Personal and Medical Bankruptcy Followup

Lloyd Stires has a great series of posts on the decline of mortality in Massachusetts compared to similar surrounding counties.  They are linked in related posts below.  

I've also received a nice response to my post on medical bankruptcies.  Here is a follow up.

I have received comments from Thomas M Miovas of appliedphilosophyonline.com that more exact methods are needed to determine the cause of these bankruptcies.  I agree completely.  However in the lack of these more comprehensive studies pilot work can be done to aid in planning these studies.

Assuming the prerecession estimate of 62.1% of all bankruptcies still holds (which may be a shaky assumption due to the state of the economy), we can multiply that percentage by the national increase in the rate of personal bankruptcies from '07-'11 of 62.15%.  We would find that there would be a 38.6% increase in medical bankruptcies and a 23.6% increase in the number of nonmedical bankruptcies over the same period assuming the rate of personal bankruptcies is constant.

We can also look at the rate of increase in personal bankruptcies in states expanding medicaid vs those who are not.  There is a somewhat higher increase in the rates in states expanding medicaid as can be seen in the boxplot below.  However there is no statistically significant difference between the two groups of states.

Group Statistics
	Expanding medicaid	N	Mean	Std. Deviation	Std. Error Mean
% change in bankruptcy	not participating or considering not participating	22	43.0%	33.79597	7.20532
	participating or leaning	29	68.4%	58.56026	10.87437

These types of analyses can provide indications of meaningful underlying patterns for future research.

**Update**

Adams County HC4ALLPA member Becky Spoon has informed me that there was a study of medical bankruptcies in Massachusetts after 2006.  There was a decrease in the rate from 59.3% to 52.9% from 2007 to 2009.  Over the same period there was a 49.5% increase in the number of total bankruptcies.  Multiplying the study rate by the % increase suggests that there is about a 25.8% increase in medical bankruptcies and a 23.7% increase in other types of personal bankruptcies.  These increases are smaller than that of the nation as a whole but the problem still persists.

 **Related Posts**

The Affordable Care Act Having an Impact in Some States but not Pennsylvania

National, State, & County Uninsured Estimates

Health Insurance and Mortality, Part 1

 

Health Insurance and Mortality, Part 2

Recent Uninsured Trends and the ACA

The Gallup Organization has produced quarterly national estimates of the uninsured rate to assess the impact of the Affordable Care Act (aka Obamacare).  It suggests that the rate is at the lowest since the fourth quarter of 2008, before the recession began in earnest.  

The graph below, not surprisingly, shows that the rates are lower for the states that are expanding Medicaid.  The rates are also decreasing at a faster rate for Medicaid expanding states (15.4% in Q4 2013 to 12.45% in Q1 2014) compared to those who are not (19.6% in Q4 2013 to 18.1% in Q1 2014)

MotherJones has printed this table with projections for future costs and coverage under the ACA.  These projections are always based on assumptions which may or may not be reasonable.

A harder thing to measure is the number of underinsured under the ACA relative to the time before the law was passed.  The way in which the word underinsured is defined makes all the difference.  It is much easier just to ask survey respondents whether they have insurance or not that to ask them extensive questions about the type of coverage they have and whether it is adequate for their medical needs.

I have reported extensively on Census Bureau Small Area Health Insurance Estimates (SAHIE)  because they provide a more local picture of trends in the uninsured.  When they are discordant with uninsured rates, the rates of medical bankruptcies could suggest troubles with underinsurance.  Getting access to these statistics is difficult however.  PNHP has conducted a study on 2007 data found 62.1% of all bankruptcies were the result of medical expenses but new studies will need to be done to assess the impact of the ACA.  States with improved uninsured rates but little change in the number of medical bankruptcies could have issues with underinsurance.

**Related Posts**

The Affordable Care Act Having an Impact in Some States but not Pennsylvania

 

National, State, & County Uninsured Estimates

 

The Affordable Care Act (ACA) having little effect on PA's Uninsured Rate So Far

Medicaid Expansion at a Crossroads

On Monday there will be a Rally for Medicaid expansion in Harrisburg.  There will be a  meeting with Legislators at 11:30 followed by the Rally in the small rotunda in the Capitol Building near the Cafeteria. Along with Iowa, Arkansas, and Michigan, Pennsylvania is now proposing it's own version of expansion.  Utah is still undecided as can be seen in the map below.

