Tag Archives: health care

Will The Supreme Court Kill Public-Employee Unions?

Mother Jones

Forget Wisconsin Gov. Scott Walker and his fellow union-bashing governors. Forget the partisan Republican attacks on organized labor. The gravest threat today to public-employee unions—which represent cops, firefighters, prison guards, teachers, nurses, and other city and state workers—is a Supreme Court case named Harris v. Quinn, which could be decided as early as this Tuesday. And, strangely enough, it is the court’s most sharp-tongued conservative, Justice Antonin Scalia, who could ride to organized labor’s rescue.

The case pits several of the nation’s mightiest labor unions, such as the Service Employees International Union (SEIU) and the American Federation of State, County, and Municipal Employees (AFSCME), against their longstanding foe, the National Right to Work Legal Defense Foundation, which helped bring the case. National Right to Work is funded by some of the biggest names in conservative philanthropy: the Bradley family, the Waltons of Walmart, Charles Koch, and DonorsTrust and Donors Capital Fund, two dark-money ATMs. Labor officials see Harris as an effort by the deep-pocketed conservative movement to wipe public-employee unions off the map—and to demolish a major source of funding and support for the Democratic Party. “This is an attempted kill shot aimed at public-sector unions,” says Bill Lurye, AFSCME’s general counsel.

The origins of Harris date to July 2003, when the Illinois legislature passed a bill recognizing certain home-care providers as “public employees” and designating a Midwest branch of SEIU to exclusively represent those workers. Before that, these workers were deemed independent contractors with no union representation, even though the Illinois government paid them with federal health-care funds. In June 2009, Gov. Pat Quinn, a Democrat, went one step further. By executive order, Quinn declared the state’s disability-care providers, another type of home-care worker, eligible for exclusive union representation. (Ultimately, the disability providers voted against unionizing.)

Organized labor hailed these moves. Unions see a huge opportunity in the rapidly growing population of elderly Americans—what SEIU president Mary Kay Henry calls the “silver tsunami.” Labor leaders believe that organizing home-care workers across the country could slow the decline in union membership.

When the Illinois labor bill passed in July 2003, no home-care worker was forced into SEIU. But if they chose not to join, the union still was allowed to deduct a small amount of money from their paychecks. Why? It was the union’s responsibility to represent every home-care worker impacted by the new law. To pay for representing union and non-union home-care workers, the union began taking what it calls a “fair share” fee. (This money cannot be used for political activity.) The Supreme Court has upheld a union’s right to collect fair share fees. (This is where so-called right-to-work laws come in. Such laws ban unions from collecting fair share fees from non-union workers even if the employees benefit from union-negotiated contracts.)

Home-care workers, consumers, and advocates in Illinois say union representation has led to higher quality care, safer workplaces, and more stability. Flora Johnson, an 85-year-old home-care worker in Chicago and SEIU member, says union-funded training sessions taught her how to properly lift a person and how to feed patients without choking them. Johnson points out that the union brought a level of professionalism to her industry. “Before we got the union, it was like we was babysitters,” she says. “We had no dignity.”

But there was a backlash. In April 2010, a group of Illinois home-care workers, led by plaintiff Pamela Harris, filed a class action arguing that the state had infringed on their First Amendment rights by forcing them to be represented by a union and pay fees. (The suit named two unions, SEIU and AFSCME, as defendants.) A district court and the US Seventh Court of Appeals each dismissed the case.

The case lay dormant until last October. That’s when, at National Right to Work’s urging, the Supreme Court agreed to hear Harris. Until that point, Harris was narrowly focused on the Illinois home-care workers; it posed no existential threat to the likes of SEIU and AFSCME. But after the high court intervened, National Right-to-Work expanded its argument to threaten all public-employee unions. As SCOTUSblog’s Lyle Denniston wrote, Harris “mushroomed…into a major test of the continuing validity of the Abood precedent.”

Cue organized labor’s freak-out. Abood v. Detroit Board of Education is the 1977 Supreme Court decision that, in effect, upheld the constitutionality of the public-employee union model. The majority in Abood said these unions did not infringe on the First Amendment by collecting representation dues and collectively bargaining on behalf of public workers.

