Transcript Will We Ever Have Healthcare for Everyone?

Medicaid:
The Safety Net We Have
Rob Stone MD
Director, Hoosiers for a Commonsense Health Plan
Assistant Clinical Professor of Medicine, IUSM
Director, Palliative Care, IU Health Bloomington
Health Insecurity Indiana
• 800,000 to 900,000
Hoosiers uninsured
• Hoosier bankruptcy filings
because of medical bills:
> 27,000 annually
US Census Dept, “Income, Poverty, and
Health Insurance Coverage” Sept 2012
Himmelstein et al, American Journal
of Medicine, August 2009
Affordable Care Act
• Original projection:
3035 million newly covered
• Half thru Health Insurance
Exchanges (Mandate)
• Half thru Medicaid expansion
• Supreme Court Decision Summer 2012
Two Very Different Public Programs
Medicare
Pre-paid health insurance
Medicaid
The only safety net
Who
• Age >65, dialysis, disability
Who
• Low-income people with
additional eligibility criteria
How
• 100% federally funded, the
same in every state
How
• 60% federal, 40% state
funded
Medicaid 101
What
•Established in 1965 with Medicare
•Administered by states within broad federal parameters
Who
•73% Caucasian, 19% African American, 5% Hispanic
•Largest numbers covered – children
•Largest expense – care of frail elderly, esp in nursing homes
Indiana Medicaid 2014
400% ($95,400)
300% ($71,550)
250%
200%
200% ($47,700)
Premium
100% ($23,850)
FPL
0
No
Premium
Children
19%
Pregnant
Y-axis is % of Federal Poverty Level;
Example of a family of four
Parents
HIP
Childless Adults
ACA Plan for Premium Support
400% ($95,400)
300% ($71,550)
Sliding scale premium subsidies:
100% - 400% of poverty level
200% ($47,700)
100% ($23,850)
100-138% poverty: patient’s choice
Medicaid in all states: up to 138% of poverty
0
Y-axis is % of Federal Poverty Level;
Example of a family of four
Medicaid Expansion Would
Help People You See Everyday
Hispanic
4.5%
White
72.7%
African
American
18.8%
Other
4.0%
Urban Institute, August 2012, Uninsured Adults newly eligible for Medicaid under the ACA
with Incomes below 138% of poverty
Parents
45%
Adults
without
dependent
children
48%
Other
7%
Medicaid Expansion Would
Help People We All Rely On
Medicaid Expansion –
Good for All of Us
• Cost to Indiana taxpayers: $50-150 million
• Federal subsidy: $1.7 billion a year
A Deal Too Good to Refuse
• HIP cigarette taxes - $121 million
• High risk pool - $48 million
• Savings from prisons and jails
“I’m just here for the dental.”
A Deal Too Good to Refuse
•
•
•
•
•
•
HIP cigarette taxes - $121 million
High risk pool - $48 million
Savings from prisons and jails
Hospitals avoid $345 M/year unpaid care
30,000 new jobs
>$100 million new tax revenues
Indiana Hospital Association Report 2/11/13
Medicaid Expansion Is Almost Entirely
Federally Funded
100%
State
responsibility
for cost of
expansion
population
75%
50%
25%
5%
0%
2014
2016
6%
2018
7%
10%
2020
10%
10%
2022
10%
10%
2024
10%
Indiana Is Being Taxed
For a Program We’re Turning Down
100%
Federal
responsibility
for cost of
expansion
population
75%
Our federal tax dollars are
paying for Medicaid but IN is
50%
not getting the benefits
25%
0%
2014
2016
2018
2020
2022
2024
Losing $5 Million a Day
Michigan Chamber Applauds Passage
of Medicaid Reform Legislation
“Make no mistake, the Michigan Chamber
remains strongly opposed to Obamacare,”
said Jim Holcomb, Senior Vice President for
the Michigan Chamber. “However,
our Board of Directors believes Medicaid
reform makes sense for our state and the
business community.”
June 13, 2013
Governor
Pence has
called
Medicaid a
“broken
program”
Is Medicaid worse than no
insurance at all?