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Gov. Corbett has proposed an expansion of Medicaid which differs from other states because it adds additional requirements such as a job search requirement and adding premiums and cutting services.  For a year, his administration has been in negotiations with the Federal Department of Health and Human Services to accept his plan but they appear to be foundering with a rejection of the plan likely.  Iowa's and Arkansas' plans have been approved by the Federal Government.


Via: The Advisory Board Company

**Related Posts**

 

MEDICAID, MEDICAL INSURANCE, HEALTH CARE and the CORBETT PLAN Op Ed by President Dave Steil

 

No Medicaid Expansion = Higher Health Insurance Premiums

 

Tom Corbett to PA's Working Poor: “Drop Dead!” (Part 1) (See all four parts.)

Medicaid Expansion Update

 

New Daily Show Post on Medicaid Expansion

The lack of Medicaid expansion is hurting many in the 19 states that have refused to take federal money.  The daily show has a segment that aired last night on it's impact in South Carolina (Stephen Colbert's home state).  The arguments for expansion sound very similar to those for a single payer system.  Pennsylvania is listed as implementing the expansion which is actually still in limbo here as described in related posts.  

As an aside Julie Sokolow and Healthy Artists are featured in the New York Times on artists' struggle with health insurance.  Many of whom are now adversely affected by the lack of Medicaid expansion. 

A Crusader on What Ails Artists

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**Related Posts**

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MEDICAID, MEDICAL INSURANCE, HEALTH CARE and the CORBETT PLAN Op Ed by President Dave Steil

 

No Medicaid Expansion = Higher Health Insurance Premiums

 

Tom Corbett to PA's Working Poor: “Drop Dead!” (Part 1) (See all four parts.)

Medicaid Expansion Update

 

The Oregon Health Experiment: The Gift That Keeps On Taking Away

Be prepared for a barrage of conservative criticism of the Affordable Care Act (ACA) that may be assumed to have negative implications for single-payer health care as well.

As I've noted before, the Oregon Health Experiment is a randomized control group design, far superior to most health care research. In 2008, Oregon hoped to expand Medicaid, but didn't have enough money, so they held a lottery. They invited everyone who was eligible to apply. Of the 90,000 applicants, 30,000 were randomly selected to receive Medicaid, while the losers became eligible for the control group. In previous data analyses, it was found that the Medicaid group spent 35% more on health care than the control group. They visited primary care physicians (PCPs) and were admitted to hospitals more often, and spent more on prescription drugs. They were also healthier and freer of financial worries, although most of the health differences are not statistically significant due to insufficient sample sizes in the study.

A new analysis by the Oregon research group reports that the Medicaid participants were also more likely to visit the emergency room (ER). Specifically, during their first 18 months on Medicaid, they made an average of 1.43 ER visits compared to 1.02 in the control group—a 40% difference.

This should not have been a surprise. If you reduce the cost of a service, people are more likely to use it. However, some ACA proponents claimed that Medicaid expansion would save money by reducing ER use. Although the ER accounts for only 4% of health care spending, an ER visit is more expensive than visiting a doctor. The pro-ACA argument was that if patients established a relationship with a PCP, they would have a place to go for medical care and these doctor visits would prevent potential emergencies. For example, Health and Human Services Secretary Kathleen Sebelius said in 2009:

Our health care system has forced to many uninsured Americans to depend on the emergency room for the care they need. We cannot wait for reform that gives all Americans the high quality, affordable care they need and helps prevent illnesses from turning into emergencies.

It is important to note that these results are not due to the fact that Medicaid provides health insurance for poor people. Private health insurance patients are also more likely to use the ER than the uninsured.

Increased ER use might not be seen as a problem if the visits were real emergencies. However, the study found ER use to be higher even for non-urgent care that should ideally have been treated by a PCP. These results could be used by the opposition to suggest that single-payer might cause an massive influx of people outside the ER waving torches and pitchforks and demanding free care.

There are several considerations that may place these results in clearer perspective.

• The time frame of the study, 18 months, may not have been sufficient to change uninsured people's lifelong habits of going to the ER every time they were sick. A three-year study of Romneycare in Massachusetts found an estimated 5-8% reduction in ER use.

• Medicaid expansion could have been accompanied by education regarding when to go to the ER and when to visit your PCP. Of course, some may argue that education is not enough and should be supplemented by punishment, such as a co-payment, for “inappropriate” ER use.

• Taking a broader view, the problem may be with the health care system rather than the patients. PCPs tend to be available Monday through Friday from 9 to 5—times that are inconvenient for most employed people. You can't always get same-day appointments with a PCP. A 2012 survey by the Commonwealth Fund found that in the US, only 35% of PCPs see patients after hours. In nine European countries and Canada, the average was 80%.

