How is the Affordable Care Act changing America? That’s one of our obsessions at Storyline. We’ve traveled the country looking at how the new law has helped or hurt or perplexed people. Follow that storyline here.
Lesson 1: Medicaid expansion (and non-expansion) is making America less equal
Her love life was disrupting her health insurance. So the woman battling breast cancer weighed her options:A) Part with her boyfriend, her gainfully employed soulmate, to stay in Washington and keep her Medicaid benefits.B) Follow that boyfriend to Virginia, lose her Medicaid benefits and rack up hospital debt.C) Follow him to Virginia, get new medical insurance, keep up her cancer treatments and stay out of debt, simply by doing the one thing she swore she’d never do again: get married.
Jeff: Let’s start with your story about Liz Church, the cancer patient living with her boyfriend. He’s a former airline pilot whose job is taking him to Virginia, where Liz would not qualify for Medicaid because Virginia is way stingier.
I thought the headline was hilariously provocative: A cancer-sufferer’s agonizing choice: marriage or Medicaid?”
Danielle: It’s true, though! And it could be the name of Kasey Musgrave’s next single, right? Follow your arrow wherever…there are, um, feasible insurance options.
Jeff: I was struck by how different her life would be in Virginia compared to the District.
Danielle: Starkly different. A single, childless adult with no income in the District typically qualifies for Medicaid coverage. The same person in Virginia likely does not.
Jeff: So she could either stay in the District, where she would have to find a place to live, or move with her boyfriend to Virginia, where she wouldn’t be able to afford health insurance…unless she married him?
Danielle: Yup. Liz is 59. She has been married three times. Each marriage ended badly. This is something she does not want to do — especially for something as, well, unsexy as health insurance.
Plus she would have a crazy commute. I mean, have you experienced rush hour traffic here?
Jeff: I grew up here. I woke up like this. So how much is she paying for health care now? How much would she pay in Virginia?
Danielle: Liz pays not a cent in the District. And she says the Medicaid-covered services have been phenomenal. In Virginia, Liz tells me she’d have to pay something like $700 monthly for insurance.
Jeff: I mean, marrying for health care is not that uncommon among military couples, right? This kind of stuff does happen.
Danielle: Some people cling to jobs they hate to keep their families covered. Others work less just to keep any kind of government coverage. At least one woman is reevaluating her love life.
Jeff: And this is the sad epilogue for Liz: Two months after that story ran, the Virginia Senate again rejected federal money to expand Medicaid — that’s about 400,000 low-income people who could be getting free health care. It’s one of 21 states that aren’t working toward expansion.
Danielle: And a lot of the people missing out there are single, childless adults. In Virginia, that group is shut out of Medicaid, regardless of income (with a few strict exceptions).
Jeff: Aha. That’s why the bros drink so much in Clarendon.
Danielle: Drowning their health-care fears, man.
Jeff: The New York Times had a lovely graphic on this — Medicaid expansion, I mean. The states that took the money had huge increases in enrollment. That’s a lot of health care, a lot of happier, healthier people.
Danielle: And a lot of tax dollars.
Jeff: Well,what’s interesting are some of the arguments against Medicaid expansion. The federal government is offering to pay for all of it in the first couple of years, and 90 percent of it thereafter. Sounds like a great deal.
Danielle: But some legislators think that even the last 10 percent will strain state budgets. They say expanding Medicaid will spawn substandard health care. They believe it could discourage some people from working.
Lesson 2: Health insurance, however you get it, makes you happier.
The hospital was a short drive into town. She intended to savor this moment by tending to her animals. Her colonoscopy was in an hour.She walked through the kitchen and into the sprawling back yard, her new medical insurance card stowed in her pocket. Her silver rings and necklace sat in the house. She wasn’t looking forward to a camera poking around in her large intestine. But she was overdue for it. She was 54. Her stomach had hurt for months, and she had avoided seeing a doctor for years. But now she had insurance.
Jeff: This was a piece about how wonderful it is to have health insurance, finally. To me it reads a bit like an Amy Hempel story: deceivingly calm, dangling above a hidden precipice.
Danielle: Yes — how scary it is to not have health insurance? Her stomach bothered her for months. She feared it could be cancer and yet couldn’t afford to go to the doctor.
Jeff: A colonoscopy is not what most of us look forward to.
