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Rauner's Budget is Bad Medicine for State's Health Services

The following post originally appeared on Crain's Chicago Business.

The much-anticipated “turnaround budget” from Illinois Gov. Bruce Rauner feels more like a “look back,” parading out failed ideas from past years. Rauner says this budget "preserves services to the state's most vulnerable residents”—but a quick review suggests this is far from true. Instead, we see a budget that:



• Further decimates a fragile community mental health system
• Reduces access to lifesaving drugs for people living with HIV and prevention services for those at risk of HIV
• De-funds critical substance-abuse treatments
• Drastically reduces cost-effective breast and cervical cancer screening services
• Makes it harder, and in some cases impossible, for people with disabilities and seniors to get support to live at home
• Reduces funding for evidence-based tobacco prevention and cessation services
• Eliminates Medicaid benefits for preventive health services, including adult dental care
• Eliminates health insurance for workers with disabilities, coverage unavailable in the private marketplace
• Slashes funding for hospitals serving Medicaid populations
• Eliminates funding for care coordination, originally designed to contain costs
• Secures Illinois' position near the bottom of states for per-enrollee Medicaid funding

It's ironic the governor calls these cuts “tough medicine,” when the proposed budget would deny any medicine and critical health care services to so many. We've been down this road before, and here's what we learned:

• Cuts of $113 million to mental health and addiction treatment services in fiscal years 2009-11 increased state costs by more than $18 million due to increased emergency room visits, hospitalizations and nursing home placements.
• Elimination of Medicaid coverage for adult dental services in 2012 caused spikes in emergency department visits for dental problems. In-patient ER treatment for dental problems averaged $6,498, nearly 10 times the cost of preventive care delivered in a dentist's office.
• Disinvesting in HIV prevention will lead to new infections, for which the Centers for Disease Control estimates lifetime treatment costs of $379,668 per case.
• For every dollar Illinois spends on providing tobacco cessation treatments, it has on average saved $1.29. Cutting funding for smoking cessation services will increase costs by up to $32.3 million annually in health care expenditures and workplace productivity losses.

As proposed, the Rauner budget is not only bad for our health, but it's bad for businesses, too, likely resulting in decreased productivity, loss of jobs and economic activity, and greater health care costs for employers. Some examples:

• The proposed child care “intake freeze” and increase in parent co-pays will lead to increased absenteeism as employees will take time off to care for children. Such absenteeism already is costing American businesses nearly $3 billion annually.
• Planned cuts to Illinois hospitals are expected to result not only in the loss of more than 12,500 jobs but $1.7 billion in economic activity.
• Cuts in funding for health care services, such as cancer screening, most certainly will increase the health care costs of Illinois businesses. One study of major employers found that patients with cancer cost five times as much to insure as patients without cancer ($16,000 versus $3,000 annually).

We urge the governor to listen to the critics of this budget and learn from Illinois' past experiences. We stand prepared to support him on this learning curve.

Barbara A. Otto
CEO
Health & Disability Advocates

From Getting Insurance to Actually Using It

After the 2015 Open Enrollment Period 347,300 Illinoisans purchased plans through the marketplace, and 541,000 people have enrolled in Medicaid since its expansion in 2014. While connecting individuals to coverage is good news, the newly insured are often overwhelmed by having to navigate the overly complex healthcare system and understand the related insurance and medical jargon.  This confusion and lack of experience counteracts one of the healthcare reform law’s major goals: to reduce medical costs by increasing access to primary care. Obtaining coverage will not offset a lifetime of avoiding the doctor’s office and visiting the emergency room for primary care. The newly insured must learn how to find a doctor, fill a prescription and read a prescription label. Without that, they are subject to poor health outcomes and high costs. The newly insured must gain health literacy which can only happen through the combined efforts of consumers, communities, providers and governing bodies.

What is Health Literacy? 

The Centers for Disease Control and Prevention define health literacy as the degree to which an individual can obtain, process, communicate and understand health information and services. People with low health literacy are more likely to be uninsured. Similarly, uninsured individuals show lower health literacy scores compared to those receiving employer-based coverage.

So Why Does Low Health Literacy Matter? 

It is not altogether surprising that the uninsured and those with low health literacy are less likely to seek preventative care; more likely to experience poor health outcomes; and more likely to encounter higher medical costs. According to the Kaiser Family Foundation, only 1 in 3 uninsured adults said they had a preventive visit with their physician in the previous year, and uninsured adults experienced higher mortality rates than the insured. An Institute of Medicine report found a similar pattern of healthcare use for those with low health literacy, stating this group was less likely to seek preventive care. Research also found that lower health literacy in Medicaid managed care settings is connected with higher mortality. This shows that the uninsured and people lacking health literacy interact with the healthcare system in similar ways: poorly. Using the healthcare system is something people must learn. Giving someone a computer does not mean they know how to type. In the same way, connecting a person with healthcare will not alter their level of health literacy.

Old Habits Die Hard. The newly insured will continue receiving care in ways most familiar to them, which can translate to using the emergency room for non-emergencies. According to the Oregon Health Insurance Experiment, individuals who received Medicaid coverage increased their emergency room use by 40%. Asked to comment on the results, the state director of policy and programs for the National Association of Medicaid Directors alluded to the importance of promoting health literacy in the newly insured. She said, “this is not something that is unexpected” and “the key to getting inappropriate costs down for all patients is educating people about where they should go when it’s not an emergency.”

