Posts Tagged ‘health policy’
[This is important. It was written by Phil Galewitz and republished (by permission) from Kaiser Health News (KHN), a nonprofit national health policy news service.]
Repealing the federal health law would add an additional 19 million to the ranks of the uninsured in 2016 and increase the federal deficit over the next decade, the Congressional Budget Office said Friday.
The report is the first time CBO has analyzed the costs of the health law using a format favored by congressional Republicans that factors in the effects on the overall economy. It is also the agency’s first analysis on the law under Keith Hall, the new CBO director appointed by Republicans earlier this year.
CBO projected that a repeal would increase the federal deficit by $353 billion over 10 years because of higher direct federal spending on health programs such as Medicare and lower revenues. But when including the broader effects of a repeal on the economy, including slightly higher employment, it estimated that the federal deficit would increase by $137 billion instead.
Both estimates are higher than in 2012, the last time that the CBO scored the cost of a repeal.
The latest report from the nonpartisan congressional watchdog and the Congressional Joint Committee on Taxation comes just days before the Supreme Court is expected to rule on the health law’s premium subsidies in the nearly three dozen states that rely on the federal marketplace. Such a ruling would cut off subsides to more than 6 million people and be a major blow to the Affordable Care Act. It could also boost Republican efforts to repeal the entire 2010 law, which would likely face a presidential veto.
Last week, President Barack Obama said nearly one in three uninsured Americans have been covered by the law—more than 16 million people.
The CBO said repealing the health law would first reduce the federal deficits in the next five years, but increase them steadily from 2021 through 2025. The initial savings would come from a reduction in government spending on the federal subsidies and on an expanded Medicaid program. But repealing the law would also eliminate cuts in Medicare payment rates to hospitals and other providers and new taxes on device makers and pharmaceutical companies.
The CBO projected that repeal would leave 14 million fewer people enrolled in Medicaid over the next decade. Medicaid enrollment has grown by more than 11 million since 2013, with more than half the states agreeing to expand their programs under the law.
By 2024, the number of uninsured would grow by an additional 24 million people if the law is repealed.
In 2012, the CBO projected repealing the health law would increase the federal deficit by $109 billion over 10 years. It said the higher amount in Friday’s report reflected looking at later years when federal spending would be greater.
I’ve written before about how children from poor families have a higher chance of needing PICU care than do children from more affluent families. Eligibility for Medicaid is a good marker for this; nearly half the population of most urban PICUs is made up of children on Medicaid, even though the national average (it varies a little from state to state) for children on Medicaid is about 25%. So poor kids are more likely to become critically ill.
A report from the Robert Wood Johnson foundation, a renowned health policy organization, lays out how poverty correlates so closely to poor health. This chart is the most telling. It measures a somewhat vague quantity, something they call “children in less than very good health.” They obtain this value by surveying parents, so you could quibble about the validity of whatever it is the term measures. That quibble would make sense to me if the numbers weren’t so striking.
But they are striking. For example, among white, non-Hispanic children, 20% of poor children have “less than very good health,” compared with 6% of well-off children. The differences among black and Hispanic children are much more dramatic. Nearly 50% of poor, Hispanic children are not in optimal health.
What this means to me is fairly obvious, and it has been obvious for a long time — health status is linked to socio-economic status. We shouldn’t need a study to tell us that, but it is helpful to have such a graphic demonstration of the effect. I’m sure it’s partly because poor families can’t afford health insurance. But that isn’t the whole story — all of these poorest children, the group with the most severe health problems, would qualify for Medicaid, even in the states with the most stringent requirements.
Thus whatever we do about healthcare reform will be closely linked to what is happening in the economy. Perhaps the best thing we can do for healthcare is reduce poverty.
There’s been a lot of attention, appropriate attention, focused on children without health insurance. These children tend to be in families with incomes too high to qualify for Medicaid, but too low to allow purchase of decent insurance. Medicaid covers around a quarter of America’s children.
There’s another insurance problem facing America’s children — under-insurance. For families who can’t get insurance through an employer, buying health insurance on the private market is expensive — prohibitively so for many families. So they buy a bare-bones policy that can easily turn out to be a total waste of money because it doesn’t give the coverage needed when a child actually gets sick. That’s called under-insurance. How common is it among America’s children? A recent study in the New England Journal of Medicine gives us some idea of the answer.
