U.S. Healthcare Outcomes and State Initiatives To Lower Costs

 Due to federal failure to enact meaningful healthcare reforms, this article reviews states that are making a difference. Three states which have taken steps to control the cost of healthcare without adversely impacting patient outcomes are Maryland, Montana, and Oregon and this article reviews what they have done. But before we get to that let’s review the current status of U.S. healthcare.

 Washington State’s 2022 report on evidence-based methods to control costs, increase equity, and improve industry transparency and regulation stated three truths that should shock the nation, if voters were only aware. Globally, U.S. healthcare continues to be the most expensive healthcare but health quality metrics continually show the results are not worth it. In 2019, the U.S. spent 16.8% of all gross national product (GNP) on healthcare. Norway, the top scoring nation for health outcomes spent 10.5%. How much longer are the American people going to have to listen to how more expensive their health care will be in a national healthcare system-clearly this is not the case. Here are the Commonwealth Funds 2021 findings for the latest metrics on global healthcare outcomes compared to the rest of industrialized nations: (Eric C. Schneider, 2021)

 U.S. ranks last in healthcare outcomes (we spend 60% more on healthcare than Norway, the top nation for outcomes)

               1. Highest infant mortality 

               2. lowest life expectancy 

               3. Lowest rate of reduction in avoidable deaths (which is what healthcare is supposed to do)

              4. Last on access to care 

              5. Last in administrative efficiency

              6. Last in health equity (discrimination in health services)

              7. Second on measures of care process (we are tracking it all as the outcomes decline)

The Commonwealth Fund has for years done an excellent job of finding methods to compare different healthcare systems and this latest report reviewed 71 measures for 2019 to arrive at its conclusions. Nations reviewed were: U.S., Switzerland, Germany, France, Sweden, Canada, Norway, United Kingdom, Netherlands, Australia, and New Zealand. Here are the metrics reviewed:

 Cost-U.S. Healthcare is 50% more expensive than other industrialized nations

Gross domestic product, which is essentially a measure of all goods services produced over a specific period of time for the country is a measure of wealth and how much of that wealth is spent on things, such as housing, education, and healthcare. It is one measure to assess a cost comparison for health systems which has been widely used. New Zealand spent the least on its healthcare, at 9.1% and one could argue that it is a tiny nation and not comparable to the complexity of the U.S., but Australia, also spent 9.4%. For nations with larger populations, France spent 11.1% of its GNP on healthcare and Germany spent 11.7%. And unlike the U.S. these nations cover most of their populations and their residents don't pay thousands of dollars out of pocket for services.

 Infant Mortality-U.S. Deaths are 70% higher than other industrialized nations

Infant mortality is a measure of babies who die and is a direct reflection on maternal child healthcare and access to care. In this forlorn measure, the U.S. has 5.7 deaths per 1,000 infant births, compared to the other nations, which had less than 4 deaths. Switzerland boasted only  3.3 deaths per 1,000 births.  

 Maternal Mortality-U.S. deaths are 5 times higher than other industrialized nations

The U.S. also has an abysmal maternal mortality rate, which is going to increase with the latest century rollback of women’s health in many states, which seek to outlaw termination of pregnancy for any reason. To be clear there were 17.4 American women who died as a result of childbirth per 100,00.  France loses only 3.2 women, even if you are math impaired that is five times the number of women who die from childbirth in the USA. Expect more to perish from ectopic pregnancies, hemorrhaging (bleeding out), cardiac conditions, and other preventable causes. In 2020, 24 women per 100,000 died from childbirth in the United States. 

In 2021, 32 women out of 100,000 died from childbirth, an astounding increase of 25% in preventable deaths. The Centers for Disease Control 2022 analysis found that 4 out of 5 pregnancy related deaths are preventable-80%. (Centers for Disease Control and Prevention, 2022) This is an appalling statistic! The U.S. is ranked 55^th for maternal mortality-a metric that clearly shows how little our females are valued.  U.S. legislators would rather a women die as a result of childbirth than alter a pregnancy. Current maternal mortality in the U.S. is equivalent to many less developed countries including: Mexico, Egypt, and much worse than Cuba (which has a national healthcare system). (Ritchie, 2023) While evaluating healthcare outcomes for women more than a decade ago I was astounded to learn of the disparities in maternal mortality and the high rate of deaths for pregnant women in Washington D.C. is seared into my mind.[1] Seemingly people don’t want to believe how bad things are for pregnant women in the U.S. or they don’t care. It feels like people are looking away as they do for the poor souls  living in tents in every U.S. city.

 Life Expectancy-Americans pay more for their healthcare and don’t live as long

The Commonwealth metrics uses the number of years attained on average by nation as the measure of life expectancy. All of the top nations had average life expectancies beyond age 80, but Americans (83.1 years) can expect to live 2.5 years less than the rest. And only in the U.S. are there sharp differences based on race, mortality for black (74.9 years) and American Indian (73 years) populations are much worse than the average.

 Reduction of Avoidable Deaths-U.S. ranks the worst

The Commonwealth Fund 2021 Report on global health outcomes reviewed the reduction of avoidable deaths and Switzerland reduced avoidable deaths by 25%,  five times the U.S. rate, which was only 5%. The next worst performer in this group of 11 nations was Germany which still reduced deaths by 13% This is another metric where the residents of the states, who are gouged and underserved for health care should be electing officials who are going to take action. Leaving it to the marketplace isn’t working.

 Administrative Efficiency-U.S. ranks the worst

Anyone who has had to obtain healthcare in the United States knows what a nightmare it is to find affordable insurance, obtain a clinician whom is accepting new patients, and choke down the copayments and fees from excluded charges for anesthesiologists, labs, and other out-of-network care thrust upon them.

