of Health published an informative report detailing how Minnesota has failed to address the needs of these vulnerable populations. It noted “increased access” to healthcare and “targeted grants” wouldn't alone solve such great healthcare disparities. Mainly because they arise from generations of structural and institutional racism built into all the systems that contribute to overall health.
In order to help disadvantaged, vulnerable populations, a “comprehensive solution” is urgently needed. It must account for the interconnectedness of healthcare to other spheres of life such as, transportation, economic opportunity, housing, criminal justice and education. These multiple factors are what researchers call the “social determinants of health,” and without addressing disparities in these individual factors, one can never achieve and attain complete health.
Thinking about the factors that create or limit opportunity will help policy makers work toward achieving health equity in Minnesota. If you think about it closely, it makes sense: if someone falls into the lower income bracket, educational opportunities are limited, that then affects their diet, the activities they partake in, and hence their overall health and wellbeing.
“Health is created, not purchased,” according to the MDH report.
Long before this report, Minnesota began to recognize its public health short comings in certain communities. In 2009, the University of Minnesota launched the NIH-sponsored Center for Health Equity, focused on the “elimination of disparities with the goal of achieving equity.”
As we move forward from this report, multiple organizations, not just the Minnesota Department of Health or the U, should pledge to improve the lives of Minnesotans who need help. Individual philanthropy is one thing, but systemic change will have lasting and beneficial effects to better the lives of all our residents.
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Will medical marijuana soon be legal in Minnesota? That’s the question getting more and more media attention as lawmakers gear up for the 2014 legislative session, when companion bills to legalize marijuana for medical use will be introduced in both the Minnesota House and Senate.
Recent surveys have shown state-wide support for legalizing medical marijuana. A poll by Public Policy Polling from early 2013 shows 65% of Minnesotans are in favor of legalization, with another 8% undecided. According to a University of St. Cloud study undertaken in late October 2013, 76% of Minnesotans favor the legalization of medical marijuana, and another 4% are undecided.
But public and legislative support may not be enough to change the state’s marijuana laws. The Minnesota Legislature has actually already approved similar legislation – in 2009, a bill permitting terminally ill patients to use marijuana for medical purposes passed in both houses, but was ultimately vetoed by then-Governor Tim Pawlenty. In exercising his veto, Pawlenty cited concerns over the extent to which legalization, no matter how limited, might compound the “serious public safety and health risks” associated with marijuana.
Pawlenty also based his veto on a lack of support for medical marijuana on behalf of law enforcement officials across the state – a factor that may also stand in the way of the current marijuana bills. Governor Dayton has gone on record several times encouraging medical marijuana advocates to gain the support of law enforcement officials; without it, he won’t sign off on a marijuana bill of any kind.
Yet law enforcement officials remain adamantly opposed to the legalization of medical marijuana. The Minnesota Law Enforcement Coalition (which consists of the Minnesota County Attorneys Association, the Minnesota Sheriffs Association, the Minnesota Chiefs of Police Association, the Minnesota Police and Peace Officers Association, and the Minnesota State Association of Narcotics Investigators) argues that marijuana is an addictive gateway drug that threatens public safety, and that legalizing it for medical purposes is just the first step toward recreational legalization.
Governor Dayton’s decision to align himself exclusively with the opinion of law enforcement officials on this matter (instead of, say, considering it alongside input from the medical community, Minnesota lawmakers, and his constituents – some of whom are electing to move to Colorado to obtain access to medical marijuana) is puzzling. It’s also downright problematic given the revenues law enforcement agencies generate through civil forfeiture in association with narcotics.
Civil forfeiture occurs when police seize property – such as cash and cars – in relation to a suspected crime (a suspect does not need to be arrested or charged – much less found guilty – before assets are seized). This property is seldom recovered by its former owners, and because law enforcement agencies get to keep the bulk of the proceeds of the properties they seize, critics argue there is a financial incentive to pursue forfeitures.
In 2012, 6,851 forfeitures were reported in Minnesota, and 47% of these were related to narcotics. Since marijuana arrests accounted for 64% of all narcotics arrests in 2012, we can assume that a significant portion of the $6,681,319 generated from asset seizures in 2012 came from forfeiture incidents involving marijuana. Of course, the proportion of this revenue related to medical marijuana is likely small, but if law enforcement agencies are opposing the legalization of medical marijuana at least in part because they fear it will lead to outright legalization, it is possible that concern regarding eventual financial losses is informing this stance. This represents a clear conflict of interest.