This study is one of a growing number that show that providing health insurance to the uninsured alone does not save money. The ACA contains some cost controls, such as the Independent Payment Advisory Board, which may eventually reduce costs. Single payer eliminates the cost of private insurance, which will save much more. Other changes may be needed. One of them may be asking PCPs to become more consumer-friendly by seeing more patients on evenings and weekends.

You may also be interested in reading:

Big News From Oregon--Not All of It Good

Tom Corbett to PA's Working Poor:  "Drop Dead"  Part 1.  Medicaid Improves Health and Saves Lives

Molly Rush: Letter to the Pittsburgh Post-Gazette

Single-payer is the way forward on health care

December 7, 2013

Letter writer Elizabeth Stelle of the Commonwealth Foundation sees government involvement in health care as a disaster and regulations and mandates as the cause of rising health care costs in this country (“Medicaid Is High Cost for Low Quality,” Dec. 2).

Rather than dealing with inadequacies of Medicaid she seems to support Gov. Tom Corbett’s refusal to extend coverage to 542,000 Pennsylvanians.

She fails to note that private insurers, drug companies and providers, whose primary interest is profits, are mainly responsible for rising health care costs.

The Department of Veterans Affairs pays 40 percent less for drugs because of its buying power.

I share Ms. Stelle’s concern about poor quality and high costs. As an analyst, is she aware of a recent study of state Senate Bill 400 by Gerald Friedman? He found that Pennsylvania could provide comprehensive care to every Pennsylvanian and save $17 billion a year through a single-payer system provided in the bill. Vermont just passed a single-payer system.

There’s nothing new about the idea. Every other industrialized country in the world has some version of government health care. They also have much healthier citizens. The United States is far behind these countries in health outcomes. Here, 120 people a day die due to a lack of health care. Half of all bankruptcies are due to medical bills. While Obamacare does provide some real improvements, it falls short due to its complexity and failure to cover everyone.

Go to www.healthcare4allPA.org. Then tell your state legislator to serve his or her constituents by co-sponsoring single-payer legislation.

MOLLY RUSH


MEDICAID, MEDICAL INSURANCE, HEALTH CARE and the CORBETT PLAN Op Ed by President Dave Steil

Outgoing Healthcare for All PA president Dave Steil has written an Op/Ed for several paper which has been published in the Bucks County Times.  

Recently, Governor Corbett unveiled a Medicaid expansion plan called Healthy Pennsylvania.  Few would disagree with the Governor’s objectives of increasing access, improving quality and making healthcare affordable for all Pennsylvanians.  Medicaid is a healthcare program funded by both the state and the federal government that provides direct care to individuals with limited income.  The fastest growing population group in this category are seniors whose income falls within the threshold of income limits for Medicaid. In effect Medicaid supplements Medicare which is for all people over the age of 65. Medicaid has income limits, while Medicare does not.  Most of the Medicaid supplements used for long term care facilities.Under the Affordable HealthCare Act, often called Obamacare, states may expand the eligibility for Medicaid, with the Federal Government picking up much of the cost. This expansion is optional for the states, although many states have already agreed to sign on. Note, it is important to distinguish between health insurance and healthcare. They are not the same. Healthcare programs such as Medicaid and Medicare pay directly the doctors and hospitals that provide healthcare services to people. With health insurance, people pay premiums to private insurance companies, who then pay the doctors and hospitals for healthcare services provided to those paying the premiums. Under Governor Corbett’s plan federal Medicaid funds would be used to buy health insurance for eligible participants, rather than providing direct healthcare. HealthCare 4 All PA (HC4APA) believes this is a poor use of money that only increases the cost and limits the funding pool available to pay for actual healthcare.  The reasoning is simple-health insurance has administrative costs in excess of 15%, meaning that 15 cents of every dollar does not go to pay for healthcare. Contrast this with Medicare and Medicaid where administrative costs are about 3%. Therefore, under the Governor’s plan to turn Medicaid healthcare into an insurance program, more money will be spent and fewer people will be treated due to this disparity in administrative costs. HC4APA also believes that decisions about your healthcare should be made by you and your doctor.

**Related Post**

Dave Steil on Kate Loving Shenk's Radio Show

The Affordable Care Act Having an Impact in Some States but not Pennsylvania

In my post on Pennsylvania's uninsured, I wrote that the Affordable Care Act (ACA) was having little effect in Pennsylvania's rate of uninsured.  I wrote in another post that I received skeptical comments on my first post. I said in that post that I would look at changes in the rates in other states.  I couldn't then because the government shutdown also shutdown the US Census Bureau site.  The Advisory Board has come out with an image that can be updated on how many sign up for the state based exchanges which are not federal.