Danielle: Which makes it all the more touching how happy she was to finally get one.
Jeff: Yes, there were a lot of delightful turns in the story. For instance, that people buy $400 brass turtles.
Danielle: Not anymore, apparently!
Jeff: Not enough to pay for colonoscopies, at five grand a pop. But this is exactly the kind of preventative care that we want to encourage so the system saves money down the road, right?
Danielle: Yes, and there was a lot of rhetoric about this during the Obamacare fight. But I remember evidence was mixed on this.
Jeff: Well, remember that really famous experiment in Oregon? Some people got into Medicaid by lottery, and some people didn’t, and so it was a natural experiment on the effect of getting Medicaid.
Danielle: What happened?
Jeff: That’s the thing. There weren’t actually that many measurable health differences. But people did get to the doctor a lot more. And they were way less stressed out and a lot happier.
Danielle: That was only after a year though, right?
Jeff: So, yeah, we might think that there are longer-term effects we’re not seeing. But we can’t discount the increases in peace of mind, either. That was the message in Todd’s story, I think.
Lesson 3: The ACA cares a lot about new ways to pay for health care. This matters.
Boling has another mission. The nation faces a dire shortage of family doctors, especially those who focus on the elderly. And no wonder: Primary care is exhausting. The hours are long and the pay is paltry compared with specialties such as dermatology or plastic surgery.“One of my goals, my career-long goals when I quit, is to have established an economic model that makes this a desirable mode of practice,” Boling says. He understands that medical school debt is crushing. “But I think if I could pay these guys like a hospitalist, like a junior cardiologist or something, many of them would be flocking to our door.”
Danielle: You wrote about a doctor who makes house calls to the elderly and how his practice, if nationally amplified, could save the government some serious money.
Jeff: Yes, many of these house-call programs have been around for decades, but they could never get the financing quite right. They tend to rely on grants and hospital set-asides to pay for the work.
Danielle: Well, what’s changed now?
Jeff: There’s been a lot of research done showing that house calls can keep old patients healthier and out of the emergency room. This saves Medicare money.
Danielle: If Medicare is saving money, then Medicare should pay for more work like this.
Jeff: Exactly, and I hate to use this terrible, colorless phrase, but “aligning incentives” is a big part of health-care reform.
Danielle: How are the incentives skewed?
Jeff: Well, for instance, doctors are pressured to see as many patients as they can in a day. Going on house calls, you might only squeeze in seven patients a day.
Danielle: Only seven? A doctor in a clinic might see 20.
Jeff: Or more! So if we believe that really sick patients could benefit from house calls, we should pay doctors enough to practice that kind of medicine.
Danielle: Or in this case, let them share in some of the money that they saved the system.
Jeff: Exactly. Incentives, by the way, work both ways. One Obamacare program that everybody talks about punishes hospitals for readmitting patients. That’s an example of a negative incentive.
Danielle: This is what “paying for quality” means.
Jeff: Ugh, more jargon.
Danielle: Is it working, though? Everybody was talking about “bending the cost curve” during the Obamacare fight, but the cost curve seems already to have been, well, bent.
Jeff: It’s probably too early to tell whether this is recession-related or not. And a lot of these programs are only in pilot stages. It will take a couple of years before we see the successful ones get rolled out nationwide.
Lesson 4: It’s really hard to cut down on health-care costs, but one way is to treat the whole patient, not just the disease.
“I can’t go back,” he tells her, softly. “This is it. The last stand. Next one’s the box.”He came here from a Brooklyn homeless shelter, where his oxygen tank was considered a fire hazard. It’s at least an hour by subway from the Montefiore Medical Center in the Northwest Bronx, where he receives treatment for blood cancer. Last time, he fainted on the train.Deirdre Sekulic, 42, doesn’t argue. Her job is guided by one belief: Sick people with no home cannot heal. Moral implications aside, that’s an expensive problem for the nation.
Danielle: I recently visited a hospital in the Bronx that saved the government $24 million last year. How? Doctors, nurses and social workers team up to meet patients’ needs outside the hospital. That includes housing.
Jeff: Homes before health care, huh?
Danielle: If a patient is homeless, a social worker told me, he’s more likely to miss appointments — and end up in the Emergency Room, which costs on average more than $1,000 per trip. The cost obviously isn’t covered by him.