The study takes the form of a survey done in 2007. It found that 19% of all children had inadequate health insurance. This was far more children than had no insurance at all during the year or who spent part of the year without insurance. What this means in practice is that a major illness in a child, such we often see in the PICU, can bankrupt a family even if they have some sort of coverage. Not surprisingly, “under-insured children were significantly more likely to have delayed or forgone care, and to have difficulty in obtaining needed specialist care.”
It’s too soon to see if the new healthcare bill will have any impact on this grim statistic. There are lots of interesting statistics in the article, analyzing many subgroups of children by income level and geographic location. If you’re interested at all in health policy, it’s well worth a look.
I’ve written before about how children from poor families have a higher chance of needing PICU care than do children from more affluent families. Eligibility for Medicaid is a good marker for this; nearly half the population of most urban PICUs is made up of children on Medicaid, even though the national average (it varies a little from state to state) for children on Medicaid is about 20%. So poor kids are more likely to become critically ill.
Now a new report from the Robert Wood Johnson foundation, a renowned health policy organization, lays out how poverty correlates so closely to poor health. This chart is the most telling. It measures a somewhat vague quantity, something they call “children in less than very good health.” They obtain this value by surveying parents, so you could quibble about the validity of whatever it is the term measures. That quibble would make sense to me if the numbers weren’t so striking.
But they are striking. For example, among white, non-Hispanic children, 20% of poor children have “less than very good health,” compared with 6% of well-off children. The differences among black and Hispanic children are much more dramatic. Nearly 50% of poor, Hispanic children are not in optimal health.
What this means to me is fairly obvious, and it has been obvious for a long time — health status is linked to socio-economic status. We shouldn’t need a study to tell us that, but it is helpful to have such a graphic demonstration of the effect. I’m sure it’s partly because poor families can’t afford health insurance. But that isn’t the whole story — all of these poorest children, the group with the most severe health problems, would qualify for Medicaid, even in the states with the most stringent requirements.
Thus whatever we do about healthcare reform will be closely linked to what is happening in the economy. Perhaps the best thing we can do for healthcare is reduce poverty.
This isn’t really about pediatric critical care, but it’s a topic that once again has come up for debate: how many doctors do we need? Do we already have enough? Is the problem mainly one of distribution, both in the sense of having too many specialists and a geographic maldistribution of doctors? A little over a decade ago the received opinion was that we were heading for a doctor glut, and should cut back on the number we trained. Now many predict we will not have enough doctors, especially with the progressive aging of our population. Several states have made plans for expanding the sizes of their medical school classes, and, for the first time in decades, new medical schools are opening. You can read a good discussion of this trend here.
On the other hand, some say the statement that we will be short of doctors is false. For one thing, we already have more doctors now than ever before — in 1950 we had 145 physicians for every 100,000 persons, and now we have 280 per 100,000. By 2020, even without expansion of medical schools, we are projected to have 294 doctors for every 100,000 citizens. The problem, some say, is a maldistribution of doctors and too many specialists. You can read a good summary of that argument here.
A major problem in all these discussions is that we really don’t know what the optimal number of doctors is. There is also vigorous debate over whether many things doctors do could be done, often more cheaply, by others, such as nurse practitioners and physician assistants. There is also the real probability that having more doctors will actually drive up demand for what doctors do, thereby increasing the costs of medical care even higher than they already are.
One thing most people don’t realize is that the federal government is the de facto gatekeeper for the number of new doctors we train because it controls much of the financial support for training of resident physicians, the next step after medical school. So it is residency slots, not medical school class size, that determines things. Currently we have more residency slots than we have medical school graduates — the balance is filled out by residents who went to medical schools in other countries. If we have more domestic graduates there will be less foreign residents, but the total won’t change unless the cap on residency slots is lifted.
What do I think? I think health care is not like other parts of our economy, and trying to use simple market-based reasoning will not work. In many ways, doctors drive the demand for our services. We do things, order things. This means, at least in our present system, having more doctors will stimulate more demand, demand which is in some ways insatiable.
There are many debates around the blogosphere about this complicated issue. You can follow a good discussion of it here.
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