During oral arguments in January, the Obama administration contended that overturning Abood would result in “radically reshaping First Amendment law.” Yet several of the court’s conservative justices appeared to want just that. Writing for the majority in 2012’s Knox v. SEIU, Justice Samuel Alito all but invited National Right to Work to challenge Abood. During the oral arguments in Harris, Alito and Justice Anthony Kennedy seemed eager to demolish Abood. The court’s four liberal justices questioned National Right-to-Work’s arguments at every turn, with Justice Elena Kagan saying that tossing out Abood would lead to a “radical restructuring of the way workplaces are run.” John Roberts, who has used his time as chief justice to push a pro-corporate agenda, gave few hints about where he stood on the fate of public-employee unions.

That leaves Justice Antonin Scalia. A conservative who says he interprets the Constitution through an originalist lens, Scalia would make for a strange ally of organized labor. Yet it was Scalia who asked some of the toughest questions of William Messenger, the lawyer for National Right to Work, challenging Messenger’s argument that public-employee unions are lobbying organizations focused mostly on influencing public policy. Forcing workers to be represented by a lobbying outfit, Messenger argued, infringes on the First Amendment rights of workers who don’t agree with the union’s positions.

Scalia didn’t appear to be buying it. He seemed to lean more toward labor’s argument: that unions exist to better the working conditions of the workers they represent. “Listening to Scalia’s voice in oral arguments made me feel like he really doubted that there was a need to go so far right now,” says Lee Adler, an expert on public-employee unions at Cornell University. “He couldn’t follow National Right to Work’s logic.”

The Supreme Court’s decision in Harris could cut several ways. It could affirm the lower court’s decision—a big loss for National Right-to-Work. It could issue a more narrow opinion, saying, for instance, that Illinois home-care workers aren’t public employees and shouldn’t be unionized without touching Abood. Or the high court could take that kill shot: Eviscerate Abood and gut public-employee unions.

Like many other court watchers, Cornell’s Lee Adler says the fate of Harris—and, potentially, the fate of public-employee unions—rests with Scalia. For the labor movement, Adler says, “He’s the great white hope.”

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Will The Supreme Court Kill Public-Employee Unions?

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Hospitals Report Big Drop in Uninsured Admissions in Blue States

Mother Jones

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Jason Millman has been listening in on earnings calls for publicly traded hospital chains, and he says they all report a big difference in admissions between states that expanded Medicaid and those that didn’t:

The Hospital Corporation of America…saw a 22.3 percent growth in Medicaid admissions, compared to a 1.3 percent decline in non-expansion states. The company also had a 29 percent decline in uninsured admissions in the expansion states, while non-expansion states experienced 5.9 percent growth in uninsured admissions, chief financial officer William Rutherford said.

Community Health Systems, with facilities in 29 states, also noticed an expansion gap. In expansion states it serves, CHS said it saw self-pay i.e., uninsured admissions drop 28 percent while Medicaid admissions increased by 4 percent. Self-pay emergency room visits decreased 16 percent in expansion states, but they increased in non-expansion states, the company said in its earnings call last week.

Tenet Healthcare reported last week that it had a 17 percent increase in Medicaid inpatient visits while uninsured visits decreased 33 percent in the four expansion states where it operates. In non-expansion states, Medicaid admissions dropped 1 percent as uninsured care rose 2 percent.

This is why hospitals support Medicaid expansion so strongly. Medicaid may not pay a lot, but on average it pays a lot better than uninsured patients. A drop of around 30 percent in uninsured admissions is a big win for the patients, but it’s also a big win for the hospitals.

Normally, of course, that would be enough to gain Republican support all by itself, but not in the world of Obamacare. The fact that Medicaid expansion benefits the poor, benefits hospitals, probably benefits state finances, and is all but free to participating states—well, it’s just not enough. Demonstrating their tribal opposition to all things Obama is far more important.

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Hospitals Report Big Drop in Uninsured Admissions in Blue States

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America Does Not Really Have a Big Aging Problem

Mother Jones

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This isn’t exactly breaking news, but the Census Bureau released a report on America’s aging population today, and the basic takeaway is something we already know: as the Baby Boomers age, our population is going to get steadily older. However, what’s less widely recognized is that this is only true for the next couple of decades. After 2030, our elderly population stabilizes at about one-third the size of the working-age population.

In other words, all the sturm and drang over Social Security aside, our demographic problem isn’t really that bad. What’s more, compared to other countries, our outlook is positively sunny. Take a look at the red bars in the chart on the right. They show the projected size of the elderly population in various developed countries in 2050, and the United States is in by far the best shape. Our elderly population stabilizes in 2030 at about 21 percent of the total population, a number that’s significantly lower than even the second-best country (Britain, at 24 percent). Most other countries not only have elderly populations that are far larger, but their elderly populations are growing. These countries have demographic problems.