 We know what we must do to improve healthcare outcomes:

1. Provide universal coverage to remove cost barriers to obtain health care-stop gearing health care investments just for wealthy suburbs. 

2. Invest in primary health care systems-not money makers for huge hospital corporations 

3. Reduce administrative burdens on patients and clinicians-integrated health systems work best

4.  Invest in social services-nutrition, education, childcare, safety, housing, transportation

 State Actions to Control Healthcare Costs

 Capitation-fixing fees

Maryland enacted a regulatory body to control hospital costs in an all-payor-model and all hospitals must participate. Maryland received a CMS waiver to use this model instead of the DRG system adopted by most other states, which is highly inflationary. The agency reviews hospital rates and has the ultimate authority on approval of changes. This governing authority has not resulted in hospital closures or patient care, but it has produced the lowest hospital prices in the country. This model is a capitation model which has worked for Maryland and was launched in 2014.

 Linking fees to a multiple of Medicare Rates

Montana, through the leadership of Marilyn Bartlett pegged state employee healthcare costs to a percentage of Medicare rates and saved the state thirty million dollars. Even the Republicans in Montana appreciate a taxpayer savings. Barlett had to fight the deep pockets of the healthcare industry, to enact this contract provision, but she won. Prior to her administration, hospitals were charging the Montana State Employees Plan five times the Medicare rates. Barlett, a CPA, has taken her leadership skills on the road advising states and business coalitions on methods to control costs. (Walker, 2021)

 Payment caps and Reference based pricing

Oregon caps state employee health plan payments for 24 of its 62 hospitals, because of differing needs of rural hospitals, critical access hospitals (urban trauma centers), and hospitals that served 40% or more of Medicaid patients (low income). Oregon also plans to limit cost increases to 3.4% per member per year. (Rakotoniaina, 2021)

 Washington’s report concludes with four recommendations to reduce the costs of healthcare including: targeted price growth regulation, expanded transparency and cost-growth benchmarks, strengthened anti-trust enforcement and consumer protection, and improved drug affordability. At least, on the latter, the federal government did finally come out with some affordable insulin mandates. But what really needs to happen is for the government to be restored to the people, by overturning the Citizens United ruling which allows corporations to make unlimited political donations. Given the current makeup of the Supreme Court, who seem intent on settling their own scores versus representing the will of the people, this seems unlikely. However, lifetime appointments does not mean we can't take administrative action under the constitution to remove court members from hearing cases. It’s time to bring in the back bench of the federal courts.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when obtaining medical care, do stipulate that for which you agree and for which you decline. For example, if your hospital refuses to recognize your medical directive, find another one for your procedure.

 Roberta Winter is an independent health policy analyst and journalist, who has published this blog since 2007. In 2013 her guidebook to the U.S. healthcare system was published by Rowman and Littlefield.

References

Centers for Disease Control and Prevention. (2022, September 19). Four in 5 pregnancy-related deaths in the U.S. are preventable. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html

Eric C. Schneider, A. S. (2021). Mirror Mirror 2021; Healthcare in the U.S. Compared to Other High Income Countries. The Commonwealth Fund. Retrieved May 9, 2023, from https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly

Rakotoniaina, A. (2021, August 31). How Oregon is Limiting Hospital Payments and Cost Growth for State Employee Health Plans. Retrieved from National Academy For State Health Policy: https://nashp.org/how-oregon-is-limiting-hospital-payments-and-cost-growth-for-state-employee-health-plans/

Ritchie, M. R. (2023, May 9). Maternal Deaths By Country. Retrieved from Ourworldindata.org: https://ourworldindata.org/maternal-mortality#maternal-deaths-by-country

Walker, D. G. (2021, February 18). Montanas Health Policy MVP Takes Her Playbook on the Road. Retrieved from Kaiser Family Foundation Health News: https://kffhealthnews.org/news/article/montanas-health-policy-mvp-takes-her-playbook-on-the-road/

 

 

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[1]  https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 

Reducing Environmental Harm From Rechargeable Batteries

 Consumers lack good access to data on the chemical components of rechargeable batteries and the environmental and personal health consequences. The world is migrating away from the internal combustion engine and a huge movement for electrification of vehicles is underway, as a direct response to global warming. It is still more environmentally friendly to ride a regular bike than one with a motor. If someone is riding an ebike instead of walking or using public transit, is that an environmental improvement? The electrification movement is hailed as an environmental coupe, which is true in the reduction of global warming gases and air pollution, but not for all environmental factors. This article digs into the toxic aspects of materials used in electrification of vehicles, bikes, and smart phones.

 Toxic components of Rechargeable Batteries

Rechargeable batteries don’t last forever and disposal of them is not universally secure. The process of creating the batteries that power Priuses, Teslas, ebikes, laptops, and smart phones creates toxic waste. Not all batteries are toxic, but lithium-ion ones are. Toxic chemicals produced include; lithium compounds, nickel compounds, arsenic compounds, and dimethoxyethane. Lithium batteries are not hazardous until they are charged and then they become toxic, which is why there are restrictions on the transportation of lithium-ion batteries. A “dry battery” means a non-lithium carbon electrode battery and is not considered hazardous. (Laura J. Vimmerstedt, 1995) Most smart phones use the lithium-ion battery because it holds a charge the longest, given the increased demands of the data required for these handheld devices. Older models, in particular, the Nokia, used Nickel -Cadmium or Nickel-Metal-Hydride and are not hazardous.

