Mar 292013

NPR is receiving significant flak for its recent series of reports entitled “Unfit for Work”, which looks at the increasing enrollment in the federal Social Security disability program. Disability advocates accuse NPR of generalizing about beneficiaries based on anecdotal stories of individuals who happen to live in economically depressed areas and have little education. They also point out that disability programs provide vital support to millions of people who would otherwise be forced to live in abject poverty.

These are fair criticisms, but both NPR and advocates fail to address some key points about disability benefits:

  • The Health Care Angle: Disability benefits provide cash assistance, but they also provide much-needed access to Medicare and Medicaid. For people struggling with physical and mental health issues and no access to health insurance, this is a lifeline. They can receive treatment for their conditions and, in many cases, their health stabilizes or even improves. While Obamacare will improve access to health insurance, it does not require private plans to cover many of the specialized services that people with disabilities need. And those medical benefits disappear if disability benefits end. Which brings me to my next point…
  • It’s A Trap!: Disability benefits are not designed to end. If an individual earns more than a few hundred dollars per month, they lose eligibility for both cash and health care benefits. This leaves beneficiaries in quandary. They can abstain from working and receive sufficient benefits to address their basic needs. Or they can attempt to work and risk losing the supports that have provided some semblance of stability in their lives. For most people, it’s not much of a choice
  • Some Things Never Change: Disability and employment are still viewed as mutually exclusive concepts by policymakers, bureaucrats, and ordinary people. Rather than regarding disability as a continuum where individuals might require varying levels of support, our laws treat disability in binary terms. Either you are disabled and you can look forward to a lifetime of subsidized poverty. Or you aren’t disabled and you’re on your own when it comes to finding health care and any other supports you might need. Advocates become understandably defensive when disability benefits are questioned, but we shouldn’t be hesitant to question the assumptions and prejudices that inform our policies. The world is changing. Disability benefits were designed at a time when we were still an industrial nation, but that isn’t true anymore. We can still provide economic security for people with disabilities while giving them the opportunity to explore the possibilities of work.


Mar 042013

Steven Brill’s longform piece in Time on the high cost of health care is getting a lot of attention from policy wonks. I know what you’re thinking. Time? Isn’t this the same magazine that runs cover stories on pressing topics like Jesus’ favorite snack foods? Someone in the magazine’s upper echelons must still care about old-fashioned investigative journalism because the piece itself is quite good. It begins by looking at the exorbitant medical bills incurred by people with little or no insurance. In Brill’s quest to understand why people with the least amount of coverage are forced to pay the most outrageous prices for care, he examines the major players in the health care ecosystem: the non-profit hospitals that really aren’t non-profit, the medical device and pharmaceutical companies that can generate huge profit margins by charging whatever they like for their products, and a federal government that is legally prevented from negotiating prices that could make health care far less costly.

None of this is exactly news to those of us in health care policy circles, but the article is excellent at illustrating just how dysfunctional the health care marketplace has become. It also reminds us that the process of reforming our health care system didn’t end with the passage of the Affordable Care Act.

Feb 212013

Republican resistance to the Medicaid expansion in Obamacare continues to crumble. Florida governor and Tea Party mascot Rick Scott announced yesterday that he will accept federal funding for a Medicaid expansion, joining a growing list of GOP governors who have developed amnesia about their previous fierce resistance to the health care law. Other states (I’m looking at you, Wisconsin) continue to hold out, but I’m guessing they’ll come around eventually–assuming they remain in office. Now, if only this epidemic of conservative sanity could spread to Congress.

Feb 132013

Count me among the fans of Obama’s State of the Union proposal to provide universal pre-K education, and not just for the usual wonkish reasons. My parents enrolled me in a pre-K program and, even though I was a white kid with middle-class educated parents, it made a huge difference in my life. From an early age, I learned to love school, to pay attention to my teachers, and (most importantly) to read. I may have been fine without this preparation, but I’m not sure I would have had the same success as an adult.

Incidentally, This American Life did an excellent report on the benefits of teaching “soft skills” to young children.

Jan 302013

Sarah Kliff writes about the challenges of  creating a health insurance exchange that is easy to use and that doesn’t overwhelm consumers with information. I’m not closely involved in the design of Minnesota’s exchange, but I’ve sat in enough design sessions to understand that this will be an iterative process. No state exchange (or the federal exchange, for that matter) will be perfect on day one. It will take time for officials to get the kinks out and optimize how information is presented. Unflattering news reports about how State X bungled its exchange implementation are a near-certainty in the coming months, but they shouldn’t be interpreted as the Fall of Obamacare. This is complicated stuff and complicated stuff takes time to get right.