It’s worth driving this point home: America doesn’t really have a huge aging problem. We have a very moderate aging problem, which could be handled in the federal budget with fairly modest changes to Social Security and Medicare. What we do have is a health care problem. But that’s a problem for us all.

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America Does Not Really Have a Big Aging Problem

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Surprise! Better Health Insurance Saves Lives.

Mother Jones

Does health insurance save lives? Since death is the least frequent outcome of poor medical care, I’ve never believed that mortality is an especially good way of measuring the value of different interventions. Even if an intervention is high value, the odds are good that it will have only a small effect on mortality.

This makes the results of a recent study in Massachusetts all the more impressive. Three researchers studied the effect of Mitt Romney’s universal health care plan and concluded that it’s saved a lot of lives so far. Adrianna McIntyre provides the summary:

Benjamin Sommers, Sharon Long, and Katherine Baicker estimate that overall mortality in Massachusetts declined 2.9 percent relative to control counties between 2007 and 2010; mortality amenable to health care declined 4.5 percent. This translates to one death prevented for every 830 people who gain insurance, and the effects were larger in counties with low income and low pre-reform insurance rates—the counties we would expect to be most favorably impacted by reform.

….If you think the study’s primary findings are impressive, consider their implications: “mortality amenable to health care” does not just magically decline. If fewer people are dying, that is almost certainly because diseases are being better treated, managed, or prevented—because of improved health. It’s hard to come by data on objective measures of health at the state level, but the “improved health” story is consistent with other findings in the paper: individuals had better self-reported health, were more likely to have a usual source of care, received more preventive services, and had fewer cost-related delays in care.

What makes this even more impressive is that the elderly in Massachusetts were already covered by Medicare. These results are strictly for those under the age of 65, who don’t die very often to begin with. Within this group, a reduction of 4.5 percent in mortality amenable to health care (the only kind we care about in this context) is a lot.

The implications for Obamacare are obvious since Obamacare was explicitly modeled on the Massachusetts program—though it’s unlikely that it will produce quite such dramatic mortality improvements since its coverage isn’t as universal as the Massachusetts plan. Still, Obamacare has so far shown that it has a lot in common with Romneycare, so there’s good reason to hope that it will demonstrate mortality improvements as well.

But don’t hold your breath for study results. Given the way research like this works, we probably won’t get them until 2020 or so.

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Surprise! Better Health Insurance Saves Lives.

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For Republicans, Fear and Confusion Are All They Have Left

Mother Jones

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We know that 8 million people have signed up for Obamacare on the exchanges. But how many of them have actually paid their premiums? Yesterday, as part of their long, twilight effort to convince everyone that the Obama administration is lying about the enrollment numbers, Republicans issued a laughable report saying the number was only 67 percent. A third of the enrollees are phantoms!

As it happens, I didn’t bother writing about this because, as political deceptions go, it was about as sophisticated as a kindergartner throwing a mud pie. The Republican numbers only went through April 15, even though a ton of people signed up at the end of March and don’t even owe their first premium payment until the end of April. Of course there are lots of people who haven’t sent in their checks yet. So how do Republicans justify this dumb talking point? Michael Tomasky asked:

Talking Points Memo’s Dylan Scott got hold of the questionnaire the committee sent to insurers, and it’s a joke. One industry source—not a Democratic operative—told Scott: “Everyone who saw it knew exactly what the goal was.”

I asked the GOP staff at the committee if they had a counter to the argument that their numbers were incomplete and in essence rigged. On background, one staffer there basically told me that they didn’t have a counter. The committee press release makes it clear, I was told, that these data represent payments only through April 15, and the committee will seek another report May 20.

In other words, this staffer is saying: Yep. Which makes it rather hard to avoid the conclusion that the committee knowingly put out a bad number. Why would a committee of the House of Representatives do something like that? Well, what am I saying? We know why.

Republicans got what they wanted: some headlines suggesting that Obamacare enrollment rates were lower than the White House says. And of course, it became a routine talking point on Fox News. Mud has been thrown on the walls, and by the time the final numbers come out, plenty of people will remain confused.

And that’s all Republicans care about right now: manufacturing doubt. They know perfectly well that by next month, when the final numbers come out, something like 90 percent of enrollees will have paid their premiums and total signups will be over 7 million. But they don’t care. As long as people are confused, life is good for Republicans. So confusion is what they’re selling.

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For Republicans, Fear and Confusion Are All They Have Left

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The Annual Medicare Doc Fix: Not as Bad as You Think!