 The tech industry isn’t exactly clean, Silicon Valley has been a superfund site since 1989 from forty years of contamination of the ground water supply by tech manufacturers. Santa Clara County has twenty-three active superfund sites. Trichloroethylene used to clean semi-conductors has been found to increase miscarriage, and create endocrine disruption. (EPA, n.d.)And though the sites are being monitored and cleaned up here, there are myriad locations throughout the U.S. and the world that aren’t.

 Cobalt Mining

Cobalt is a precious metal found in most rechargeable batteries used in devices that need a long-lasting charge. Prevalent use of child labor, lack of any environmental safeguards, and literal enslavement of workers through indentured contracts are all occurring in the Democratic Republic of the Congo (DRC). The DRC, formerly known as Zaire which produces the vast majority of cobalt for the developed world. Siddharth Kara exposes the depravity in his latest, Cobalt Red-How the Blood of the Congo Powers Our Lives. (Kara, 2023) Over multiple trips to mining regions of this mineral rich land he was eye witness to unbelievable cruelty and apathy towards human suffering. It seems no matter what the agreements are with purchasers (Tesla, Apple), there are always end runs around compliance. Even if the no-child labor rules are enforced, the reason these children are forced to work at the age of ten or twelve is to provide food for their families, for often they may be the next provider after a parent is maimed or killed when a tunnel wall collapses.

 Remedies for this horror:

1. Workers need to be paid a living wage, not two dollars a day and a dollar for children. The Global Living Wage Coalition indicates a living wage is nine dollars in the DRC. Absolutely no one should be working for free or forced into labor.

2. Public schools should be free for children, because many of these families are unable to afford the six dollars monthly tuition, thrusting their children into the work place. 

3. Safety standards should be adhered to and any abrogation of them subject to heavy fines, deportation and imprisonment of contractors whom do not comply. 

4. Inspections by an independent third-party entity, similar to the global nuclear inspections would help with the clean up of this industry. There are enough profits in this industry to improve this assualt on humanity.

 Sources of Cobalt Outside of Africa

Given the fact 60% of the world’s Cobalt supply is in the Congo and controlled by the Chinese, the rest of the world is racing to shore up supply lines and develop alternatives. Russia and Australia are the next largest producers. Canada, the Philippines, and Cuba all produce a similar amount. The United States has a single cobalt mine in Idaho, which opened in October of 2022 and will contribute 10% of the global supply. The entire mine is underground and high tech. However, since the volume generated by this mine will initially be so small the processing of the cobalt ore will take place off shore in Sao Paulo, Brazil. This company is owned by Australian mining corporation, Jervois Global. (Kirk Seigler, 2022) Though the US has cobalt minerals in several locations, only the Idaho mine is active. (Burger, 2018)

 Cobalt-free Batteries

Researchers at the University of California Irvine in cooperation with four national labs have found a way to make a rechargeable cobalt-free lithium-ion battery. Huolin Xin and his colleagues were able to show that with an amalgamation of other metals, including titanium, magnesium, and manganese the battery could withstand high temperatures from repeated charges and remain stable. This research was funded by the US government, Department of Energy Efficiency and Renewable Energy. (Bell, 2022) Transitioning away from dependence on cobalt to power devices is smart. Creating a cleaner battery from manufacturing to distribution is smartest.

 The next time you hear an ebook reader tell someone who is reading a hardcover or paperback book that they are more environmentally friendly because they didn’t kill a tree (which are farmed and are a renewable resource), remember how many children die for the minerals in those devices. And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when you agree to inpatient medical procedures. Do stipulate that for which you agree and decline.

 Healthpolicymaven is a trademark which has been in continuous use since 2007. Roberta Winter is the author of  a guidebook to the healthcare system, Unraveling US Healthcare-A Personal Guide, published by Roman & Littlefield in 2013. This column provides no healthcare advice and opinions here are her own.

 References

Bell, B. (2022, September 21). Cobalt-free Cathode Could Lead to Safer, Longer-lasting Batteries for Electric Vehicles. (B. N. Laboratory, Ed.) Brookhaven National Laboratory.gov. Retrieved March 27, 2023

Burger, M. S. (2018). Cobalt Deposits in the United States: US Geological Survey Data Release. doi:doi.org/10.5066/P9V74HIU

EPA. (n.d.). Superfund Sites in Reuse in California. Retrieved March 23, 2023, from United States Environmental Protection Agency: https://www.epa.gov/superfund-redevelopment/superfund-sites-reuse-california

Kara, S. (2023). Cobalt Red-How The Blood of The Congo Powers Our Lives. In S. Kara, Cobalt Red-How The Blood of The Congo Powers Our Lives. St. Martin's Press. Retrieved March 28, 2023, from https://www.amazon.com/Cobalt-Red-Blood-Congo-Powers-ebook/dp/B09Y462D6Z

Kirk Seigler, E. W. (2022, October 8). In Idaho, America's first, and only, cobalt mine in decades is opening. (NPR.org, Ed.) NPR.org. Retrieved March 27, 2023, from https://www.npr.org/2022/10/08/1127310649/in-idaho-americas-first-and-only-cobalt-mine-in-decades-is-opening#:~:text=%22Idaho's%20is%20the%20only%20cobalt,important%20asset%20for%20the%20country.%22

Laura J. Vimmerstedt, S. R. (1995, September). Current Status of Environmental, Health, and Safety of Lithium Ion Electric Vehicle Batteries. Golden, CO: US Department of Energy. Retrieved March 27, 2023, from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://afdc.energy.gov/files/pdfs/

Deciphering the True Cost of Health Care for People in the USA

Americans are often confused about actual healthcare costs versus their out-of-pocket expenses, this article reviews the latest information on what U.S. residents pay for their health care. In 2021, the Centers for Medicare and Medicaid reported that private insurance plans through employers contributed only 17% of total healthcare costs for people in the U.S. This is a surprisingly small contribution considering that about half of the workforce obtains medical insurance through their work. For years the percentage of actual health care spend has been decreasing from employers, with more of the total funding cost passed on to employees. This makes the argument by the insurance industry that employers provide more of the funding for healthcare than the government look pretty weak.

