Monday, April 17, 2017

Health care II

It is submitted that Rep. Palmer is imparting to his constituents little comprehension of the difficulties with America's health care system and how best for the country to try to address the same. (For background, see Health care.)

In his March 24th press release, Rep. Palmer said:
"I believe pulling the bill from the House floor was the right call. The American people have suffered for the last 7 years under Obamacare, and I know we can provide them a better solution that will put healthcare decisions back in their hands, not in the hands of the Federal Government. I look forward to working with my colleagues in Congress and President Trump to do just that. Working together we can still pass a bill that allows Americans to access the doctors they want, decide the coverage they need, and lower their healthcare expenses.

At a February 25th Hoover Town Hall, Rep. Palmer indicated that his solution would include health savings accounts, portability of insurance, and allowing sale of insurance across state lines.

Rep. Palmer needs to provide an analysis of the immense difficulties the current health care system presents before any credibility can be given to his proposed solutions. At a minimum, he should give citations to books or articles which Rep. Palmer believes set forth analysis, information and argumentation that can be consulted to understand the reasons for Rep. Palmer's belief in what he proposes as a solution. Those books and articles may be subject to extensive critiquing, but that is part of evaluating Rep. Palmer's proposed solution.

Maybe Rep. Palmer is only mouthing things said by Secretary Price and by other Trump policy advocates, and maybe Rep. Palmer does not have any particular conviction on his own. If that is the case Rep. Palmer's constituents deserve to know that.

I have been endeavoring to solicit input for health care reform from experts and others in Alabama (see Alabama expertise re health care), but little is forthcoming.

I have been advised that three local pediatricians met with Rep. Palmer and submitted to him the below American Academy of Pediatrics Blueprint for Healthy Children. While it has a narrow focus compared to all of health care in the United States, the blueprint is helpful in evaluating how good a job Rep. Palmer is doing for his 6th district constituents regarding health care reform.


AMERICAN ACADEMY OF PEDIATRICS BLUEPRINT FOR HEALTHY CHILDREN

·        Affordable high quality heath care for all health care children
·        Access to primary and subspecialty pediatric care as well as mental health specialties

CONTINUED FUNDING FOR MEDICAID IS CRUCIAL FOR ALABAMA CHILDREN
A large number of children in Alabama, as well as the US as a whole,live in impoverished circumstances and families cannot afford health insurance for their children.“Growing up in poverty is one of the greatest threats to healthy child development. Poverty and financial stress can impede children’s cognitive development and their ability to learn. It can contribute to behavioral, social and emotional problems and poor health.” Annie E Casey Foundation KIDS COUNT 2017


ROLE OF FEDERALLY FUNDED MEDICAID AND CHIP (ALLKids) INSURANCE FOR ALABMA CHILDREN

In 2017, we had achieved greater than 97%coverage for Alabama children. 625,000 children rely on Medicaid and ALLKids CHIP for health insurance. By comparison only 8000 children were covered on Marketplace plans.

The State of Alabama greatly benefits from the current Medicaid payment structure to cover children’s health insurance. Current Medicaid funding results in a tremendous net benefit for Alabama with more than 70% of Medicaid costs for Alabama paid by the federal government, with the State responsible for the remainder. Given the serious budget restraints at the state level, the amount contributed by the state is limited for the foreseeable future.

Both Medicaid block grants or per capita funding for Medicaid would leave the State of Alabamahaving to pay a larger share of children’s health care services, or else to significantly cut services by decreasing the number of insured children or limiting covered services. With fixed annual federal funding to Alabama, there would be no flexibility to cover new therapies for diseases, or to address unanticipated emerging health care problems such as infants severely affected by Zika virus, or pandemic influenza. Should there be an economic downturn in Alabama in the future resulting in an increased number of eligible children, This would further stretch the limited Medicaid funding for children’s services, resulting in fewer children covered or a marked reduction in services.

Loss of federal Medicaid fundingby cuts or by capped funding with block grants or per capita funding would result in

1.   Great difficulty for State of Alabama to generate the difference between current Medicaid funding methods and new funding strategies.
2.  Decrease in the coverage of provided services
3.  Increase in the number of uninsured children 


Any decrease in Medicaid funding would not only lead to loss of insurance for children but ultimately would undermine the pediatric medical and mental health care infrastructure for Alabama’s children.

One significant example would be Children’s of Alabama
The number of inpatient discharges increased substantially between 2013 to 2016:  from 13,993 to15,784.Medicaid is the predominatpayor for inpatient stay at Children’s of Alabama.