If medical marijuana is legalized in Minnesota, law enforcement agencies will certainly play a crucial role in ensuring it is being used in accordance with the law. Such agencies can and should contribute their opinions and expertise on the potential consequences of legalizing medical marijuana, the challenges of regulating it, and the viability of possible enforcement strategies. However, it's also important that lawmakers consider all the reasons for law enforcement's stance.
Conservatives continue their solitary drum beat: repeal or dismantle Obamacare through misinformation. Pursuing that mantra, in a Fox News editorial, Congressman John Kline, along with two co-authors, says health insurance premiums will increase by up to 400 percent.
To be sure, health insurance costs continue to increase. We must get health care costs under control. There are methods to do this. But Obamacare is not the culprit.
According to the Minnesota Council of Health Plans, there are approximately 5.1 million people eligible for health insurance in Minnesota. Health insurance premiums historically increase with the cost of health care, regardless of Obamacare. Average health insurance premium increases prior to Obamacare have been:
2010 4.86 %
These numbers are rough averages; costs for any one person vary widely based on many factors. Spending on health care has seen similar changes over the same time period.
The Council of Health Plans has projected the allocation of health care coverage and related cost increases for 2014, as affected by Obamacare (click the pie chart on the side of the column):
76% (3.7 million) of Minnesotans are ensured by large and medium companies, Medicare, and Medicaid. These folks will see little or no premium increases for 2014, based on Obamacare.
Another 7% (342,000) are insured through small companies, but only 140,000 of these people might experience an increase. The rest will see a decline or have their premiums stay the same.
Mncare/MCHA has about 3% (167,000) of folks, 14,000 of which will be shipped to the open market.
Nine percent (488,000) of Minnesotans have no insurance, but most will qualify for a free or subsidized plan.
Five percent (276,000) will self purchase.
Rough math, puts the number of Minnesotans that might see a noticeable increase at about 8%.
That's before factoring in a) federal insurance premium subsidies; and b) the ability to shop for less expensive premiums. Individuals earning up to $45,000, or a family of four earning up to $94,000 are eligible for federal subsidies. An estimated 35% of people are eligible for financial assistance with their premiums. And, in terms of shopping in the marketplace HHS estimates that consumers will have an average of 53 insurance plans to choose from in every market.
Health insurers must file their rates with the Minnesota Department of Commerce. Many describe the rationale for their respective rate increases. Blue Cross, for example, cites these reasons for its premium rate increase:
- Increase in statewide morbidity
- Improved coverage and benefits
- Health cost trends
- New taxes and fees (attributable to ACA)
Preferred One’s rate filing expresses similar issues. Certainly Obamacare has some impact here, but not to the extent Mr. Kline complains.
Conservatives still want to repeal or delay the Affordable Care Act. That train has left the station, and they're still standing on the platform. Many people have benefitted from the health law: those with pre-existing conditions, those who are eligible to remain on their parents’ plans, those who might otherwise have broken through the benefits cap on their plan because of catastrophic illness. Conservatives, including Rep. Kline, still want to take these benefits away.
The conservative crowd that includes Mr. Kline is doing what it does best: fear monger without a constructive alternative plan.
A few months back the Star Tribune ran a story in which Congressman John Kline said the Affordable Care Act (ACA), often called Obamacare, will undermine education. However, the evidence he provided for the article on how exactly the ACA would undermine education was extremely thin. Further independent fact checking shows almost no evidence of the ACA undermining education in his own district.
Kline argues because employers will have to provide insurance to more part time employees to comply with the law, they will cut other staff and programs.
Industry analysts with whom we spoke and who work with employers confirm that the requirement to extend health coverage to workers who average 30 hours per week has very little impact on most organizations. It is already common for many schools, and other business, to extend benefits to employees working at least 32 hours per week. Consequently, for most organizations, moving the eligibility requirement to 30 hours results in relatively few newly eligible employees.
The issues Kline and other conservatives refer to are much more common in the retail, restaurant and hospitality industries. It is unlikely ACA would create a significant financial burden on most schools. While there may be a small increase in the number of individuals eligible for a school's benefits, most people agree that employees working at or near full time during the entire school year should not be denied benefits simply because they are classified as a “classroom aide” or food service worker.”