 This table shows who actually pays for healthcare in the U.S.

Who Pays for Healthcare	Percentage of the total spent nationally
Federal government	34%
State & local governments	15%
Employee contribution	27%
Employer contribution	17%
Other private sources	7%
Grand Total	100%

In addition to employee and government contributions, other private revenue sources contributed 7% of all healthcare costs, which represents GoFundMe, private foundations, and contributions from individuals.(Centers for Medicare and Medicaid, 2022)

Components of Health Care Costs

Now let’s look at the various and confusing components of insurance premiums, deductibles, co-insurance, and other pass-through costs that individuals and their families end up paying in the U.S. The mean income (just  as many people are above and below this income level) from employment for an American worker was $54,132 in 2022. The mean household income was $70,784 in 2021. In addition to paying their cost for the insurance premium, those covered in the American health system also are expected to pay co-insurance, which is a percentage of total billed charges, up front deductibles and copayments. Finally, there are uncovered charges for health care services which vary based on the insurance plan. In general, mental health care or counseling is covered very poorly in the U.S., both in terms of actual reimbursement and availability of counselors. Other expenses that may be reimbursed inadequately are prescription drug expenses. This article does not review the cost or adequacy of dental or vision care, although they are certainly health care.

Medical Insurance Premiums

For single employees the amount they paid for their medical insurance was $1,643 per year if they had an employment-based plan. The employers paid $5,737 of the total $7,380 for an individual’s medical insurance in 2021. (Kaiser Family Foundation, 2021) Expenses for family members are typically paid by employees through payroll deductions and the average cost was over $20,000 a year.

Deductibles

A deductible is an upfront expense that an individual must pay in the U.S. before the insurance plan will pay anything. This doesn’t necessarily apply to all services, for example, the Affordable Care Act mandated that plans provide an annual wellness exam and certain other preventive services pre-deductible. In 2021, the Kaiser Employer Survey found the average deductible was $2,004 for an individual and $3,868 for a family. Deductibles were higher in small firms averaging $2,379 versus $1,397. (Kaiser Family Foundation, 2021)

Co-Insurance Expenses

According to Kaiser State Health Facts the average co-insurance for Americans was 19% for primary care and 20% for specialty care in 2020, for those covered on employer plans. Hospital copayments were found to average 20% of charges.  And after paying all of these expenses, the cost sharing doesn’t stop until the individual reaches his/her out-of-pocket maximum which found the majority of employees had out-of-pocket-maximums in excess of $6,000. (Kaiser Family Foundation, 2021) For those covered in the Affordable Care Act Insurance Exchanges out-of-pocket expenses are similar to these, but the cost of the medical insurance premiums are subsidized by tax credits which are advanced from the federal government to help people obtain medical insurance.

Budget Impact on Real People

This table shows one actual person’s budget and data from Kaiser Family Foundation and other sources applied to an individual representing the mean for 2021. As you can see, health care costs are second only to housing for Americans.

Budget Expenses-Individual	$30,000 Annual Income	$54,132 Annual Income
Rent/Housing	$9000 (yr./shared housing)	$22,512 (yr./av/1 bd apart)
Car Insurance/transportation	$1,290 (av/yr./cost)	$1,290
Medical Insurance Premiums	$1,643 (av/yr.)	$1,643
Deductible	$1,669 (av/yr.)	$1,669
Co-insurance & Uncovered expenses	$2,880	$1,444
Taxes(SSSI/Medicare, state, fed)	$4,500	$10,826
Net Available to Live on	$11,898	$14,748

 Impact of Uncovered Health Care Expenses

In the U.S, individuals and families must bear all of the cost of the co-insurance, unless a major expense is incurred and they reach their out-of-pocket maximum which runs thousands of dollars. As observed the ability of middleclass American workers to pay for major expenses is just not sustainable given their wages and the high cost of health care. Medical debt is one of the biggest consumer problems in the country and many states are enacting laws to limit the egregious actions of medical debt collectors and hospitals. Three million people in the country owe over $10,000 in medical debt. The Kaiser Family Foundation 2022 survey found that 7% of the U.S. population has medical debt. Here are some organizations that are advocating for consumers to alleviate this problem:

 https://www.washingtonlawhelp.org/resource/getting-help-with-medical-debt-in-washington

 https://ripmedicaldebt.org/

 https://rightcarealliance.org/

Politicians like to paint a rosier picture of U.S. worker wage gains, but wages haven’t moved much for many millions of people in the nation, averaging a mere 3% per year over the last twenty years. Yet health care continues to become less affordable, with annual costs increasing 4.2%. Despite the federal tax subsidies for corporations and individuals who obtain health insurance, costs are escalating far in excess of inflation annually, representing 18.3% of the gross national product of the country. No other nation spends that much money on healthcare, typically spending 40% less than the U.S. and achieving in many cases, better health outcomes. In a 2020 poll by nonprofit Pew Research, 63% of Americans favored a national healthcare plan, up from 59% the previous year, and this number will continue to increase until the people of this nation have some relief from health care costs.

 And this is the healthpolicymaven encouraging you not to sign blank releases at healthcare organizations when agreeing to inpatient or surgical procedures, do stipulate that for which you agree and which you decline.

