Posts Tagged ‘Medicaid’
In all the noise of our current debate over government funding of healthcare, most people seem unaware that the government — federal and state — already pay half of our nation’s healthcare bills. Although some of this funding comes through the Veteran’s Administration system, the bulk of it is in the form of two government programs — Medicare and Medicaid. Again, most people lump them together in their minds. Physicians and hospitals, however, realize that, although the two programs were begun at the same time in the mid-1960s, they are very, very different.
Medicare is the federally funded program that cares for the elderly. We pay into the program with a payroll tax and are generally eligible for coverage under it when we reach age 65. Everybody is eligible, regardless of income. In contrast, Medicaid is a program jointly funded by the federal government and the states. It is for children of low-income families, pregnant women, and the disabled. (This is slated to change with implementation of the Affordable Care Act, aka Obamacare, with low-income adults also eligible.) The ratio of federal money to state money in Medicaid varies — the federal contribution is higher for poorer states — but for most states the number is about fifty-fifty.
That’s the funding side. Looking at the payment side, the money paid out to hospitals and doctors shows a huge disparity between Medicare and Medicaid that few people outside healthcare know about. Medicare typically pays much more to the provider than Medicaid does FOR THE EXACT SAME SERVICE. You can read more about the details of this disparity, which the Affordable Care Act also aims to change, here. As with all things about Medicaid, it does vary from state to state. But it is not unusual for a physician to be paid ten times as much by Medicare for the same thing. Why is this?
The fundamental reason is that, when Medicaid was established, the Congress needed to compromise to get it passed. That compromise needed to accommodate Congressmen who were frank racists, mostly Southern Democrats. As Timothy Jost wrote:
The fact that Medicaid is a federal-state cooperative program, rather than a national program like Medicare, is an artifact of a history of which we should not be proud. It is in part the history of trying to keep poor people on relief under the thumb of local government, where their lives could be managed more closely. It is also in part the history of racism, with which President Roosevelt had to come to terms to get his New Deal programs past Southern Democratics in Congress who insisted on control over who got welfare and how much.
A huge proportion of poor people in the South during the 1960s were black. And Congress wanted to make sure of two things: not as much money would be spent on them; and the individual states could keep the medical care the poor received worse than that of more affluent people by the simple expedient of paying doctors and hospitals less money to deliver it.
The effects of this huge disparity in reimbursement has had predictable effects on physicians, who frequently lose money with every Medicaid patient they see. Not surprisingly, six times as many physicians refuse to see Medicaid patients as refuse to see Medicare patients.
It’s all a sorry legacy, and its correction is a key component of the Affordable Care Act.
It’s pretty well known that emergency room use is on the increase. This recent study summarized the trend over the past decade (the complete article is behind a paywall — let me know if anybody wants a complete copy). The authors compared 1997 with 2007, looking at the number of ED visits per 1000 population. They found that the total number of visits had increased from 353 per 1000 persons in 1997 to 390 per 1000 persons. The total number of visits was about double what you would predict just from population growth. So more folks have been going to the ED over the past decade. How many of these were children?
It turns out that the rate among children has not changed significantly over the past decade — it’s stable at 362 per 1000 population. So the past decade’s growth in ED use has come from other age groups. The study found all adults between 18 and 64 years of age increased their rate of use. Interestingly, older people, those over 65, did not.
ED use by insurance status confirmed what all of us have known for quite some time: the uninsured and those with Medicaid have the highest rate of ED use. A patient with Medicaid was roughly twice likely as a patient with insurance to go to the ED for care, and someone with no insurance was half again as likely to go to the ED as an insured person. The reason for this is most likely little or no access to regular primary care, care which would keep them out of the ED. It’s getting harder and harder for kids on Medicaid to find a doctor, largely because the reimbursement rate is so bad. In my state, for example, a pediatrician gets paid less to see a child with complicated health problems than it costs to change the oil in your car.
Another recent study, this one just involving children, examines the issue of inappropriate ED use. After all, if children can get care from a regular doctor, they are less likely to use the ED to get routine care. (Unfortunately there’s a paywall on this article, too.)