Mother Jones

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Here’s a bit of contrarianism for you today: Austin Frakt says that the much-maligned Medicare “doc fix” actually works pretty well. This is Congress’s annual charade in which it overrides the formula for Medicare reimbursements to doctors, resulting in doctors getting paid more—but without ever changing the formula itself. (Why? Because changing the formula would cost money, and they’d have to figure out how to pay for it. Better to just kick the can down the road each year.)

So from one point of view, the formula is just a joke. However:

From another point of view, the formula — as flawed as it is — has helped keep Medicare spending lower than it might otherwise have been. Instead of cutting physician payments by the large amount the S.G.R. demands, Congress has increased payment rates, but typically by only tiny amounts — at an annual rate of just 0.7 percent. That pace does not keep up with the typical cost of care.

The gap can be seen in the chart below. The bottom line illustrates how Congress has permitted Medicare physician payments to grow. The middle line shows an index of medical spending — spending at a typical physician’s practice over time — that is a proxy for the change in price for a typical, or average, medical treatment.

….The relatively gentle increases in Medicare payment rates makes clear that the formula is not the problem. I think that the formula has actually helped Congress be more fiscally responsible than it otherwise might have been. To physicians who fear a double-digit decrease in payment rates called for by the formula, a 0.5 percent or a 1.5 percent increase that Congress passes looks like a great deal.

So there you go. Two cheers for the Sustainable Growth Formula!

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The Annual Medicare Doc Fix: Not as Bad as You Think!

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John Boehner Speaks Up For Main Street Republicanism

Mother Jones

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I’ve always felt a little sorry for John Boehner. In another era—a non-tea party era—he would have been your basic Main Street Republican, willing to cut compromises to keep the country moving along in a tolerably orderly way. The kind of guy who would have taken his cues from the Middletown Rotary Club.

Speaking of which, Boehner spoke to the Middletown Rotary Club yesterday and let his hair down. For most Republicans, this would have meant getting caught making some kind of incendiary remarks about Obama thuggery and class warfare against job creators. In Boehner’s case, it meant some incendiary remarks about the, um, unrealistic attitudes of the more excitable members of his caucus:

On immigration: “Here’s the attitude. Ohhhh. Don’t make me do this. Ohhhh. This is too hard,” Boehner whined before a luncheon crowd at Brown’s Run County Club in Madison Township. “We get elected to make choices. We get elected to solve problems and it’s remarkable to me how many of my colleagues just don’t want to … They’ll take the path of least resistance.”

On Obamacare: “(To) repeal Obamacare … isn’t the answer. The answer is repeal and replace. The challenge is that Obamacare is the law of the land. It is there and it has driven all types of changes in our health care delivery system. You can’t recreate an insurance market over night.”

On the tea party: “I don’t have any issue with the tea party. I have issues with organizations in Washington who raise money purporting to represent the tea party, those organizations who are against a budget deal the president and I cut that will save $2.4 trillion over 10 years….I made it pretty clear I’ll stand with the tea party but I’m not standing with these three or four groups in Washington who are using the tea party for their own personal benefit.”

This is all about pragmatism, a cri de coeur against the Foxification of the Republican Party. And I guess it means one of two things. Either Boehner doesn’t really care much about holding onto his leadership position anymore, or else he’s sensed that there’s a burgeoning Main Street backlash against the radicalism of the tea party wing of the modern GOP.

Boehner has always wanted to govern, and he’s never believed that compromise was surrender. That’s not the kind of pol he is. But he’s been hemmed in by the demands of the tea party, and now maybe he’s starting to think it’s time to bust out. The Middletown Rotary Club is probably more interested in keeping things on an even keel than in endless confrontation and hostage taking that does nothing except hurt the economy. They think immigration reform is good for business, and even if they don’t like Obamacare, they probably understand by now that it’s not a catastrophe and it’s time to make the best of it. Maybe they’re finally starting to find their voice.

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John Boehner Speaks Up For Main Street Republicanism

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Aetna CEO: Obamacare Pretty Much On Track

Mother Jones

Aetna is one of America’s biggest health insurers, and it’s currently operating in 17 different Obamacare exchanges. On a call this morning, CEO Mark Bertolini passed along a couple of interesting factlets:

Bertolini said about half of the company’s premium increases, whatever they turn out to be, will be attributable to “on the fly” regulatory changes made by the Obama administration. He cited as an example the administration’s policy of allowing old health plans that were supposed to expire in 2014 to be extended another three years if states and insurers wanted to.