 Roberta Winter is a healthpolicyanalyst and freelance journalist who accepts no money from any sector of U.S. healthcare. She is the author of Unraveling U.S. Healthcare-A Personal Guide, which was published by Roman & Littlefield in 2013. She has been a speaker for public, business, and international groups on U.S. healthcare policy, as well as a guest lecturer at the University of Washington.

https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

References

Centers for Medicare and Medicaid. (2022). National Health Expenditure Data-2021. Retrieved January 13, 2023, from Centers for Medicare and Medicaid.gov: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet

Kaiser Family Foundation. (2021). 2021 Employer Health Benefits Survey. Kaiser Family Foundation . Retrieved January 17, 2023, from https://www.kff.org/report-section/ehbs-2021-summary-of-findings/#:~:text=The%20average%20coinsurance%20rates%20are,hospital%20admission%20or%20outpatient%20surgery.

 

 

In Defense of Our Boys

 In 2017, after Trump was inaugurated the 45^th President of the United States despite the scandalous sexual harassment evidence of his odious behavior towards females, the MeToo Movement exploded in America and spread throughout the World. I walked in the Seattle Women’s March, part of the five million women who stood up and said, “We are not going to take it anymore!” Women effectively used social media to build a platform for public reforms in the attitudes and behavior of many males towards females. As I commuted into Seattle two hours a day by ferry, there was ample opportunity to discuss current events with my bike buddies on the boat. Men under the age of forty were surprised that women had experienced such direct assaults in the workplace and in their personal lives. With each commute on the Cathlamet or Chimacum, my salon of younger men sat in my booth or adjacent to it and asked questions. For these were males who understood how adverse older men had made the lives of their mothers, wives, sisters, and girlfriends. They wanted to know the facts so they could be better men for all of the women in their lives. They were also concerned about a potential backlash towards them because of the message these leaders were sending.

 Fast forward five years, Biden has been president for two years, and though public discourse has improved towards females, very little improvements have been made in the lives of women. The United States is the only major industrial country which lacks mandatory paid maternity (family leave), affordable child care, and universal health care. The dialogue may have improved, but the circumstances for families, especially working-class families have changed little. Harms done to the families from lack of affordable childcare, adequate health care, and paid family leave hurt the children even more than their parents. Youth are our most precious resource for they represent our investment (or lack thereof) in our collective future. Boys suffer just as much as girls when their mothers can’t find work, are home alone as latch-key kids at far too tender ages, go hungry, are unable to access health care, and all manor of social circumstances that harm their physical, social, and emotional development.

 As a feminist mother I realized that our zeal to change public discourse into a more egalitarian society has now become an over correction harming the other half, our boys and men. It is now assumed that girls are better students and boys must take medicine to “behave like the girls in school.” This attitude has resulted in fewer boys believing they can go to college and master academic work than in the past. Young boys coming of age have much less confidence now than their fathers. There are so many positive messages for young girls now, but fewer for boys. It is just assumed that boys will work and fulfillment of their dreams is not mentioned with as much urgency. Girls are now told they can choose between motherhood and a career, but what choice do men have? Boys are expected to grow into stoic hard-working men, to serve society without complaint, regardless of the difficulty of the task. Yet, boys and men are constantly assaulted with negative messaging about men. It has to be exhausting to constantly feel under attack regardless of one’s individual character. We must change this trend to become more inclusive to the feelings and perspectives of our boys as they become men.

 In 2022, I pursued conversations with men of all ages about their experiences, as fathers and as single men, in today’s environment and here are some of their observations;

 Male aged 25- “There may not have been economic parity for older women, but women are much more likely to earn wages equal to men for similar work now. This changes the power dynamic for dating, men are not expected to pay for everything.”

 Male aged 25- “Women have all the power in obtaining and consenting to sex. Men just put themselves out there and hope to be selected. Men must deal with a lot of rejection to find a woman.”

 Father aged 47- “My son deals with reverse discrimination now, for being male and white. It is no longer assumed that his future is as bright as his was. Young men have to deal with much greater complexities social-emotionally than their fathers.”

 Single father aged 49- “The courts have changed so much, tilted in favor of women. Even if the mother is a bad mother, it is very difficult for a father to be given custody of his children. My lawyer has said there is no hope that I can retain full custody.”

 Married mother of a 16-year-old son- “My son said to me, Mom, it is so much more complicated now than when you were in high school. All you needed was a car and you could get a date. The level of permissions and scrutiny is much greater for our sons. Everything is geared toward the protection of our daughters but what about our sons? “

 Married 70-year-old retired master carpenter- “We are made to feel like we aren’t worth as much if we don’t go to college. This is wrong we need people working in the trades, craftsmen are dying out in this country.”

 Musician-in his forties- “It is hard to be a man now, thank you for your words.”

 The vast majority of men and boys are not the problem, but if we are to have a successful pluralistic society we need to train and support all of our children to communicate in a respectful manner, which means being heard, having empathy, and not making assumptions of inherent value. Harming half of the population will not make for a great society. The truth is, we need each other for different but complimentary purposes, as we always have. We have made much progress in our new way of seeing the male female paradigm, but we still have work to do.

 The Better Men’s Club™ started as a response to misogynistic actions by men in power, but let’s put that into perspective and recognize that we have created many better men already, in our sons, partners, friends, and even fathers. I would not have been able to achieve many of the milestones in my life without those good men and for them I am grateful. As we seek peace and understanding in the new year, I hope we can listen to all voices with equal respect and empathy.

 And this is the healthpolicymaven signing off wishing you informed healthcare decision making through better transparency and public resources.