The authors examined the characteristics of what they called “inappropriate” use of the ED — essentially things for which, if the child had a regular doctor, they would not have come to the ED. Their findings also confirmed what we would have suspected: poor kids, kids on Medicaid, and uninsured kids — those who had trouble finding a regular doctor — were more likely to use the ED for routine care. ED care is extremely expensive care: the same visit for asthma, for example, is far cheaper in the office than in the ED. But if you’re a parent whose child is without regular healthcare, where are you supposed to go, if not the ED? From the article:
“Specifically, patients identified access barriers in the primary care clinic as the major reason for choosing the ED instead of the clinic. They reported a cumbersome scheduling system, long waiting times for appointments, and no availability of walk-in care.”
All this seems obvious. But sometimes we need actual research studies to confirm the intuitively obvious. And excessive ED use is one of the engines in our ever-increasing healthcare bills.
Medicaid is the joint state/federal program that covers low-income families with children, disabled persons, and long-term care for the elderly. It’s particularly important for our PICU patients: although only a quarter of America’s children are on Medicaid, half of PICU patients are (details here).
With the implementation of the new healthcare reform bill, a key feature is that Medicaid coverage will be extended to low-income adults who are not in these categories. The federal government pays at least 50% of the costs of Medicaid, with the individual states picking up the rest.
Some states, however, receive far more help than others. Mississippi pays only 25% of its Medicaid costs, for example. (You can see what each state pays here.) Why the difference? Is that fair?
The answer is that Medicaid was set up so that the poorest states — those with the lowest per capita personal income — got more support from the federal government. The intent, I think, was to reduce disparities in medical care quality from state to state. It’s not clear it has turned out that way.
Medicaid is an enormous financial problem for most states, largely because many are forbidden by their constitutions to run a deficit; so every year they need to find a way to pay their share of the Medicaid bill. In contrast, the federal government is allowed to use deficit spending for its obligations.
One way to make the system fairer between the states would be to federalize it. After all, Medicaid was enacted at the same time as Medicare, and the latter is entirely a federal program. As Maggie Mahar has pointed out, this was actually Ronald Reagan’s preference. It is unfair to demand, as we currently do, that the states finance Medicaid one way while the feds are allowed to finance it another way. Federalizing the program could also ensure that citizens of poor states get the same care opportunities of those living in richer states.
Making Medicaid a federal program should at least be a financial wash to the total economy — new expenses for the federal government would be countered by reduced expenses to the state governments. There should be administrative savings, since right now there are, in effect, fifty separate Medicaid administrations. As someone who has practiced medicine in several states, I can testify that they vary substantially in how (and how well) they operate.
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.
By now everybody knows that the Senate passed a healthcare reform bill last week. The House passed such a bill last month. The bills differ in important respects, and of course it is still unclear if the two bills will be reconciled in conference committee to produce a bill that both houses will pass. If a final conference bill does pass, it will have ground-breaking effects on medical care. What might change in the PICU?
My first-blush answer is that it will have important effects for me, my colleagues, and our patients, but not so much as it might for other aspects of medical practice. Why do I say that? First, look at where our current healthcare dollars come from (source is here):
Private insurance: 35%
Medicaid and SCHIP: 15%
Other public funds: 12%
Other private funds: 7%
These figures are for the entire system. As I’ve written before, the PICU is different — very different. Around half of children in the PICU already are covered by Medicaid, the joint federal/state program for children of poor families. This startling statistic is a reflection of the fact that poor children are far more likely than are affluent children to end up in the PICU.
But even though half the children in America’s PICUs are on Medicaid, half are not, and the healthcare reform bill can have a major impact on them, especially those from families who are presently uninsured. A PICU bill can bankrupt those families. This bill will reduce the number of times that will happen, and I think that is a good thing.
We have known for a long time poverty is associated with illness. Tiny Tim did not die at the end of Dickens’ Christmas Carol. The reason he lived was because, just in time, Scrooge had an epiphany and raised the Cratchit family’s standard of living. That Christmas goose brought more than good cheer to the Cratchits — it brought good health, too. Some historical studies, such as those of Thomas McKeown, have linked the long population rise of the past century to improved nutrition. Experts still debate if this is true or not, but either way it is old news.
