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Archives for March 2017

Why we should support Meals on Wheels

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There’s been some hoopla about cuts to Meals on Wheels in the proposed Trump budget.   The argument, such as there is one, seems to be that states should decide whether or not to fund a program that according to Mick Mulvaney sounds good, but doesn’t work.Meals on Wheels delivery

Overall, the budget is unclear so how much will ultimately be cut and through which avenues of funding is murky, but Meals on Wheels has become a symbol.  It’s a program that helps millions of people. It’s about more than meals.  It depends heavily on volunteers.  The federal funds that are provided gives local communities leverage to raise more money and make a real difference. It’s an example of how federal funding is not just about the dollars, but about federal, state, and local partnerships to make life better for people.

Mulvaney’s offhand remark about how programs like this don’t work is just another demonstration of how this administration really doesn’t understand the real world and the real effects their decisions have on real people.  Or that they just don’t care.

But I digress.  This is #justthefactsfriday, not #soapboxsaturday.

Here is some data.

Here’s a nugget that I found particularly striking.  For 60% of those 2.4 million people, one of those home delivered meals provides half or more of all of their food for the day.

Just stop and think about that for a minute.  That’s a large group of older adults who are surviving on very little food.

Who receives home delivered meals?

  • 64% of them are women
  • 40% live in poverty
  • 28% belong to a minority group
  • 37% live in rural communities
  • 52% live alone

And it’s pretty clear that Meals on Wheels provides more than just food.

A 2012 study of 626 older adults at 8 sites in Texas, Florida, Georgia, North Carolina, New Jersey, and Rhode Island shows just what an important service Meals on Wheels is.

Participants who were on a waitlist were randomized into three groups.  One group received hot meals daily, another group received a weekly delivery of frozen meals (one potential way to cut costs), and a third group remained on the waitlist for the 15 weeks of the study.  The participants and the people who delivered their meals were surveyed at the beginning of the study and again at the end.

Here is some of what they learned.

  • The two groups receiving meals reported less anxiety at the end of the 15 weeks with those receiving daily meals showing the most improvement.
  • Among those who had previously fallen, participants receiving daily hot meals were less likely to have fallen again compared to both the waitlist group and those receiving frozen meals once a week.
  • Those who received daily meals were less worried about being able to stay home compared to the other two groups. This was particularly true among those who lived alone.
  • They also felt less isolated and more safe.  This was partly because they didn’t have to cook or leave the house, but more importantly it was because they knew someone would be checking on them everyday.

In the grand scheme of things, Meals on Wheels and other community-based programs don’t cost much given the amazing services they provide.

It’s time to speak up.  Let our representatives know that this is not okay.

Call your elected officials.

Find a town hall near you.

On dog birthdays and mental health

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Last week my dog Loki turned three. She’s the third dog in my life. There was Boop – the dog of my childhood – and Zeke – our first cattle dog.  I used to haul Boop up into our crabapple tree in a bucket or put her in the hammock with me.  I have a distinct memory of reading a Wrinkle in Time and other favorites during long Ozarkian summer afternoons with Boop by my side.  Zeke was an expert Frisbee artist and mood dog.  He had an uncanny ability to absorb and reflect back the emotional energy in the house. I loved both of those dogs and miss them each in different ways.

But my relationship with Loki is different.  Maybe it’s because we got her when she was only six weeks old. I met Zeke when he was about two and I’m not sure how old Boop was. I was only six myself and don’t really remember her puppyhood as distinct from my own. Or maybe it’s one of those things that animal people know. Sometimes you just connect with a particular quadruped. As my sister says, we get the quadrupeds we deserve, or maybe more accurately the quadruped we need at that moment.

The thing is, Loki entered our life just as I was dealing with a serious bout of depression.  I was blindsided by this dark period because it actually happened at a point when everything was going well. It made it that much more difficult to understand why getting out of bed in the morning was so hard; why I couldn’t concentrate long enough to read a mystery novel, let alone write an academic paper; why nothing tasted good; and why I had concrete blocks for arms and legs and a lead corset strapped around my torso.  Hyperbole and a half does a good job of describing the experience.    Fortunately, I was never suicidal, but for the first time I understood how someone could get to that point and that was scary enough.

Eventually I got help from a mix of medications, therapy, and meditation.  And, honestly, a six-week old ball of happy, stinky, destructive, messy, toothy snuggles was part of that mix too.  Depression can seem like self-absorption, even selfishness, from the outside.  It does a bit from the inside too, but it’s accompanied by this silent struggle of will power against chemistry with a heavy overlay of guilt. As the meds started to take off the edge, Loki demanded attention and there were minutes, and then hours, and then days when it was just really hard to be depressed with this up in my face.