 Roberta Winter is a health policy analyst and freelance journalist who has continuously published this column since 2007, when her brother died from complications of type I diabetes. She is the author of a guidebook to the US healthcare system that was published by Rowman & Littlefield in 2013.

https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 

 

Health Insurance Premium Refunds Under the Affordable Care Act

 One of the consumer-friendly provisions of the Patience Protection and Affordable Care Act (ACA) provides refunds to the individual participants in the health insurance exchanges whose insurer spent less than 80% of all collected premiums providing actual benefits to participants. In 2021, some of the insurance companies who participated in the exchanges, were required to refund over one billion dollars to the enrollees in the insurance exchange plans. Over six hundred million was distributed to those enrolled in individual plans and the remainder to small employer plans in 2022. The average refund, which was provided via check or digital deposit was $141. I personally received a refund and this is the second time I have received a refund from my ACA plan. For the 2021 plan year over eight million participants received refunds. Since inception, the Affordable Care Act has paid out nearly twenty billion dollars in premium refunds to individuals and small group plans (SHOP) because of this provision. The rule uses a three-year loss ratio average to determine if an insurer overcharged insurance exchange participants. This provision protects the insurance companies from shock loss years and allows a smoothing of participant claim utilization over time. Without the government mandate insurance companies would pocket the extra premiums as reserves, if they are nonprofits or profits. Insurance companies can always elect to lower rates or charges to their customers, but this is rare, especially for individual health insurance. It is also important to note that only a few insurers each year are required to refund excess premiums, most meet the 80%-of-premiums-must-be-spent-paying-benefits-to-the insured rule.

 Money Refunded to Insurance Exchange Participants since 2012 (Norris, 2022)

2021-$2,100,000,000

2020-$2,460,000,000

2019-$1,370.000.000

2018-$   707,000,000

2017-$   447.000,000

2016-$   397,000,000

2015-$   469.000,000

2014-$   332,000,000

2013-$   504,000,000

2012-$1,100,000,000

 The Kaiser Family Foundation found that prior to the Affordable Care Act mandate of spending at least 85% of insurance premiums to provide benefits for the health exchange SHOP group plans and 80% for individual plans, most group plans met the threshold but only half of the individually insured plans did. This meant that people buying individual medical insurance overpaid for what they received and the insurer kept the profits. (Cynthia Cox, 2013)

 Of course, the insurance industry was not happy to have to reveal profitability to a government agency and worse yet, refund overcharged premiums to their customers. Due to pressure from the insurance industry many states were granted waivers from this minimum loss ratio rule, with the argument it would force insurance companies out of their marketplaces. This has not been the case and both insurance companies for which I received premium refunds since 2012 are still in business in Washington State, a semi-rural state. Insurance companies are very conservative when calculating their premium charges for their contracts, based on actuarial science. The data for predictive health impacts has only grown stronger and the behemoth insurance industry has more tools at its disposal to maximize profitability.

 During the pandemic, the Biden Administration provided additional financial subsidies to help people obtain healthcare insurance through the insurance exchanges through the American Rescue Plan.

 Clearly, millions of Americans have benefited by the government mandates in the insurance exchanges, which use an ingenious method of advancing tax credits to make medical insurance more affordable to individuals, families, and small businesses. It is always good to be reminded of the benefits we receive from our government, especially during an election year. 

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when submitting to inpatient medical procedures, do stipulate that for which you agree and decline.

 Roberta Winter is a freelance journalist and health policy analyst. She accepts no payment from any sector of the US healthcare system. Her guidebook to the US healthcare system was published by Roman & Littlefield in 2013. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

  

References

Cynthia Cox, G. C. (2013). Beyond Rebates: How Much Are Consumers Saving from the ACA’s Medical Loss Ratio Provision? Kaiser Family Foundation. Retrieved November 13, 2022, from https://www.kff.org/health-reform/perspective/beyond-rebates-how-much-are-consumers-saving-from-the-acas-medical-loss-ratio-provision/

Norris, L. (2022). Billions in ACA rebates show 80/20 Rule’s impact. Health insurance.org. Retrieved November 16, 2022, from https://www.healthinsurance.org/obamacare/billions-in-aca-rebates-show-80-20-rules-impact/

Opportunistic Practices Based on Profits Not Patients in U.S. Hospitals

Hospital corporations are misusing subsidized patient care programs to generate profits at the expense of the public. There are many methods that huge hospital groups like Providence use to generate profits, which unlike their advertisements, are not wholly plowed back into the communities they serve, but into its venture capital fund which had 300 million in 2019. (Reed, 2019) Saturday’s New York Times had not one but two articles on mercenary and unethical practices used by hospital corporations seeking greater profits. (Katie Thomas, 2022)  This article addresses some of the primary methods hospital groups pad their revenues at the patient’s and public’s expense, while highlighting what some states have done to combat egregious behavior by healthcare corporations.