It may be old news, but for today’s Tiny Tims it is very much still current news. The furious debates over what to do about health care reform are often about choice — what choices Americans should have selecting their health care, what choices doctors should have in providing it, and what choices society has in paying for it. I take care of children, so that is the lens through which I see the issue. And children have no choice at all in this matter, because the family they are randomly born into determines everything, even if they will live or die. Across America we have constructed what are, in effect, a series of laboratories to test the results of what happens when different sorts of children get severely ill. These laboratories are pediatric intensive care units.
Poor children are far more likely than affluent children to end up in a PICU. The simplest indication of this is to look at the proportion of children in PICUs who are on Medicaid: it is generally at least half, often more. Yet the proportion of children in the general population who are on Medicaid is roughly a third. Why is this? Why are poorer children more likely to become critically ill or injured?
One reason is that pregnant woman who are poor are more likely to deliver prematurely, and former premature infants have a high prevalence of residual medical problems, things which often lead to future PICU admissions. Thus more premature births equals more PICU admissions. Another reason is that, because of low reimbursement rates for providers, it is often hard for a child on Medicaid even to find a doctor. So children with chronic problems, such as asthma or diabetes, often cannot get the kind of good routine care that would keep them out of the PICU. These reasons are straightforward, ho-hum, so obvious we have become inured to their implications. (Though we should not be.)
If we dig deeper, though, we find other disturbing possibilities. For example, a study by Evans and Kim on the physiological effects of poverty found that poor children have chronically high levels of stress hormones that correlated with the length of time they were in poverty. Adolescents who were recently poor did not show these findings; what mattered most was the duration of poverty. We know childhood poverty is strongly associated with poor health as an adult, and this may be one of the reasons. Even if a poor child somehow later breaks through to affluence, the health effects linger on.
Thankfully, evidence shows that once children on Medicaid who need a PICU get there, they get the same level of care and have the same outcomes as children with private insurance. That is reassuring; poor kids on Medicaid do not get second-class care and have the same risk of mortality as the affluent ones. However, the research uncovered a very disturbing finding — children without any insurance at all were more likely to die. Why? Because they were sicker when they first arrived in the PICU, undoubtedly because their parents feared to bring them to the doctor. Because of our current dysfunctional non-system, the parents waited, and their children died as a result. Personal anecdotes are not research, but I have thirty years of them saying the same thing — uninsured kids are sicker when they get to the PICU. This is entirely predictable. Of course the prospect of a massive, bankruptcy-inducing medical bill makes even the best of parents equivocate and delay why they should not.
It is fair to debate how many adults without health insurance are in that situation owing to their own choices, although I think that argument is a straw man, as is the notion that many homeless adults choose to live in boxes under bridges. But it is not fair to inflict this debate on children, who are stuck with their birth situation. Childhood poverty carries life-long health care risks, but at least Medicaid generally gets the poorest children the care they need. Denying children health care insurance, however, kills them. I find this to be obscene.
I’ve written before about how poor children and children without health insurance are far more likely to need PICU care than are more affluent children. For example, although children on Medicaid account for 20 – 25% (depending upon the state) of children in America, about half of all children in America’s PICUs are on Medicaid. Once in the PICU, though, do the poorer kids have worse outcomes than the richer kids? Does their chronically disadvantaged situation set them up for being more difficult to treat and cure?
I’ve been looking for information about this crucial question for some time and recently found some disturbing data about it, in the form of an article in the journal Pediatric Critical Care Medicine (volume 7, pages 2-6, 2006). You need a subscription to the journal to get the article, but I’ll summarize its important findings for you.
First, the study confirmed that children without insurance are far more likely to suffer critical illness: ” . . . far more serious illness and injuries were associated with uninsured children admitted to the PICU.” But did that make it more likely that these children would suffer worse outcomes, or even make it more likely for them to die?
Unfortunately, uninsured children did have poorer chances of survival. In fact, they were three to four times more likely to die in the PICU. Why was that? The answer was not that they received different care in the PICU once they got there; the answer was that they were much sicker to start with. Compared to children with either private insurance or public assistance (Medicaid), the uninsured children came into the PICU in much worse shape, with far worse derangements in their physiological state. Most likely their parents, fearful of the cost, delayed bringing them to the hospital until sometimes it was too late to save them.