Cute little puppy face

 

Recently the White House asked people to submit their Affordable Care Act stories.  They, of course, want to hear disaster stories, but I shared my positive take.  I’m one of the privileged ones.  I have good coverage through my employer.  But the Affordable Care Act affects me because it requires that mental health is one of the things included in that coverage.  That was really, really important for me a few years ago and continues to be so.  One thing this experience made me realize is that I’ve struggled with depression all my life.  I will continue to do so and sometimes that means getting medical help that I wouldn’t be able to afford without health insurance coverage.  Loki is a powerful antidepressant, but only as part of a well-rounded treatment plan.

So far, the health care plan proposed by the Republicans maintains the ACA’s requirement that ten categories of essential health benefits be covered – one of which is mental health and substance use care.  Of course, that won’t matter much to the millions of people who will lose their health insurance.

It’s time to speak up.

Share your Obamacare story with the White House.

Call your elected officials.

Find a town hall near you.

 

What Medicaid covers and what the Republican plan will change

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Medicaid is not part of the Affordable Care Act. It’s been around since 1965 when President Johnson signed both the Medicaid and Medicare bills into law.  It’s future, however, has become tied to that of the ACA because of Medicaid expansion.  That’s the part of the ACA that gave states the option of expanding who qualified for Medicaid. In the 32 states that did this, 11 million newly eligible adults gained coverage.

Medicare, Medicaid, the Children’s Health Insurance Program, and Affordable Care Act marketplace subsidies together accounted for 25% of the budget in 2015. About 2/3 of this went to Medicare which provides health coverage to people over 65 and those with disabilities.

The Republican health care plan would shift Medicaid funding to a block grant model that would cap the amount of federal funding each state gets. These caps would not take into account state level differences in things like population demographics or health care prices.  This means states will have less flexibility than they currently have in who they fund and at what levels and states will be less able to respond to changing needs. This effects a significant number of our fellow citizens.

Medicaid provides health coverage for 1 in 5 Americans.

This includes:

  • Children
  • Pregnant women
  • Parents of dependent children
  • Other adults with disabilities or other long-term care needs

Eligibility ranges from less than 50% of the federal poverty level depending on which of these groups you fall into and what state you live in.  The federal poverty level for a family of three in 2017 is $20,420.

Chart depicting percent of different populations with Medicaid coverage

Medicaid is the main source of financing for long-term care in the United States.

This can include older adults as well as people with disabilities and chronic health conditions that limit their daily functioning.  Long-term care services help with daily self-care like eating and dressing and household activities like meal prep, cleaning, and managing medications.

Long term care may be provided in an institution like a nursing facility or a group home, but can also be provided in the individual’s home. In fact, most long-term care is provided by unpaid caregivers like family members with the help of home and community-based services.  These esrvices keep people who would otherwise be in nursing homes living independently in the community.

In 2015, the typical cost of a year in a nursing facility was $91,000.

The number of people needing long-term care is growing.

So what is likely to happen under the Republican plan?

A number of things are likely to happen as state budgets feel more pressure from the federal caps.

  • Reduced coverage and access to care for low-income people
  • Higher out-of-pocket costs
  • Increased uncompensated care costs for hospitals and other providers which will be passed on to other health care consumers
  • Reduced access to long-term care for older adults and people with disabilities.

There could also be negative effects on health care premiums more generally.  Marketplace premiums in states that expanded Medicaid are about 7% lower than in non-expansion states.  This may be because including a wider range of people in Medicaid changed the compensation of the risk pool in these states.

There you have it.  And because it is #justthefactsfriday and I don’t know everything, corrections, additions, and conversation are welcome.

Cheaters assume everyone else is cheating. Liars assume everyone else is lying.

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The current administration has given the green light for hate and bigotry. It has also given those in power (particularly of the Republican ilk) a newfound freedom to display the contempt they feel for the people they are supposedly elected to serve, many of whom put them office.

A few examples from recent news:

Congressman Robert Marshall

Congressman Roger Marshall is a physician on the GOP Doctors Caucus, a group of physician lawmakers who want to repeal the Affordable Care Act.  He recently dismissed poor people and homeless people as a group “that just don’t want health care and aren’t going to take care of themselves”. They won’t take advantage of preventive care even if you give it to them. And why should we give it to them when they won’t eat healthy or exercise.  I’m reminded of a single mom I once knew who held down an office job, got her kid to school every day, and then returned home to her car every night after a hard day’s work to help her kid with her homework.  Eating was a goal, not eating healthy.  Surviving another cold Chicago night was a priority, not getting to the gym. Dr. Marshall described the hospital of his dreams as “more like a hotel with customer service that delivered five-star health care.” But gosh darn it that pesky Affordable Care Act that provided coverage to all those poor, sick people got in the way.

