What Health Care Reform Means for: ‘Young Invincibles’
by Sabrina Shankman and Olga Pierce, Continued from page one. 

     When Neil Thurgood graduated college in the fall of 2006, his health insurance lapsed while he looked for a job. At the time, he says, “I just kind of figured, I’m young and healthy and everything is cool,” so he didn’t worry when it took longer than planned to find a job.  His wife eventually got one that offered insurance, but the premium was still too expensive for Thurgood to be covered.
     That wasn’t a problem until January 2007, when Thurgood came down with what he now refers to as “some crazy renegade virus,” which landed him in the hospital with a fever of 105. A spinal tap and a day later, Thurgood was sent home with fuzzy understanding of why he was sick and a bill for about $6,000.
     Nearly three years later things are looking up for Thurgood. He’s landed a job and is now insured through his wife’s coverage, which costs them $260 a month. But he’s still paying down his hospital debt.  “I feel bad having those kinds of obligations outstanding,” he said. “It’ll be paid when it’s paid.”
     Thurgood is part of the group called “the Young Invincibles.” Young adults between 19 and 29 have the highest uninsured rate of any age group – they aren’t as worried about getting sick, they’re less likely to have jobs that will offer insurance, and they typically make less money than other age brackets so they can’t buy private insurance. In the last year, 47 percent of people between age 19 and 34 went without health insurance at some point, and one in three is uninsured now.
     What Health Reform Means to Him:
     A series of changes offered by both the House and Senate’s reform bills mean the “invincibles” will have more options for insurance – whether as a dependent on a parent’s insurance, Medicaid or as a purchase through an exchange — but one option that will no longer be available is skipping health coverage.
     For relatively well-off young people, like Thurgood and his wife, health care reform will mean a new health insurance requirement, but not much help affording it.
     Both health reform bills mandate that everyone has insurance, which means young adults wouldn’t have the option of staying uninsured unless they want to pay a fine. The House bill would fine them either 2.5 percent of their adjusted income ($1,624 for the Thurgoods) or the price of the lowest premium on the exchange, whichever is lower. The Senate bill would phase in a penalty over the next six years, eventually fining them $750 a person, or $1,500.
      As of now, coverage from a parent’s private plan or through a public program that covers children usually ends at age 19. But the both the bills extend the age that children can remain as dependents. The House extends it to the child’s 27th birthday, and the
Senate extends it to the 26th.
     For the poorest group of young people, Medicaid may be an option. The program does not currently cover young adults without a child or a disability, except for in 15 states that have waivers, but that’s about to change. Both the House and Senate bills would extend the population that they cover to include childless adults.
      The Senate bill also expands Medicaid to cover up to 133 percent of the federal poverty line (about $14,000 for a single person) starting in 2014, and the House bill expands it to 150 percent, or about $16,000, in 2013.
     But at his current household income, Thurgood wouldn’t qualify for Medicaid.
     If he decided he didn’t want to use his wife’s insurance, both bills would allow him to purchase health insurance through an exchange. However, it’s not clear how much exchanges will benefit healthy young people who earn too much to also qualify for government subsidies.
     The House plan would create a national exchange, and the Senate plan would create state-based exchanges. The exchanges function like large pooling mechanisms, allowing people who would normally buy insurance through the individual market to buy into one of a menu of private group plans. The House bill also includes a public option – but that did not make it into the Senate
version, and House leaders have indicated a willingness to drop it.
     If he’s buying through the exchange, Thurgood could choose the Senate’s “young invincible” option, which offers people under 30 bare-bones coverage for a discount price — a possibility that would no longer be open to others who buy through the exchange, since levels of benefits will be set by Congress.
     Lower-income young people who qualify for subsidies would probably skip the “invincible” option, because they could buy better insurance with government help, as the Congressional Budget Office has pointed out.
     But the Thurgoods earn too much to qualify for subsidies, so buying coverage through the exchange may not help them much. The Thurgoods are above the income threshold to qualify for subsidies for premiums that are offered under each plan, which is 400 percent of the federal poverty line, or $58,280 for a family of two by 2009 standards. 