Out of the four schools cited in the November Strib article, only one has signaled a possible cutback in hours for newly hired food service and transportation employees.
Northfield public schools have no plans to "cut employee hours or jobs," according to the Strib reporting. The Minnesota state college system has not yet determined whether the ACA will have an impact, and the University of Minnesota declined to comment because its health insurance programs are largely governed by union contracts. Only in the Hastings School District was there any mention of cutbacks because of the ACA, and these cutbacks were described as potential, not certain. From this evidence, it is not rational for Mr. Kline to conclude that the ACA will “undermine education.”
We went a step further and contacted a number of other school districts in Kline’s Congressional District, and received responses from 12. None have present plans to change their employment practices, by reducing hours or firing workers. None have present plans to change their insurance benefits for their employees. Many of the schools’ health plans are governed by union or other collective bargaining contracts, so ACA is essentially irrelevant to them.
Conceptually, some schools indicated that increased costs of health care might affect other programs—but not one said that such a concern has become a reality. Most schools were mindful of the 30 hour per week limit, and wanted to ensure they comply with the law.
The biggest issue raised by some districts is the need to improve monitoring of their part-time employees to ensure their compliance with ACA. All schools want to ensure that they provide benefits to those eligible—and don’t inadvertently overpay those employees who are not eligible for benefits. This issue was mentioned on several occasions in the context of substitute teachers and sports coaches. And, while this monitoring might cost some money, it will not likely “undermine education.”
The pattern emerging from this inquiry is clear: the impact of the ACA on schools is not likely to be consequential. And, as has so often been the case, John Kline overstates the evidence to suit his desired conclusion.
In my first three months as a MNsure Navigator, I’ve worked with people in a wide range of situations: all ages, all income levels, different immigration statuses. Some of them haven’t had health insurance in years, while others are diligent about staying covered. The only thing they all share in common is the need for help with enrolling in a new health insurance plan.
MNsure has yet to release any statistics about how many people have used Assisters (Navigators, Brokers, and Application Counselors) to enroll in insurance (and I suspect they will underreport, since many Assisters have answered questions or provided a bit of help even to people who didn’t give the Assister “official credit” in their application). If my anecdotal experience is any indication, though, MNsure Assisters are an essential piece of the MNsure puzzle.
The first role Assisters fill is obvious: technology help. As a Navigator, I’ve helped many people without the computer skills necessary to get through the online insurance application. (The site is currently filled with little quirks and glitches that seem to scare off many people, even those comfortable with computers. Sometimes I need two different computers and/or web browsers to complete an application because one will inexplicably fail.)
Even for the computer-savvy, though, MNsure Assisters are important. I work in Minneapolis, where MNsure offers over 60 insurance plans from five providers. Finding the best deal for their unique situation can be overwhelming for some people. Since everyone uses medical care differently, there’s no one-size-fits-all solution. Tax credits, deductibles, coverage networks, out-of-pocket limits, and other insurance concepts are complicated. Being able to talk through these options with a trained third party helps my clients feel more confident in their choices and more prepared for what their medical costs may be.
For most of my clients, the MNsure process has gone pretty smoothly once they connect with a Navigator. The insurance offerings have met their expectations and they go home happy with the process and their new insurance. While the eventual demand for Assisters may decrease somewhat, I hope that MNsure continues to invest in the training and funding needed to keep a strong statewide network of people ready to help Minnesotans access insurance.
When people hear that I’m a MNsure Navigator, their first question is usually, “How is the website working?” And my answer is, “Generally, pretty well.” While the publicity has been overwhelmingly negative, the reality isn’t as bad. The newsmaking behind-the-scenes turmoil hasn't prevented people from being able to enroll in plans. I’ve written before about MNsure’s successes. Here’s my take on what isn’t working so far, at least in my anecdotal experience:
When I’m working with an applicant, most applications go smoothly. We can usually fix little technical issues that arise by switching web browsers or computers. The problems begin for those who have serious issues with the website (for instance, if there’s an incorrect eligibility determination) or made a mistake on their insurance application (such as misreporting income).
