United States Health Care Reform:  Progress to Date and Next Steps | JAMA | JAMA Network

The president got published in JAMA! This is a lovely, academic, chock-full-of line graphs sum up of the past 6 years of changes. Uninsured rates are way down, access and quality measures improving. The economy has responded positively. The health care world is topsy-turvy, and it is undeniably rough in the ranks of hospital management. But in spite of the challenges to the health care industry, the protections that the Affordable Care Act legislation provided make me as a believer in health care as a human right happy. And very frustrated with my home state and others that have declined to expand Medicaid.

It’s strange and sad that I celebrated the upholding of the ACA in the office of a Free Clinic where I volunteered, thinking it might be the end of clinics covering adults below the federal poverty level with a patchwork of volunteer services, state funds, and grants. I’m sorry that virtually nothing has changed for the patients we saw at that clinic. Hospitals in non-expansion states are still going uncompensated for millions of dollars of care. The federal government DSH (disproportionate share hospital) dollars that used to support public hospitals with large numbers of uninsured have declined as that money was plowed into ACA program support. One last insult: if you are paying federal taxes in a non-expansion state, your money is fed into Medicaid for adults in other states, while your health infrastructure is starving. But that is not the main focus of the article. This is a celebration. A statistically-backed victory lap. But don’t take my word, listen to Barack Obama, JD:

The United States’ high uninsured rate had negative consequences for uninsured Americans, who experienced greater financial insecurity, barriers to care, and odds of poor health and preventable death; for the health care system, which was burdened with billions of dollars in uncompensated care; and for the US economy, which suffered, for example, because workers were concerned about joining the ranks of the uninsured if they sought additional education or started a business.

Source: United States Health Care Reform:  Progress to Date and Next Steps | JAMA | JAMA Network

From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages – ProPublica

Under federal law, nonprofit hospitals must offer care at a reduced cost to lower income patients, a service often called charity care. But crucial details—how poor patients need to be, how much bills are reduced, and how policies are publicized—are left to the hospital. The Affordable Care Act empowered the IRS to set new requirements for publicizing this information, but those have yet to be finalized.

If a patient can’t pay and Northwest obtains a judgment, it’s too late. Hospital policy says once the collection agency has “incurred legal fees” on a case, the patient is ineligible for charity care, regardless of earnings.

via From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages – ProPublica.

I’m breaking my break because this spectacular piece of investigative journalism is really all I wanted for Christmas. This is an issue that makes the individual mandate, as Salt-N-Pepa might say, very necessary.

Charity care/financial assistance is available at my academic health system. Patients qualify for financial assistance based on income and payments are calculated with a sliding scale. They may owe nothing, a percentage of the total, or be put on a payment plan. This article uncovers that the criteria for how a patient finds out about or applies for or qualifies for financial assistance is largely left up to the hospital. As a recent cancer patient with massive bills but good insurance and 2/3 of a graduate degree from the academic health system where I received treatment, I still messed up paying the hospital. Medical billing is incomprehensible and damn tricky. Adding the difficulty of applying for financial assistance on top of your stack of bills from many non-communicating entities is the real cherry on top of the garbage sundae. No, it’s an additional garbage sundae on top of the garbage sundae. No, it’s just a pile of garbage.

Bottom line: Access to aid is limited. Barriers to aid are significant. And, most shockingly to me, once you have been sued successfully by the hospital, you no longer qualify for aid. *MIND EXPLODES*

Open Access. For journals. For everything.

The journals that publish those papers are, in many cases, for-profit institutions — and they prefer charging for access.

via The Gates Foundation pushes to make more academic research free and open to the public – Vox.

The (TAXPAYER FUNDED) National Institutes of Health, which spends about $30 billion yearly on medical research, began in 2008 requiring that research studies it funds be made open access a minimum of one year after publication. The Gates Foundation now requires that publication of the research it funds be openly accessible by the public starting now and for, like, ever–meaning that publishing in big brand name subscription-only journals might be off the table. This puts pressure on those journals to provide open access. HOORAY! Science evolves!

At the moment clinical research is the area of study least likely area to be open access. The community hospital I work at provides its clinicians no scholarly resources. My school bestie and I our putting our thesis where our mouth is by choosing to study and promote access to clinical resources for staff nurses…despite being told by every adviser we have that it’s a bad idea. We may (probably will) go down in flames, but sometimes the amount of push-back you get is proportional to how right you are.

Ethical problems crop up in establishments that sustain themselves by limiting access. Closed institutions embolden those with access to manipulate those without, provide a nice incubated broth for corruption, weaken the rigor of their founding principles, and encourage opacity to protect against anything that might devalue access.

Am I talking about academia? The journal Nature? Fraternities?

If you opt for open access and promote a culture of transparency you’ll get two things: 1.) Diffusion of knowledge making fertile ground for creativity and innovation, 2.) Confronted with the fact that there’s a lot of bad wood underneath the veneer. Which is the first step in getting that rotten stuff out of there.

How Obamacare Lowers Your Property Taxes – Forbes

How Obamacare Lowers Your Property Taxes – Forbes.

Key point:

A snapshot of this trend can be seen in Cook County, Illinois, where the public hospital system has seen a decrease in patients who cannot pay their bills thanks to the law’s expanded Medicaid health insurance for poor Americans.

Long and short–Medicaid expansion offers insurance to people in poverty, which is a means to provide payment to public hospitals and health systems that are mandated to give care regardless of an individual’s ability to pay.

Here’s the AHA reports on uncompensated care through 2012 for those who want numbers (before Medicaid/marketplace).

PS- I love working for a public health system because it is the closest thing I’ve seen to fulfillment of that phrase under Lady Liberty’s feet. That’s corny as hell, right?

Falling into the gap.

Midsummer 2012 the supreme court upheld the majority of the provisions of the ACA, and people like me who had made every major life decision since turning 22 based on where I could get health insurance (hello preexisting conditions) breathed a deep sigh of relief, wept one tear, and took a long nap.

Fast-forward to now and the part of the decision that made it optional for states to decline to expand their Medicaid programs is taking it’s toll. In states where Medicaid was not expanded, the majority of adults making under 100% of the federal poverty level have no options for health insurance. They do not qualify for the incentives available through health insurance exchanges. They cannot afford private coverage. Unethical.

Just for fun, here’s the states by political party in 2013 (source):

governors 2012

Uninsured people will still use emergency departments and be inpatients, putting hospitals in a tough position as part of the ACA takes away the pre-ACA measure of DSH (disproportionate share hospital) funding (federal dollars) that hospitals needed to account for the absence of reimbursement from these uninsured folks. DSH dollars were supposed to be replaced by payments from Medicaid insurance dollars. In states that did not expand Medicaid, DSH dollars are being replaced by zero dollars. IMHO this is on the state–but Obamacare takes the knock. From the patients denied access to affordable care, the hospitals that are in dire straights financially, and the communities that are losing their hospitals (and often largest employers) as they just can’t stay afloat.

I’m working up posts describing how one qualifies for Medicaid in non-expanded states, the state incentives offered by Medicaid expansion, and the burden on local communities with large numbers of uninsured people in poverty. This is a mire, but I can’t think of one more worthwhile to wade through. PARTY TIME!