ProPublica - December 22, 2009

Contractors Continued

The Labor Department oversees the system, mandated under a law known as the Defense Base Act [4]. It requires federal contractors to purchase workers compensation insurance for civilians working in overseas war zones. But the agency has failed to enforce key provisions of the law, including informing employees of their rights and ensuring that companies purchase such insurance.

The system has produced hundreds of millions of dollars in out-sized profits for the private insurance companies, primarily the American International Group, the largest provider of battlefield insurance in Iraq and Afghanistan. Taxpayers pay the premiums for the insurance and the government reimburses private carriers for any costs arising from combat injures. The top four providers received $1.5 billion in premiums through 2008, yet paid out only $900 million in benefits -- a profit margin of nearly 40 percent.

So far, more than 1,400 civilian have died in Iraq and Afghanistan and more than 31,000 have reported injuries. The toll mounts daily.

 

First Lady Michelle Obama: health care coverage from her perspective as a woman and a mother. (click here)

Preparing for a Pandemic, State Health Departments Struggle With Rationing Decisions

 

This story was co-published with the New York Times.

New York state health officials recently laid out this wrenching scenario for a small group of medical professionals from New York-Presbyterian Hospital:

A 32-year-old man with cystic fibrosis is rushed to the hospital with appendicitis in the midst of a worsening pandemic caused by the H1N1 flu virus, which has mutated into a more deadly form. The man is awaiting a lung transplant and brought with him the mechanical ventilator that helps him breathe.

New York’s governor has declared a state of emergency and hospitals are following the state’s pandemic ventilator allocation plan -- actual guidelines drafted in 2007 that are now being revisited. The plan aims to direct ventilators to those with the best chances of survival in a severe, 1918-like flu pandemic where tens of thousands develop life-threatening pneumonia.

Because the man’s end-stage lung disease caused by his cystic fibrosis is among a list of medical conditions associated with high mortality, the guidelines would bar the man from using a ventilator in a hospital, even though he is, unlike many with his illness, stable, in good condition, and not close to death. If the hospital admits him, the guidelines call for the machine that keeps him alive to be given to someone else.

Would doctors and nurses follow such rules? Should they?

In recent years, officials in a host of states and localities, as well as the federal Veterans Health Administration, have been quietly addressing one of medicine’s most troubling questions: Who should get a chance to survive when the number of severely ill people far exceeds the resources needed to treat them all?

The draft plans vary. In some states, patients with Do Not Resuscitate orders, the elderly, those requiring dialysis, or those with severe neurological impairment would be refused ventilators, or admission to hospitals. Utah divides epidemics into phases [1]. Initially, hospitals would apply triage rules to residents of mental institutions, nursing homes, prisons and facilities for the “handicapped.” If an epidemic worsened, the rules would apply to the general population.

Federal officials say the possibility that America’s already crowded intensive care units would be overwhelmed in the coming weeks by flu patients is small but they remain vigilant.

The triage plans have attracted little publicity. New York, for example, released its draft guidelines [2] in 2007, offered a 45-day comment period, and has made no changes since. The Health Department made 90 pages of public comments [3] public this week only after receiving a request under the state’s public records laws.

Mary Buckley-Davis, a respiratory therapist with 30 years experience, wrote to officials in 2007 that “there will be rioting in the streets” if hospitals begin disconnecting ventilators. “There won’t be enough public relations spin or appropriate media coverage in the world” to calm the family of a patient “terminally weaned” from a ventilator, she said.

State and federal officials defend formal rationing as the last in a series of steps that would be taken to stretch scarce resources and provide the best outcome for the public. They say it is better to plan for such decisions than leave them to besieged health workers battling a crisis.

“You change your perspective from thinking about the individual patient to thinking about the community of patients,” said Rear Adm. Ann Knebel of the Department of Health and Human Services.

But some health professionals question whether the draft guidelines are fair, effective, ethical, and even remotely feasible.

Most existing triage plans were designed for handling mass casualties. They sort injured victims into priority categories based on the urgency of their medical needs and their potential for survival given available resources. Much of the controversy over the state plans focuses on two additional features.

These are “exclusion criteria,” which bar certain categories of patients from standard hospital treatments in a severe health disaster, and “minimum qualifications for survival,” which limit the resources used for each patient. Once that limit is reached, patients who are not improving would be removed from essential treatment in favor of those with better chances.