The most important function of these exchanges is to ensure that people can get timely access to affordable health insurance. As long as that happens, states should have the breathing room they need to make necessary improvements.

Nov 302012

Ken Blackwell joins other conservatives opposing ratification of the U.N. Convention on the Rights of Persons with Disabilities. Because freedom! Or something. Blackwell doesn’t give any substantive explanation for opposing the treaty. Instead, he just natters on about sovereignty and abortion. The only thing missing from his diatribe is mention of black helicopters. Meanwhile, former presidential candidate Rick Santorum calls the Convention an assault on families of children with disabilities.

I get that this opposition has little to do with people with disabilities and everything to do with right-wing paranoia, but it’s still disappointing. The Convention won’t end discrimination against people with disabilities anytime soon, but it’s the most significant declaration of disability rights to come from the international community. For the United States to refuse to ratify the treaty is an insult to every American who has advocated for those rights both here at home and around the world.

I’m hopeful that a more progressive Senate will ratify the treaty next year. Santorum and Blackwell are welcome to retreat to their underground bunkers for as long as they like.

Nov 212012

If health care reform is to be a success, the Obama administration must find a way to educate people about how the law affects them. As Sarah Kliff notes in another typically smart article, those who stand to benefit most from the Affordable Care Act have no idea how the law affects them. They don’t know that they may be eligible for insurance subsidies or Medicaid. They don’t know that they will be able to purchase insurance even if they have preexisting conditions.

A massive public education effort will be needed to spread the word about the law’s benefits before open enrollment begins in the exchanges next October. The administration has a clear interest in ensuring a successful kickoff, but so does another critical stakeholder group—the insurance companies. They need lots of people to enroll in their plans to cover the costs of covering people with more chronic health care conditions. That gives me some confidence that we’ll see a coordinated and effective public outreach campaign. The last thing the administration wants to see at this time next year is news headlines proclaiming the lack of interest in Obamacare.

Nov 162012

Last week, I wrote about how many GOP-led states are declining to establish health insurance exchanges, choosing instead to cede to a federally-administered exchange. Residents of these states will still be able to purchase insurance and receive subsidies through the federally-facilitated exchange. But as Sarah Kliff explains, these states are also declining to participate in the Medicaid expansion that the Supreme Court made optional in its June ruling. Low-income people in these states will suffer as a result. They can go to the Exchange, but coverage will not be nearly as affordable as Medicaid. Hospitals and other providers will also lose out on funds to deliver what is currently uncompensated care to these individuals.

Denying access to affordable health care for what amounts to geographical reasons is both cruel and unnecessary, but those are the politics of the moment. Perhaps these states will be more inclined to expand Medicaid once bordering states do so, sparking complaints from local advocates and health care providers. Some states are pushing the Obama administration to lower the income threshold required for the expansion, but I’m not sure that diluting the law’s intent is a good idea. Medicaid is already a fragmented program with wildly varying eligibility requirements across states. Allowing states to duck that requirement would only perpetuate that fragmentation, which the Affordable Care Act was designed to remedy. An all-or-nothing expansion requirement might not help some people in the short term, but it will eventually result in a stronger Medicaid program.

Nov 092012

I’m looking forward to a long weekend free of obsessively refreshing the FiveThirtyEight blog. For your Sunday health policy reading, I recommend Sarah Kliff’s piece on how recalcitrant Republican governors are letting the federal government step in to run health insurance exchanges instead of establishing state-based exchanges. GOP governors figure that, rather than try to do all the heavy lifting necessary to set up an exchange, it’s better to let the feds shoulder the burden.

It’s hard to disagree with their reasoning. Minnesota is creating an exchange and it’s a gargantuan task requiring lots of planning and coordination. I’m learning more about business process modeling than I ever anticipated or desired. Minnesota will be successful in its efforts, but I don’t see how a state that previously resisted health care reform could now reverse course and have an exchange ready to go by next year.

Sep 072012

It warms my wonkish heart to see the media give more attention to Medicaid as a campaign issue. Bill Clinton considered the topic important enough to include in his speech on Wednesday evening. The complexity of our publicly financed health care system doesn’t lend itself to concise explanations, but Democrats need to start pointing out that plenty of middle-class families rely on Medicaid to care for elderly and disabled relatives. And they need to point out how Republican plans to slash Medicaid spending would almost certainly shift more of the financial burden of providing such care to families. Obama’s DNC speech acknowledged this threat only in passing. Here’s hoping he follows Clinton’s lead and hits the issue hard during the debates.