“Medicaid Patients Have More
Complications After Spine Surgery”
Any Adverse Event after
Spine Surgery
50%
Analysis
43%
40%
30%
29%
21%
20%
14%
10%
0%
Medicaid
Self-Pay
Private Medicare
Insurance
Hacquebord, J. Spine. Vol 38, Issue 16,
P1393-1400. July 15, 2013.
•Sicker people have
more adverse events
•Sicker patients are
more likely to be
signed up for
Medicaid
“Oregon Proved That
Medicaid Does Not Improve Health”
Randomized Controlled Trial
•Expanded Medicaid via a
lottery in 2008
•Most recent data is two
years after the lottery
•6,387 newly insured,
5,842 controls
Baicker, K. The Oregon Experiment. NEJM
2013;368:1713-22
Commonly reported results
•No significant difference in
average blood pressure,
cholesterol, or glucose
•Utilization increased,
outcomes did not
The Rest of the Story in the Oregon Study
Study not powered to show broad
population impact
• Average patient in the study for 17 months
• Most people don’t have these conditions, diluting any broad
population measures
• Averages for both total populations were normal
Measured endpoints were all encouraging
• Intermediate markers showed dramatic improvements
Baicker, K. The Oregon Experiment. NEJM 2013;368:171322
Oregon: Expand Medicaid,
Increase Preventive Medicine
Screened for
Cholesterol
50%
Pap Smears
In Women
Mammography in
Women >50
70%
70%
60%
60%
50%
50%
30%
40%
40%
20%
30%
30%
40%
10%
54%
more
0%
32%
20%
more
10%
0%
Control Medicaid
20%
10%
103%
more
0%
Control Medicaid
All results valid at P<0.02 or better.
Baicker, K. The Oregon Experiment. NEJM 2013;368:171322
Control Medicaid
Oregon: Expand Medicaid, Improve Health
Elevated Blood
Pressure
18%
16%
14%
12%
8%
relative
drop*
10%
Elevated Total
Cholesterol
15%
6%
14%
5%
13%
12%
11%
4%
17%
relative
drop*
3%
2%
18%
relative
drop*
1%
10%
Control Medicaid
Uncontrolled
Diabetes
0%
Control Medicaid
*Clinically meaningful but not powered to show statistical significance
Baicker, K. The Oregon Experiment. NEJM 2013;368:1713-22
Control
Medicaid
Oregon: Expand Medicaid,
Improve Mental Health
Diagnosed
After Lottery
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
Current Rx
For Depression
35
25%
30
20%
79% more
likely to be
identified*
Test Positive
For Depression
25
15%
20
10%
15
5%
33% more
likely to be
treated
0%
Control Medicaid
*p<0.05
Baicker, K. The Oregon Experiment. NEJM
2013;368:1713-22
10
5
30% less
likely to be
depressed*
0
Control Medicaid
Control
Medicaid
Oregon: Expand Medicaid,
Reduce Medical Bankruptcies
Catastrophic
Medical Bills
Currently in
Medical Debt
Borrowed Money
to Pay Bills
6%
60%
30%
5%
50%
25%
4%
40%
20%
3%
30%
15%
2%
20%
10%
1%
10%
5%
0%
0%
0%
Control
Medicaid
*p<0.05
Baicker, K. The Oregon Experiment. NEJM
2013;368:1713-22
Control Medicaid
Oregon: Expand Medicaid,
Increase ER Usage by 40%
5
Annual
emergency room
visits per person
4
3
A 40% relative increase means
one extra visit per person
every four years
2
1
0
0.68
0.95
No Medicaid
Medicaid
Taubman, S. Science Magazine. Jan 2, 2014.
Medicaid Expansion Is About
Life and Death In Indiana
Better women’s health
• 5,893 more mammograms
• 14,246 more Pap smears
Better treatment of chronic diseases
• 14,225 more diabetics receiving medications
• 23,971 less adults with depression
Many fewer preventable deaths
• Between 240 and 758 less deaths
• Consistent with the “Culture of Life”
Annual data for Indiana from Dickman S, Himmelstein D, McCormick D, and
Woolhandler S. Opting out of Medicaid Expansion: The Health and Financial
Impacts. Health Affairs Blog. January 30, 2014
Countries with Universal Healthcare