Now that the shutdown is over I can look at the Census Data for the Small Area Health Insurance Estimates (SAHIE) for states from 2008 thru 2011.  To determine which states had a significant decline in the uninsured rate from 2010 to 2011 (the period where portions of the ACA have taken effect such as allowing parents to keep their kids on their insurance until age 26), I marked a state as declined if it had a rate that declined outside its margin of error (MOE).  There were 14 states with a significant change in their rates and 37 (including DC) that either stayed the same or increased.   States with larger populations have smaller margins of error.  

Five of the states are summarized in the graph above, California, Massachusetts (which has it's version of the ACA), Pennsylvania, Texas (with the largest rate in the US), and Vermont (which is the first in the US to pass a single payer plan).  California, Texas, and Vermont had significant decreases in the rates while Pennsylvania and Massachusetts remained within the margin of error (MOE) of 0.2% for both years.  Missouri is the only state that showed a significant increase in it's rate from 15.3% to 16.0%.

ACA Decrease in uninsured * Medicaid Expansion Crosstabulation
		Medicaid Expansion			Total
		not participating or considering not participating	participating or leaning	expanding through alternate means or considering
ACA Change in uninsured	No	16	15	6	37
	yes	6	8	0	14
Total		22	23	6	51

I tried to see if there was any association between decreases in the rates and other state level variables but there was none.  The table above shows that there is no relationship between a significant decrease in the rate and whether or not the state is participating in Medicaid Expansion (p=0.254).  PA Gov. Corbett has proposed a draconian version of Medicaid expansion which Lloyd Stires has written extensively about.   Below is a table showing where each state stands on the ACA decrease and Medicaid expansion.

	State	ACA Change in uninsured	Medicaid Expansion
1	Alabama	No	not participating or considering not participating
2	Alaska	No	not participating or considering not participating
3	Arizona	No	expanding through alternate means or considering
4	Arkansas	No	expanding through alternate means or considering
5	California	yes	participating or leaning
6	Colorado	No	participating or leaning
7	Connecticut	No	participating or leaning
8	Delaware	No	participating or leaning
9	District of Columbia	No	participating or leaning
10	Florida	No	not participating or considering not participating
11	Georgia	No	not participating or considering not participating
12	Hawaii	No	participating or leaning
13	Idaho	yes	not participating or considering not participating
14	Illinois	yes	participating or leaning
15	Indiana	No	expanding through alternate means or considering
16	Iowa	No	expanding through alternate means or considering
17	Kansas	yes	not participating or considering not participating
18	Kentucky	No	participating or leaning
19	Louisiana	No	not participating or considering not participating
20	Maine	No	not participating or considering not participating
21	Maryland	yes	participating or leaning
22	Massachusetts	No	participating or leaning
23	Michigan	yes	participating or leaning
24	Minnesota	No	participating or leaning
25	Mississippi	No	not participating or considering not participating
26	Missouri	yes (only one that increased)	not participating or considering not participating
27	Montana	No	not participating or considering not participating
28	Nebraska	No	not participating or considering not participating
29	Nevada	yes	participating or leaning
30	New Hampshire	No	not participating or considering not participating
31	New Jersey	No	participating or leaning
32	New Mexico	No	participating or leaning
33	New York	yes	participating or leaning
34	North Carolina	No	not participating or considering not participating
35	North Dakota	No	participating or leaning
36	Ohio	No	participating or leaning
37	Oklahoma	No	expanding through alternate means or considering
38	Oregon	yes	participating or leaning
39	Pennsylvania	No	expanding through alternate means or considering
40	Rhode Island	No	participating or leaning
41	South Carolina	yes	not participating or considering not participating
42	South Dakota	No	not participating or considering not participating
43	Tennessee	No	not participating or considering not participating
44	Texas	yes	not participating or considering not participating
45	Utah	No	not participating or considering not participating
46	Vermont	yes	participating or leaning
47	Virginia	No	not participating or considering not participating
48	Washington	No	participating or leaning
49	West Virginia	No	participating or leaning
50	Wisconsin	yes	not participating or considering not participating
51	Wyoming	No	not participating or considering not participating

**Related Posts**

National, State, & County Uninsured Estimates

Obama on the Employer Mandate: ". . . never mind"

Save Dollars. Save Lives: An evening with Dr. Gerald Friedman