What can we learn from this? Lack of health insurance kills children. That is both a tragedy and a terrible indictment of how we presently care for America’s children.
I’ve written before (here and here) how well-documented it is that poorer children tend to have more serious illnesses. For example, although children on Medicaid (a good marker for family income) account for around a quarter of all children, about half of the children in most large PICUs are on Medicaid. Thus poorer children are twice as likely to suffer serious illness or injury.
I’ve never seen any scientific explanations before about why this is so. Certainly it makes sense that the better fed, clothed, and housed a child is, the more healthy overall that child will be. Affluent children also are more likely to have good heath insurance with good access to preventative care, so a chronic condition like asthma or diabetes is more likely to be kept under control.
These explanations, though probably part of the answer, always seemed sort of vague to me — soft data. The scientist in me wanted some biological explanation, some harder data that might explain what is happening. I recently ran across some research that takes a few steps down that path.
Two professors at Cornell recently reported in the journal Psychological Science their findings in poor children on some well-known biological markers of stress. (You can find a summary of their article here.) In their study of thirteen-year-old children, they found much higher biological markers of stress — blood pressure, levels of stress hormones in the body, and the ability of the body to respond to stress. All of these things are known to affect illness.
They also found that poverty early in life tended to establish in children these abnormal responses in a way that they didn’t improve later, even if the child’s economic circumstances improved. So early poverty has life-long effects. You can find a more general discussion of the research and its implications here.
Findings like these reinforce the argument that one of the best ways to improve Americans’ health is to reduce levels of poverty, especially among children.
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.
Anyone who works in a children’s hospital, and particularly in a PICU, soon comes to know many children we call technology-dependent. This term includes a wide variety of children with a wide variety of problems, but a good working definition is a child who requires some item of technology to stay alive. This requirement need not be minute-to-minute. For example, some children require feedings delivered by a mechanical pump, either into their veins or into their intestinal tract. If the technology fails for some reason, the parents usually have several hours at least to bring their child to the doctor to fix the problem.
For some technology-dependant children, however, their reliance on machinery really is minute-to-minute — if the equipment fails, it’s a life-threatening emergency. These usually are children on mechanical ventilators — respirator machines. The day-to-day life for these children and their families is complicated. For example, everyone who cares for the child must be trained in how to trouble-shoot the machinery as well as in more than basic CPR if everything quits working. The machinery takes power to run, and every family needs to have a plan for what to do in the event of a power failure. These are only a few of life’s complexities for these children.
How many of these children are there in the community? Those of us who work in pediatric intensive care believe the number is increasing steadily as our technological capabilities increase. Are there any data about this? The answer is some, but not as much as we’d like.
For large university children’s hospitals, the prevalence is quite high. One recent such study estimated 20% — 1 in 5 — of all the children discharged from the hospital were dependent upon technology in some way, and 1% of these needed a ventilator. Of course large, tertiary children’s hospitals see only the sickest of children: what about the general population? The only comprehensive data I could find for the USA are twenty years old, when a study from the federal Office of Technology Assessment estimated the total as 50,000 children (or about 5/100,000 persons) were technology-dependent, 2,000 of these needing ventilators. A 2006 study of just home-ventilated children for the state of Utah found a 25-fold increase over the intervening decades in the prevalence of this most fragile subgroup of children. There is no reason to doubt that what is going on in Utah is not going on in the rest of the country.
Besides complicated lives, these children and their families also have very expensive lives. How expensive? Ten years ago I looked at the bills of several of my ventilator-dependant children, and they ranged from $75,000 to $300,000 per year. At that annual cost many families quickly reach the cap on their health insurance policies. There is help for them, although it varies from state to state (and the process is long and complicated), with such things as Medicaid waiver programs and Supplemental Security Income from the Social Security Administration.
With the number of these children increasing dramatically, accompanied by a corresponding increase in cost to our cash-strapped healthcare system, what are we to do? Anything? In the abstract, I think it is unethical to deny anyone care based upon cost. But the example of technology-dependant children is a real-life example of where the abstractions of the healthcare debates meet the reality of children’s lives. As a society, we can’t buy everything for everybody. Yet amid all the hub-bub of the debate, we can’t lose sight of the plight of these children and their families.