Jeff: So, the motivating logic here, again, is that an ounce of prevention…
Danielle: …is a pound of public money saved or invested elsewhere.
Jeff: I feel that people’s eyes tend to glaze over whenever cost-saving experiments are brought up. This stuff is not sexy.
Danielle: Mentioning tax dollars might jolt your audience awake.
Jeff: How does the program save money?
Danielle: Montefiore assigns, essentially, a team of health-care workers to each patient. Nurses call home to make sure patients remember to take their medicine. Social workers follow up, even deliver MetroCards to patients who can’t afford to take the train.
In order to pay for all this, Montefiore signed up to become a Pioneer Accountable Care Organization, an intensive type of ACO. If it saves Medicare money, it gets bonus payments. If it costs Medicare money, it gets penalty fines.
Jeff: I feel that people get confused between ACOs and HMOs. What’s the difference?
Danielle: Well, HMOs are run by insurers, whereas ACOs (which were introduced by Obamacare) are run by hospitals or networks or health-care providers. The practical difference for patients is that people aren’t locked into ACOs.
Jeff: But financially, the incentives are similar, right? The hospitals make money if they save money for the health system.
Danielle: It’s a new name for a fairly old set of ideas.
Jeff: Unfortunately, I don’t think the latest results for the ACOs were encouraging. I read that about half of them ended up not saving any money last year.
Danielle: That’s true. but Montefiore was a top performer. Nationwide, Pioneer ACOs saved the government $96 million last year. $87.6 million in 2012. Of course, that’s meager when you consider how much America spent last year on Medicare, Medicaid and the Child’s Health Insurance Program: $772 billion.
Jeff: What do you think Montefiore did differently?
Danielle: Montefiore is huge. Most patients receive some form of public assistance. The medical center has lots of money. And it had a reputation for focusing on holistic health care long before ACOs existed.
Lesson 5: Obamacare launched a fleet of cost-saving programs. Some of them petered out. Some of them continue to thrive. All of them offer lessons about health-care efficiency.
Thanks to an unfortunate quirk of our health-care system, hospitals often aren’t reimbursed for money-saving programs under Medicaid, including those that help low-income children. This is in stark contrast, health-care experts say, to the various preventative care incentives aimed at the elderly under Medicare, which give hospitals a cut of what they save the government.
Danielle: Here’s a less heart-warming story: An Obamacare-funded grant creates a cutting-edge child asthma management program in a rural Delaware town. Social workers visit families, many in public housing. They remove airway irritants such as old mattresses, strong perfumes, bleach cleaners…
Jeff: Sounds a lot like what Montefiore was trying to do: holistic health, treating environmental factors, etc.
Danielle: Yes, and it did save money. Over the first two years, the program cuts child E.R. visits in the area by 40 percent. It’s on track to save Medicaid nearly $4 million. But economically, it’s doomed to fail. It will probably disband in July.
Jeff: Wait, why is it doomed to fail?
Danielle: The struggle in Seaford, Del., highlights what can happen when care models and payment models aren’t in synch. This hospital — like many hospitals — is paid fee-for-service. They make money each time a kid lands in the E.R.
There aren’t financial incentives to keep kids out of the hospital. There aren’t financial incentives to keep kids healthy, as brutal as that sounds. (The CEO of the regional children’s health system wrote us a letter about it.)
Jeff: Well, that’s one of the goals of the ACO program, right, to let hospitals share in the savings?
Danielle: Yes! It makes the programs feasible. Otherwise, hospitals would be improving to their own financial demise. Shared savings give hospitals the means to keep these operations afloat.
Jeff: I liked this story because it gave us the other perspective. A lot of cost-saving programs operate primarily by reducing hospitalizations. But how do hospitals feel about that?
Danielle: The doctors I spoke to feel good. They aren’t blocking necessary hospitalizations. (Imagine that dystopian plotline.) They’re working to prevent needless E.R. trips. In a perfect world, everyone benefits.
Jeff: It also gives us a preview of what’s coming up in the next couple of years. The ACA created an innovation center that’s supposed have the power to expand these cost-saving experiments if they’re successful.
Danielle: This is the fun part, even if you aren’t a health-care nerd — all of these are experiments. We can’t know what will happen or how, exactly, health care will transform in this country over the next few years. We can extract lessons and start making meaningful tweaks today.