Work requirements for those on Medicaid

Republican governors are pushing for work requirements for those on Medicaid.   Not new, I know. Neither is the paternalistic holier than thou belief that if we provide a helping hand we’re just giving people an incentive not to work.  In this case, health care is at issue, specifically Medicaid and its expansion in some states through the Affordable Care Act to more adults without disabilities. The fact is, most adults on Medicaid are working and most of those are working full-time, but that doesn’t mean they have health insurance.  In fact, for many, Medicaid coverage has allowed them to get the care they need so that they CAN work.

Drug testing people on welfare

Drug testing people on welfare is also gaining popularity.   Those who support it claim it saves money by getting rid of drug users and reducing spending on benefits.  So far states who have done this have spent millions of dollars to discover that welfare applicants actually test positive at a lower rate for drug use than the general population.  And yet, other states are forging ahead to root out all those mooching addicts.

Rampant unemployment fraud in Michigan

And, finally, one of my favorites – the automated system designed to uncover the rampant unemployment fraud that the Republican government in Michigan was just sure must exist.  Automated systems are programed by humans.  Clearly this one was subject to the biases of its developers because it made wrong accusations in at least 20,000 cases.  Ninety-three percent of the accusations made via this system were wrong.  The huge spike in fraud after putting the system in place didn’t apparently raise any red flags, presumably because it supported what those in power expected to find. Meanwhile, innocent people are losing unemployment, being fined thousands of dollars, and having taxes garnished.

To my mind these stories not only lay bare a contempt for a huge swath of our citizenry, but they also reveal a great deal about how those enacting these draconian rules think.  They assume everyone is trying to cheat and game the system.  Why?  Because they are always trying to cheat and game the system, in their case perhaps the tax code or the world of commerce.

I still have my moments when I hope the Republican establishment will step up, come to their senses, and help stop our free fall into fascism, but each time I see one of these types of stories, that hope fades a little more.

What’s on the horizon for health care reform?

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Posters saying "Health Care for American Now!" and "Health Care Can't Wait!"There’s been lots of bluster about repealing and replacing the Affordable Care Act since the day it was enacted.  The reality of actually doing it is apparently turning out to be a bit more  . . . um . . . complicated than anticipated.   This week Senator Rand Paul engaged in a little theater with the Great Health Care Bill Hunt. It seems that either Republicans are being ridiculously secretive about what’s in the works – even with members of their own party – or there’s no viable legislation available to share.

In either case, the big talk without concrete details is making people nervous. The best guess of what proposed legislation would look like is Paul Ryan’s plan put forward in June 2016.  This plan would, among other things:

  • Remove individual mandates to have coverage, but continue to prohibit insurers from denying coverage based on pre-existing conditions. Without an individual mandate, premium costs are likely to increase dramatically because insurers are covering more sick people and therefore have more costs which they will need to pass on.  Or insurers will just bail and people will lose coverage entirely.
  • Provide a flat, age-adjusted tax credit for those without coverage through an employer, Medicare, or Medicaid. Flat means you get the same amount regardless of your income unlike the ACA where credits were paid on a sliding scale. So if my income is $1000 a month and your income is $4000 a month and we need to buy insurance that will cost us $300 a month we both get the same amount of credit.
  • Repeal ACA cost sharing subsidies that reduced deductibles, copays, and out-of-pocket limits for qualified households. So not only do you and I get the same amount of help with paying for premiums, but we also have the same deductibles, copays, and out-of-pocket limits despite our vastly different income.
  • Push the use of high deductible health plans. These plans have cheaper monthly payments, but require that you pay a lot up front when you need care.  Payments for out of network services do not count toward that deductible.  In 2017 the minimum annual deductible for high deductible plans is $1300 for an individual and $2600 for family coverage. The maximum annual out of pocket expense is $6,550 for individuals and $13,100 for families.
  • Push the use of health savings accounts. You put money in your account pretax and then draw on it for copays and other approved expenses. What expenses would qualify under Ryan’s plan isn’t clear. In 2017 the maximum annual contribution to a health savings account is $3400 for an individual and $6750 for a family so you better hope your expenses aren’t any more than that.

There are also lots of changes to both Medicare and Medicaid proposed that deserve individual posts of their own.

You can learn more through the Kaiser Family Foundation  or read Ryan’s policy paper.

And because it is #justthefactsfriday and I don’t know everything, corrections, additions, and conversation are welcome.