Discouraging Development in High-need Low-income Locations

Large hospital groups use a variety of long-term profit driven methods to reduce their footprints in low-income locations and move clinics, practices, and facilities to areas with higher private-sector insurance reimbursement rates. Typically, a campaign is developed explaining why the existing community hospital, often built with public dollars is obsolete, which is preceded by an aggressive build out of clinics and facilities in wealthier areas. Case in point, Bremerton, Washington a city of 38,000 had its hospital closed after operations were moved to an unincorporated suburb. Bremerton has the highest concentration of low-income residents in the county, many of whom are veterans, in part because of previous county legislation mandating the financially disenfranchised live in that community. And the community hospital was built with public funding, but acquired and then closed by St. Michaels Hospital Group. The New York Times front page featured Bon Secours hospital in Richmond, Virginia, built specifically for the Black population which was acquired by Mercy Healthcare and subsequently bled of resources. Death via hospital closure ensued following a slow strangulation of the intensive care unit, maternity ward, and cardiac care. (Katie Thomas, 2022)

 Noncompliance With Charitable Care Standards

People of low to moderate incomes are eligible for free or reduced care at hospitals in the United States, but this standard has not been routinely enforced. Case in point, behemoth hospital group Providence, hired McKinsey Group to aggressively reduce its charitable (free or reduced cost) care in order to generate more profits. (Katie Thomas, 2022) As a result of the thug-like bill collecting tactics, where hospital employees went to patients in their hospital beds to extract money, Providence reduced its charitable care from the industry standard of 2% to 1%. Keep in mind these nonprofit hospitals receive federal and state funding for patient care, pay no taxes, and generate huge profits, for a measly 2% of aid.  Providence is by no means the only hospital group that pursues profits this way. Some states have interrupted this opportunism by enacting laws standardizing what income level and family size engenders eligibility for free or reduced cost charitable care. Even in the face of this, Providence still abused the state standards and was charged by Bob Ferguson, Washington Attorney General, for which it settled with a twenty-four million dollar fine. (Hagar, 2022) Another Catholic Hospital-St. Josephs in Tacoma was also sued by Washington State for failure to offer financial aid and predatory collection practices. (Bosco, 2021)

 Promotion of Procedures Linked to Financial Incentives as Opposed to Patient Care

There are many examples of financial incentives gone awry, but include procedures, especially in geriatric patients that do not improve health but generate revenue. For example, the Washington State Attorney General’s case against Providence Hospital for unnecessary neuro procedures at St. Mary’s Hospital, which resulted in two surgeons losing their privileges after an internal whistleblower reported the practice. Not only were the procedures dangerous and harmful, the propensity for these types of surgery were directly related to a financial incentive program which paid executives handsomely for increased volume in the complex surgeries. (Winter, 2022)

 Misuse of Federal Programs to Generate Profits

The federal government established the 340-B drug program which provides reduced drug costs to hospitals in urban areas, like public hospitals and trauma centers. The idea was to provide lower costs to those facilities and their patients, which provide services to the vulnerable. But, the financial gurus in the hospital corporations figured out they could acquire a public hospital, get the federally subsidized 340-B drug prices and then have an affiliated hospital in a wealthier suburban location also have access to the discounted drugs. The hospital would then charge the private sector companies a multiplier for the same medications, resulting in profits of $40,000 per patient for one drug. (Katie Thomas, 2022) In the case of Bon Secours Mercy Hospital in Richmond, Virginia, Mercy acquired the facility and used the urban designation of a 340B facility to buy discounted drugs and gouge the private sector for payments. This is a classic example of how profit making in healthcare is not in the best interests of the public or the patients.  

 What You Can Do to Avoid Opportunistic Behavior by Hospital Groups

1.  Know your rights, do not sign blanket releases when agreeing to procedures.

2.  Ask for an estimate of the cost of the procedure in advance and understand what you are expected to pay. Be careful about signing installment payments which can have unfavorable terms.

3. Know what your state’s standards are for charitable or reduced cost health care.

4. Write to your elected representatives to let them know about your concerns over treatment at a healthcare facility, especially financially.

Ths table shows existing state laws of elegibility for lower cost or free health care for which hospitals must comply.

State	State Mandates for Charitable Care at Hospitals (Bosco, 2021)
California	Families without medical insurance, those with high medical costs, and people within 400% of the federal poverty rate are eligible for financial assistance.
Colorado	A 2022 law strengthens protections from medical debt and requires all hospitals to provide medical assistance.
Connecticut	Requires all hospitals to screen for financial aid, but only mandates aid consideration for persons not covered on Medicare, Medicaid, or other coverage and whose income is below 250% of the federal poverty rate.
Illinois	Hospitals must offer financial assistance to families within 600% of the poverty rate, free care is mandated for those within 200% of the poverty rate, and hospitals are prohibited from collecting more than 20% of a patient’s income for payment in a twelve-month period.
Massachusetts	Families whose incomes are within 200% of the federal poverty rate are eligible to receive financial assistance.
New Jersey	Specifies families without medical insurance and those with low reimbursement from insurance plans are eligible for charity care. Also stipulates that healthcare providers can only collect a portion of patient income for repayment and the law stipulates what that payment ceiling is based on income.
Oregon	Requires hospitals provide full financial aid for those within 200% of the federal poverty rate and a sliding fee scale for those within 400% of the poverty rate.
Texas	Requires financial aid for those within 21%-200% of the federal poverty rate.
Washington	Families with incomes below 100% of the federal poverty rate must receive free care; families within 200% of the poverty rate are eligible for financial assistance.

 A 2015 study by Rutgers University found that only 44% of hospitals are informing patients of their rights for financial assistance nationwide (Susan Singer, 2022). Even worse, in states with no regulations for offering charity care, like Virginia or Tennessee, up to 40% of people carrying medical debt were eligible for financial assistance, but the hospital did not offer it to them. And of course, the twelve states that did not expand Medicaid eligibility with the passage of the Affordable Care Act are denying state residents access to federally subsidized free health care.  It is time for regulatory reform for hospitals, distinguishing the community based public hospitals from the behemoth hospital groups for tax exemptions. Now do your part to get what you deserve in the inequitable US healthcare system by understanding your state laws and demanding access to publicly mandated benefits to reduce the cost of your care. Patients should not be concerned about profits for hospitals, but of their health and wellbeing.