A version of these concepts was outlined in a post-9/11 medical journal article that suggested ways to handle victims of a large-scale bioterrorist event. The author, Dr. Frederick Burkle Jr., said he based his ideas in part on his experiences as a triage officer in Vietnam and the gulf war and on a cold war-era British plan for coping with a nuclear strike. Dr. Burkle said that during the gulf war he once instructed surgeons to halt an operation and work on another patient who was more likely to survive. Surgeons later returned to the first patient.

Dr. Burkle’s ideas were key aspects of guidelines Ontario authorities drew [4] up after SARS to plan for avian flu and other pandemics. This approach and one by a team of Minnesota doctors [5] were modified by groups developing similar guidelines in the United States.

There were important distinctions. Dr. Burkle’s original paper did not anticipate withdrawing care from patients and stressed the need to reassess the level of supplies “sometimes on a daily or hourly basis” in a fluid effort to provide the best possible care.

Some states’ triage guidelines are rigid, with a single set of criteria intended to apply throughout the severe phase of a pandemic. That disturbs Dr. Burkle. “I have said to my wife, I think I developed a monster here,” he said.

Recent research highlights the problem of a one-size-fits-all approach to triage. Many state pandemic plans call for hospitals to remove patients from ventilators if they are not improving after two to five days. Studies show that people severely ill with H1N1 flu generally need a week to two weeks on ventilators to recover.

There is also controversy over what values and ethical principles should guide triage decisions, how to engage the public, and whether withdrawing life support in the hospital and withholding it at the hospital door are distinct.

Normally, removing viable patients from life support against their or their families’ will would be considered murder. The New York-Presbyterian Hospital employees who participated in the recent exercise said they would not comply unless given legal protection.

They also never figured out what to do with that hypothetical patient who had his own ventilator, said Dr. Kenneth Prager, a pulmonologist and ethicist. “The issue of removing patients from ventilators,” he said, “was so overwhelming that it precluded discussion of further case scenarios.”

Robert Carroll Expresses View that Health Care Rationing Already Exists

Having represented injured and ill persons in my law practice for more than 37 years, I have to wonder how Dr. David McKalip has managed to miss the "rationing" of medical care which has been with us my entire life.

For starters, people without insurance certainly know only a weak dribble of care gets through the supply hose to them. This is because our society has elected to ration America's limited medical care primarily to those who have insurance or enough money.

Then there are those who have been injured on the job and frequently have to beg to get what they require unless they have an attorney serving as a battering ram.

Even the insured patient faces the back-office preauthorization team at the health insurance company and the forbidden drug list. Some procedures and drugs, judged to be necessary by many doctors and patients, aren't available because they cost too much.

We are delusional if we feel "rationing" has not been with us for many years. The present system is simply the capitalistic method of rationing that assures the best care for the well-heeled among us. Referring to this system as "the sacred patient-physician relationship" may allow our medical providers to feel good about themselves, but it is, unfortunately, a snow job.

Nobody needs to worry about leaving "their doctor's office wondering if the doctor is working for them or serving a rationing plan." The doctor is already serving a rationing plan. It is just not a very good one for most Americans.

Dr. McKalip's suggestion that Americans can just save their way to high-quality medical care at the lowest cost is, sadly, why it may be a mistake to "trust your doctor" to create a fair health care delivery system for our nation.

Robert J. Carroll, Palm Harbor

     [Mr. Carroll's personal injury firm (727-796-8282) practices law in Clearwater.  His piece appeared recently in an out--of-town newspaper, the St. Petersburg Times.  He was responding to a letter by a St. Petersburg doctor known for opposition to efforts directed at stopping over-prescription of antibodics.  Reprinted here with permission of the author.] 

 

Diagnostic Clinic Requires Uninsured to Post Cash Deposit

     The Diagnostic Clinic in Largo has a large practice involving patients who are members of HMO's / PPO's.  When a patient no longer has health insurance, the clinic requires the patient to post a $250 cash deposit before seeing the patient again.  The policy is driving business to nurse practitioners and alternative health providers and results in a rise in home remedy treatment. -

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