Fixing a mistake after an application was submitted requires a call to MNsure to ask them to throw out the entire application. Processing this request can take a few days, after which the applicant must start a new application from scratch. I look forward to seeing this aspect of the application experience improve as MNsure adds new features to its website. Even allowing users to withdraw and restart their own applications within the first 24-48 hours after submission would be extremely helpful.
Allowing for changes would also make it easier for people to experiment with different scenarios: what happens if they take a pay cut, if they get married, or if a child is no longer a dependent? Right now it’s very difficult to research such situations, because by the time one gets to the “results” page where they see their eligibility for tax credits or public plans, an application is considered submitted and unchangeable. They can’t go back to change their reported income, family size, or other potential variables.
Another issue has been reaching help at the MNsure call center. It has long wait times (I’ve waited well over 90 minutes to speak with someone) and the staff, while unfailingly professional under pressure, can’t always provide an instant resolution. Sometimes several days go by between when I report an issue and when I hear back from someone about it. Now that the initial crush of applications is over, I hope that getting help through the contact center will be easier.
The other main problem has been in how insurance applications are processed once they’re submitted. The backlog is massive, particularly for those enrolling in public programs (Medical Assistance or MinnesotaCare). People have waited months to get their insurance cards or even confirmation of their enrollment. While MNsure has been very clear that anyone who applied by December 31 will be covered on January 1, those assurances have only partially eased folks’ anxiety (and again, it’s difficult for them to get answers from the contact center).
I realize that the MNsure marketplace represents a massive change in how many people access health insurance. No rollout is without its challenges, and the expectations were wildly high for MNsure. The entire system was authorized, funded, and created within mere months, and the traffic was crushing from the day it launched. Few websites this complex go through a development process like that—it’s not as if Amazon.com was flooded with thousands of shoppers on its first day trying to purchase life-or-death products.
I’m optimistic that we’ll look back at this challenging transitional period as a temporary bump in the road. I’ve seen firsthand how powerful this new system has been for helping my clients access better and less-expensive medical care. By and large, they’ve been happy with their insurance options and relieved to complete enrollment in new plans. Let’s hope that their positive PR begins to drown out the loud chorus of naysayers.
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In a December 5 letter to constituents, John Kline writes that “Medicare provides critical assistance to tens of millions of Americans.” He is, of course, correct on this. Why, then, does he vote against Medicare when he has the chance?
His votes for the 2012 and 2013 Ryan budgets were votes to essentially end Medicare. Under the House Republican budget, Medicare would no longer be a defined benefit plan for future seniors. Instead, the budget would convert Medicare to a “premium support” system that would offer the elderly an allowance to buy a private plan, or allow them to enroll in traditional Medicare. “It would end traditional Medicare, make it harder for seniors to choose their own doctors, and increase health care costs for both current and future retirees,” the National Committee to Protect and Preserve Social Security and Medicare reported.
The Ryan budget for FY 2014 sets the following priorities on Medicare (this is was not in the recently passed budget deal):
- Preserve Medicare for those in or near retirement.
- Reform Medicare for younger generations.
- Repeal the health-care rationing board.
- Reform the medical-liability system.
- End the raid on the Medicare Trust Fund.
- Means-test premiums for high-income seniors.
This means: beginning in 2024, for those workers born in 1959 or later, Medicare would offer a choice of private plans competing alongside the traditional fee-for-service option on a new Medicare Exchange. Medicare would provide a premium-support payment either to pay for or to offset the premium of the plan chosen by the senior. Interesting that a Medicare Exchange is acceptable to conservatives, while under the Affordable Care Act, such Exchanges are anathema.
In addition, Mr. Kline has proposed raising the age of eligibility for Medicare.
He also voted against requiring Medicare to negotiate prices with pharmaceutical companies, like all good health insurers do.
Perhaps that is why Kline is rated at 9% by the Alliance for Retired Americans (Lifetime Score), and 0% by the same group on his positions. And, perhaps, that is why one should watch Mr. Kline’s actions, not listen to his words.
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Congressman John Kline is fond of bashing Obamacare with all he is worth. He has voted dozens of times to repeal it or defund it. Now he cites five anecdotal examples of individuals who have had difficulty with their insurance. Without interviewing Linda, and Kurt, and Debbie, and Jim and Mark, it is hard to know the details of their circumstances, other than as filtered through Mr. Kline’s anti-Obamacare lens. However, just for the sake of argument, let’s find some contrary examples.