 And this is the healthpolicymaven signing off. Roberta Winter is a healthcare analyst and freelance journalist who accepts no money for this column. Opinions here are her own and are not meant to provide medical advice. She is the author of a guidebook to the US healthcare system, which was published by Rowman & Littlefield in 2013. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972 

References

Bosco, A. B. (2021). An Ounce of Prevention-A Review of Hospital Financial Assistance Policies In the States. National Consumer Law Center. Retrieved September 24, 2022, from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.nclc.org/images/pdf/medical-debt/Rpt_Ounce_of_Prevention.pdf

Hagar, S. (2022, September 24). More details emerge on Providence St. Mary Medical Center's $22.7 million insurance fraud settlement. Union Bulletin. Retrieved April 13, 2022, from https://www.union-bulletin.com/news/courts_and_crime/more-details-emerge-on-providence-st-mary-medical-centers-22-7-million-insurance-fraud-settlement/article_9ef81200-bab2-11ec-9bf3-03450d16ba13.html

Katie Thomas, J. S.-G. (2022, September 24). Profits Over Patients-How a Hospital Chain Used a Poor Neighborhood to Generate Huge Profits. The New York Times. Retrieved September 24, 2022, from https://www.nytimes.com/2022/09/24/health/bon-secours-mercy-health-profit-poor-neighborhood.html

Reed, T. (2019, January 18). Providence St, Joseph Health Announces New 150 Million Health Care Fund. Fierce Health.com. Retrieved September 25, 2022, from https://www.fiercehealthcare.com/hospitals-health-systems/providence-ventures-closes-150m-healthcare-fund

Susan Singer, E. W. (2022). Understanding Required Financial Assistance in Medical Care. Consumer Financial Protection Bureau, United States Government. Retrieved September 24, 2022, from https://www.consumerfinance.gov/data-research/research-reports/understanding-required-financial-assistance-in-medical-care/#6

Winter, R. (2022, April 14). Nonprofit Hospital Defrauds State of Millions. Straight Talk On Health Care. Retrieved from https://healthpolicymaven.blogspot.com/2022/04/nonprofit-catholic-hospital-group.html

 

 

 

 

Pregnancy in the US Just Got More Dangerous-Post Dobbs v Jackson Decision

 

Pregnancy in the US Just Got More Dangerous-Maternal Mortality

 A woman in the U.S. is more likely to die from maternity now than her mother. (Ritchie, 2013) The United States has the worst maternal mortality rate of the industrialized nations, ranked 57^th, tied with Latvia with 19 deaths per 100,000 live births. By contrast, the countries with the lowest maternal mortality rates including; Iceland, Norway, Japan, and Singapore have less than 2 maternal deaths per 100,000 births. If this metric isn’t poor enough, women are far more likely to die from complications of childbirth in the US since the overturn of Roe-v-Wade in the Dobbs v Jackson Women’s Health Organization Supreme Court decision. The wrongly decided ruling actually interferes with physician’s ability to treat their patients. There are many reasons why maternities are not carried to term, including fetal failure to develop, life threatening health complications for the mother, and unfortunately, lapses in the health system. This article reviews political trends in reproductive health care in the United States and impacts on maternal health.

Top reasons for Maternal Mortality in the United States

Hemorrhage

Blood clots

Hypertension

Pre-eclampsia and eclampsia

Infections

Obstructed labor

 Comparison of maternal outcomes in states which have near total bans on abortion

Researchers at Tulane University used data from the National Center for Health Statistics for thirty-eight states and the District of Columbia and ranked eight abortion restricting mandates by state.  The criteria included: gestational limits for abortion, reduction in the number of Planned Parenthood Clinics, state mandated counseling, mandatory waiting periods, mandatory ultrasound, mandatory parental involvement, denial of abortion coverage in private insurance plans, restrictions on public funding for abortion.

Findings for state health policy decisions to maternal mortality: (Vilda, 2021)

 1.  States with higher scores for abortion restrictions had an overall increase of 7% for maternal deaths

 2. States that refused to expand state Medicaid benefits when the Affordable Care Act was passed had a      29% higher total maternity mortality rate

           3.  States with a licensed physician requirement (versus nurse practitioner, physician’s assistant) had a       51% higher total maternal mortality rate than those without the mandate

        4.  Gestational limits for abortion had a 38% increase in maternal mortality

 The evidence clearly shows more women are dying preventable deaths due to pregnancy in the United States, than other peer industrialized countries. Given the political climate in this dystopian nation, Kevin McCarthy or some other politician will have the power to decide which women have access to health care and by virtue of that, who lives and who dies. Meanwhile the minority view of the evangelical religious right is congratulating themselves. Surely this will not stand.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket medical releases when you agree to inpatient procedures, do stipulate that for which you agree and decline. Opinions expressed are those of Roberta Winter, a freelance writer and do not give medical advice. She is the author of a guidebook to the US medical system, which was published by Rowman & Littlefield in 2013.

https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 Works Cited

Ritchie, M. R. (2013). Maternity Mortality. OurWorldinData.org. OurWorldinData.org. Retrieved August 26, 2022, from https://ourworldindata.org/maternal-mortality#citation

Vilda, D. W. (2021). State abortion policies and maternal death in the US, 2015-2018. American Journal of Public Health, 111, 1696-1704. doi:https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2021.306396

Winter, J. (2022, August 12). Why a Life-Threatening Pregnancy Complication Is on the Rise. The New Yorker. Retrieved August 26, 2022, from https://www.newyorker.com/science/annals-of-medicine/why-a-life-threatening-pregnancy-complication-is-on-the-rise?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Daily_081222&utm_campaign=aud-dev&utm_medium=email&utm_term=tny_daily_digest&bxid=62c6ee59096ac1a