Medicaid 65%
Blue Cross 25%
HMO/PPO/Commercial 5%
Other government 3%
Self pay (uninsured) 2%

         





CHILDREN LESS THAN 18 YEARS OF AGE LIVING IN POVERTY
(KIDS COUNT data center)
POVERTY LEVEL

US
2015
Alabama
2015
Congressional
District 6
Extreme poverty <50% poverty
$12,018 (2 adults, 2 children)
6,618,000
9%
138,000 13%
15,000 (2010)
8%
< 100% poverty
$24,036 (2 adults, 2 children)
15,000,000
21%
291,000
27%
20,000
12%   (2009)
<150% poverty
$36,054 (2 adults, 2 children)
23,493,000
32%
423,000
39%
43,000
24%  (2010)



Income Eligibility for Alabama Medicaid
Household size
1
2
3
4
5
Maximum annual income
$15,800
$21,307
$26,813
$32,319
$37,825

Alabama has no minimum wage law: Federal minimum wage is $7.25/hr. Annual salary for fulltime work (2080 hours) at minimum wage= $15,080, often without benefits including health insurance, sick leave. Many times employers limit hours so that employees cannot get fulltime work.

If a parent misses work to take their children for a doctor visit for a chronic health problem, they may lose their job: this is a not uncommon if children have chronic health problems.


MEDICAID IS THE INSURER FOR 58% of ALABAMA PREGNANCIES

Prenatal and delivery care are essential for healthy babies!
Alabama has long had one of the highest infant mortality rates in the nation

·        US: 5.9 deaths /1000 live births (2015)
·        Alabama: 8.3 deaths/1000 live births

“Babies born with a low birthweight have a high probability of experiencing developmental problems and short- and long-term disabilities and are at greater risk of dying within the first year of life.” KIDS COUNT data center
·        US births with low birth weight: 8% in 2014
·        Alabama: 10.1% in 2014

Births to women with late or no prenatal care
·        US: 6%, 220,920 in 2014
·        Alabama: 7%, 4204 in 2014
·        Adequate prenatal carefor only76.2%of Alabama pregnancies in 2013

IMPORTANCE OF INSURANCE COVERAGE FOR MENTAL HEALTH DISORDERS AT PARITY with MEDICAL INSURANCE

In Alabama, 172,000 children or 17% of all children had one or more emotional, behavioral or developmental conditions in 2011-2012

For all ages of children and young adults, deaths due to accidents and violence have a strong behavioral component.

Unintentional injury was the leading cause of death for children ages 1-4, 5-9, and 10-14, and 15-24 in 2014, and the fifth leading cause of death for infants less than 1 yr of age.

Suicide was the second leading cause of death for ages 10-14 and 15-24.

Homicide was third leading cause of death for ages 1-4, fourth for ages 5-9, and fifth for ages 10-14, and third for ages 15-24.  

8,894 Alabama children experiencedabuse and neglect in 2014 (2017 Annie E Casey Foundation KIDS COUNT data center). Infants, toddlers and preschoolers are the most vulnerable for abuse and neglect.  It is crucial that these children receive mental health services for their trauma, as abuse and neglect can have consequences that persist far beyond childhood: anxiety and depressive disorders, hyperactivity, aggression, avoidant behavior, increased suicide risk, and poor school performance during childhood and adolescence (Knutson and DeVet 1995), and in adulthood, increased depression and anxiety, substance abuse, suicide, personality disorders, and health issues (Zlotnick et al 2008; Arnow 2004). 

INTERSECTION OF PHYSICAL AND MENTAL HEALTH
Asignificant number of children with chronic medical issues develop psychological conditions during treatment for serious conditions, and these can play a huge role in determining the experience of serious medical diagnoses and quality of life. 


Depression is very frequent in chronic illnesses:
          Diabetes: 10-20%
          Heart disease: 20-30%
          Chronic pain 40-60%
          Cancer 10-20%
          Neurologic disorders 10-20%

Depression and anxiety can further worsen perception of pain and function. If both are present, adherence to treatment and self-care tends to decrease, functional impairment increases, utilization of medical service increases, and with increase in complications and even mortality. Children develop abdominal pain, headache, but also back and limb pain and fatigue with mental health problems

Psychological and psychiatric illnesses, which are either primary or secondary to a traditional medical illness, can result in increased health care costs:

1.   Increased utilization of medical diagnostic testing and
2.   Unnecessary procedures
          3.  Multiple referrals
          4.  Inappropriate self-care
(Family Practice 2008, 9:30)

This increase in costs may be as much as 9 times the average average costs.  Indirect costs are due increased absenteeism at work and decreased work productivity and school absence and poor academic performance. (Mental Health in Family Medicine 2010; 7:197-207)

The medical care of children with organ transplants, kidney disease, cancer, and diabetesare often associated withpsychological challenges.  These can impact the adherence to medical therapies and can lead to poorer medical health outcomes if they are not addressed.  Treating both physical and mental health issues together in a holistic way results in more efficient use of health care dollars.


The infrastructure for mental health services in Alabama is already limited.  At discharge for Children’s, there is often no place to send children for continued mental health care once they leave the hospital. There are large pockets of Alabama where there is no access to mental health services or only limited or very poor mental health care available.

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