On Facebook, there is a page entitled ACA "Obamacare" Signup Success Stories. Check it out.
A resident of New Hampshire got health and dental insurance for $127 per month, down from the $600 per month he was quoted in the private market. He was previously denied coverage because he is a cancer survivor.
Terry Mitchell writes he got much better pricing on his exchange than he could get in the private market. And his two sons are back on his policy, after being off for more than 6 years. Sherry Davis, whose son has asthma, says the same thing.
Laura Quigley writes about a man from Walmart who signed up in 30 minutes in California. His premium went from $550 per month to $90 per month.
Patrick McSwain in Georgia got health insurance for the first time at age 31. Cost: $287.32 per month.
Curt Welty in Colorado describes how his son and girlfriend have health insurance for the first time at $130 for both of them.
Mr. Kline: call you, and raise you. Let us talk to the five people you wrote about. Let’s see if we can’t help them, rather than just complain about them. After all, your job is to help them. Haven’t seen you try yet.
Taking care of people with disabilities and the elderly is a difficult and important job. Many do it out a feeling of service, others do it because it's a passion. But for too long the pay for these workers has remained flat. This legislative session, disability advocates are kicking off the 5% campaign, asking legislators for a 5% increase in there pay. The hope is this will provide enough for the workers to stay out of poverty and curb the high turnover rate among this workforce, which is tough on the people they serve.
Yesterday we discussed the perception by patients that health care costs are increasing exorbitantly. While that may not be true overall, it certainly is true when it comes to out of pocket dollars. Regardless of whether and how much health care costs are increasing, we need to do everything we can to bring these costs under control. All sectors of health care must participate in bringing these costs into line.
First, with the increase of deductibles and co-pays, consumers are paying more for medical care out of their own pockets. If a free market system is to truly work, consumers must be able to make proper economic decisions about what they purchase. Thus, there must be price transparency for the provision of medical services. Price transparency can have some effect on the costs of health care. For example, price transparency already is at work in elective medical care, such a Lasik surgery, eyeglasses, some dental care, some cosmetic surgery. In non-catastrophic care, this model likely can have some influence: do I really need—and want to pay for—an MRI to diagnose tennis elbow? In catastrophic and emergency care, price will not be influential. There will not be time to make economic decisions in emergency care; in catastrophic circumstances, the deductible will be used whether the price of care is $100,000 or $1,000,000.
Second, the vehicles for providing medical services need to change. Dr. Molly Cooke, President of the American College of Physicians recommended the following changes to the Medicare reimbursement formula:
- Development of evidence based clinical guidelines to prevent over use of ineffective and harmful care
- Payments based on usefulness of care, rather than fee for service
- Creation of new, patient based methods of health care delivery
- Measurement of physician results based on clinical success
- Reducing federal spending based on realistic rather than arbitrary budget cuts (sequester)
Of course, an ounce of prevention is worth a pound of cure.
Next, drug costs under Medicare Part D must be brought under control. In 2011, 47 percent of Medicare spending on Part D was co According to Joe Baker, President of the Medicare Rights Center, there are some straightforward solutions to the prescription drug excesses now faced by Medicare:
- Require the same drug manufacturer discounts be paid to Medicare as paid to Medicaid and private health insurers. This could save $141 billion over ten years.
- Create a Medicare drug formulary, again similar to private health insurance, which allows Medicare to control drug pricing
Finally, focus on the health care payment system. There are frequent reports of fraud in the Medicare system. One study suggests that the rate of fraud in Medicare is between 3% and 10%. Others have estimated the amount at $50 billion to $90 billion. There is already law on the books called the Medicare Secondary Payer Act which includes a provision permitting a “private cause of action” for recovery on behalf of Medicare. However, Courts have construed this provision narrowly, to the point where such claims cannot be brought. Congress should fix this problem, and turn the lawyers loose on behalf of Medicare, and bring back all those fraudulently obtained payments.
It is probably true that each of these components of the health care system must participate in bringing down overall health care costs. And each has a variety of vested interests that would likely oppose change. It would take a truly bipartisan, thoughtful Congress to make these solutions happen. Can we elect one in 2014?
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