….Aetna has added 230,000 paying customers from ACA exchanges, and it projects to end the year with 450,000 paid customers. It said it can’t yet draw a “meaningful conclusion” about the population’s overall health status.

The first is interesting because it suggests that Aetna’s premium increases won’t be based on fundamentals. That is, they aren’t rising because the customers Aetna signed up were older or sicker than they expected. That’s good news, even if the regulatory shakeouts of Obamacare’s early days are causing a bit of pain.

And the second is interesting because Aetna apparently expects to double its Obamacare customer base by the end of the year. That’s roughly what the CBO projected earlier this year, and this is a bit of evidence suggesting that they got it right.

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Aetna CEO: Obamacare Pretty Much On Track

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Here’s a Great Argument for Easing Up on Professional Licensing Restrictions

Mother Jones

Adrianna McIntyre has a fascinating little tidbit up today about how Medicaid expansion affects access to health care. Here’s the question: By increasing demand for doctors, is it likely to result in longer wait times for everyone?

A trio of researchers took a look at dental care to get an idea. Some states cover it for adults, some don’t. So what happens in states where adult Medicaid is expanded to cover dental care? The first-order answer is surprising: more dentists participate; their incomes go up; and wait times barely budge. But how is that possible? The second-order answer is even more interesting:

Dentists accomplish this mainly by making greater use of hygienists: following the expansion of public coverage, dentists employ a greater number of hygienists and hygienists provide about 5 additional visits per week. As a result, dentists’ income increases following the adoption of Medicaid adult dental benefits by approximately 7 percent. These effects are largest among dentists who practice in poor areas where Medicaid coverage is most prevalent.

We also find that these coverage expansions cause wait times to increase modestly less than a day, on average. However, this effect varies significantly across states with different policies towards the provision of dental services by hygienists. The increased wait times are concentrated in states with relatively restrictive scope of practice laws. We find no significant increase in wait times in states that allow hygienists greater autonomy.

Licensing and “scope of authority” restrictions are sort of a hot topic these days, and this is a pretty good example of why. I haven’t yet dived into the whole thing enough to have a settled opinion, but it’s becoming fairly common to believe that licensing restrictions are far too strict in some professions, acting more as a way of propping up salaries than as genuine public safety measures. Nurses and hygienists could be given more autonomy, for example, but this is often resisted by doctors and dentists who don’t want to give up a lucrative monopoly on the services they provide.

The arguments are sometimes arcane, but this example brings it down to earth. Ease up on the restrictions placed on hygienists, and dental practices can provide more and better service to the poor—and, in the end, do it without sacrificing income. That’s worth knowing.

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Here’s a Great Argument for Easing Up on Professional Licensing Restrictions

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Medicaid Expansion Now an Even Better Deal For States

Mother Jones

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Need some more good news on Obamacare? How about some mixed news instead? Here it is:

Congressional Budget Office (CBO) estimates released last week show that health reform’s Medicaid expansion, which many opponents wrongly claim will cripple state budgets, is an even better deal for states than previously thought….CBO now estimates that the federal government will, on average, pick up more than 95 percent of the total cost of the Medicaid expansion and other health reform-related costs in Medicaid and the Children’s Health Insurance Program (CHIP) over the next ten years (2015-2024).

The good news is obvious: the Medicaid expansion is an even better deal for states than we thought. The federal government will pick up nearly the entire cost of expansion, and when you account for money that states will save from reduced amounts of indigent care and greater help with mental health costs, the net cost of expansion gets very close to zero.

The mixed nature of this seemingly good news comes from the reason for CBO’s more optimistic budget projection: it’s because they think the program will cover fewer people than they previously projected. There had always been a fear among states that lots of people who were already eligible for Medicaid—but had never bothered applying for it—would hear the Obamacare hoopla and “come out of the woodwork” to claim benefits. Since these folks weren’t technically part of the expansion, states would be on the hook to cover the bulk of their costs.

CBO now believes this fear was overblown. Apparently most people who didn’t bother with Medicaid before Obamacare took effect aren’t going to bother with it now either. That’s good for state budgets, but obviously not so good for all the people who could be getting medical care but aren’t.

For what it’s worth, this is a tradeoff we’re going to see a lot of. Unless the actual cost of medical care comes down, the budget impact of Obamacare is always going to depend on how many people benefit from it. If lots of people sign up, that’s good for public health but costly for taxpayers. If fewer people sign up, then government spending goes down but fewer people receive medical care. There aren’t very many ways around this iron law.

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Medicaid Expansion Now an Even Better Deal For States

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