How to Address Health Literacy

Government Efforts
State initiatives, including an Illinois Emergency Room Diversion Grant are acknowledging the importance of patient education and using outreach to reduce ER use. In Illinois, hospital staff led outreach explaining the proper use of the ER and offered a 24-hour nurse triage line as an alternative. Meanwhile, Maine is targeting ER super-utilizers through community care teams that offer intensive case management including home visits and health coaching. Recognizing state efforts like that of Illinois and Maine, CMS listed patient education as a recommended component of programs targeting ER super-utilizers.

Health Professional Efforts
Beyond education on how to use their health insurance, health professionals can improve the usability of health services by reducing medical speak in patient interactions. Healthcare systems can also create plain-language pamphlets for patients to reference after leaving the doctor’s office. By speaking with patients in a relatable manner and sharing usable information, doctors better position healthcare consumers to adhere to medical recommendations.

Northwestern University’s Division of General Medicine and Geriatrics focuses on improving engagement between providers and patients and has developed plain-language materials that communicate complex health topics. For example, researchers created written information and videos available in Spanish and English that teach patients diabetes self-management. The modules use simple language and rely on pictures to communicate aspects of diabetes care, such as how the disease can impact a person’s eyes. By using these materials when interacting with diabetes patients, health professionals communicate vital aspects of care in an accessible manner, increasing the likelihood that patients adopt the healthy behaviors.

Community Health Literacy Efforts
The Be Covered Illinois campaign is promoting health literacy by generating easy-to-read written and online materials, creating short videos explaining critical concepts and utilizing community partnerships to expand the reach of their communications.  By producing written fact sheets on finding the right doctor and developing web content on using your coverage Be Covered empowers the newly insured with the knowledge to navigate health insurance and health care systems more effectively. Be Covered’s Dr. Lopez video series, presented in both English and Spanish, addresses health insurance topics, chronic disease, prevention and more. Be Covered broadens the reach of their education efforts by partnering with 82 organizations in Illinois, including Illinois Health Matters, that share information and materials with their own constituencies.  As part of that effort, Be Covered provides regular content for social media and shares copies of consumer friendly resources free of charge to partners.

Illinois Health Matters recognizes the importance of not only getting insurance but using insurance. The website features resources such as a Medical Cost Look Up, that allows consumers to estimate out-of-pocket costs for medical services and a resource on Immunizations and the ACA, outlining the vaccines children and adults can access for free because of healthcare reform. The website also has a tip sheet titled What to Know About Provider Networks, explaining steps consumers can take to avoid high medical costs associated with out-of-network care. These are just a few examples.

Illinois Health Matters is taking on the challenge of supporting a more health literate population, but we can’t do it alone. Join us. One great way to start: subscribe to our newsletter to stay informed and share the knowledge with your clients and coworkers. The healthcare community can achieve the vision of the Affordable Care Act, but only through the joint efforts of providers, policymakers and organizations supporting health literacy.

Bryce Marable MSW
Health Policy Analyst 

What’s in the New Health Care Law for Women? Well-Woman Visits That Can Improve Your Health

As an emergency physician, I tend to work on the other side of preventive care services. I see what happens when women don’t know about safer sex and birth control, and end up with complications from sexually transmitted infections. I see what happens when women do not get routine screening for cervical cancer and struggle with life-threatening cancer. I see what happens with out-of-control hypertension and diabetes, and the heart attacks and strokes that are detected far too late.

These experiences have shown me that prevention is the best medicine. That’s one big reason why the Affordable Care Act provision requiring new insurance plans to cover women’s preventive care without any extra charges or co-pays is a real victory for women. These requirements, which go into effect Aug. 1, will be phased into existing insurance plans over time.

Because of this change, women will be able to obtain complete contraceptive care, screening for sexually transmitted infections, and screening and counseling for intimate partner violence. This builds upon earlier requirements that insurance companies cover – at no additional cost to women -- mammograms and screenings for cervical cancer. It’s clear to me that these mandates will significantly improve women’s health and lives and ultimately lead to a reduction in health care costs.

The Well-Woman Visit

One of the easiest ways to obtain preventive services is through a well-woman visit. These visits, which will soon be covered with no co-pay, give you the opportunity to ask key questions about birth control, sexually transmitted infections, and other reproductive issues, along with questions about diet and exercise and any health concerns you have. You can also discuss changes in your family’s medical history that are important for your health care provider to consider. For example, when my mother was diagnosed with breast cancer, my doctor recommended that I get earlier screenings.

Along these same lines, your health care provider may have questions or issues to discuss with you. Smoking, drinking and recreational drug use can create and contribute to health problems, and often need to be discussed and addressed multiple times before change happens. Well-women visits also give your health care provider a chance to screen for potential high blood pressure, diabetes, depression, domestic violence, and more.

The well-woman visit is important for another reason: it gives you and your health care provider a chance to get to know each other. Most people go to their provider or to a clinic only when there’s a problem, but the best time to get to know your provider isn’t when you’re in distress from a painful or troublesome condition. Studies have shown that health care providers make more accurate diagnoses when they know their patients and can put the symptoms in the context of your life. A well-woman visit is a precious opportunity to build this trusted relationship.

As an emergency physician, I am excited about the new provisions taking effect Aug. 1, which include annual well-women visits for those who want them. I would much rather women regularly visit their health care providers than come to the E.R. later suffering from preventable problems. So please take this opportunity and make an appointment with your provider. The importance of investing in your health is too crucial to ignore.

Leana S. Wen, MD
Dr. Wen is an emergency physician at Brigham & Women’s Hospital and Massachusetts General Hospital and a clinical fellow at Harvard Medical School. She is the author of a forthcoming book on patient advocacy, “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests.” For more information, visit her blog When Doctors Don’t Listen or her website. You can also follow her on Twitter @DrLeanaWen.

(This post was originally posted here on Our Bodies, Ourselves as part of the Countdown to Coverage Campaign)