When he tried to enter a cardiac rehabilitation program to learn how to reduce the odds of having more heart trouble, the Medicare office told him to call Medicaid. The Medicaid office told him to call Medicare. In the end, he said, both denied coverage.
“I was like a ping pong ball,” said Kim, 51, who lives in Los Angeles. “Nobody wanted to take responsibility.”
So Kim kept returning to the emergency room, racking up expensive medical bills for taxpayers.
Kim and other patients like him are among the nation’s sickest and poorest residents, and their high-cost medical care places an untenable financial burden on states and the federal government. Because he is poor and disabled, he qualifies for both the federal Medicare program and the state-federal Medicaid program, called Medi-Cal in California.
These patients – 1.1 million in California alone – are some of the country’s priciest government health care consumers. Called dual eligibles, they accounted for close to 40 percent of Medicaid spending in California in 2009, nearly $10 billion, but constitute only about 15 percent of enrollees. Nationwide, the nearly 9 million dual eligibles have similarly disproportionate outlays and cost roughly $250 billion annually in Medicare and Medicaid funds.
Now, as federal officials look for ways to control costs under health care reform, they are zeroing in on millions of patients like Kim. But system reform is a sensitive issue.
“It’s a much more fragile population,” said Casey Young, who works for AARP in California. “It is always concerning when the motivation is cost savings and not improving care.”
The government spends so much on dual eligibles because of their illnesses: multiple sclerosis, cerebral palsy, Alzheimer’s disease and other debilitating conditions. The expenditures also are high because patients bounce between the two plans and often receive unnecessary, duplicative and poorly coordinated services. They cycle through emergency rooms, hospitals and nursing homes more than other Medicare or Medicaid enrollees, according to the Kaiser Family Foundation.
The result, health care officials and other experts say, is not only inflated expenditures but also gaps in medical treatment for the most vulnerable patients: the elderly, poor and disabled.
How will people track this accountability?
One of our values is that we should be measured not just by what we say, but by our results. And central to our results is how we have expanded health coverage and access. So we will have a whole range of metrics on what percentage of people who are eligible actually enroll, how we are doing with different target populations, how we are doing in urban versus rural areas. So, we will be a data-rich and transparent organization.
There are members appointed by the previous governor on the board, is there any concern about consensus?
I left the Obama administration to join the California health benefit exchange in part because I was so phenomenally impressed by the strength and diversity of perspectives of this board. It’s a strong and well-informed board. I’ve been at a number of board meetings, both in public and closed session, and it’s a board that’s working phenomenally well together that brings perspective and values to what is a very complex set of issues. So the climate that I can speak to, is the climate that I’ve witnessed at board meetings and otherwise, which is one that has been collegial, sleeves rolled up to wrestle with a tough issue.
There have been attempts to repeal the federal health care act. What would that mean for the California exchange if something were to happen to federal funding?
Our job at the exchange is to deal with the realities we have. We are implementing a federal law, we are also implementing a state law. And our charge is to be ready to help more than six million Californians get health insurance. The what-ifs out there raise all sorts of hypotheticals, but we are being distracted from making sure that we are going to be expanding coverage. I spent a lot of time in Washington looking at the what-ifs, whether it's court case or electoral, and in some ways I think they aren’t worth spending a lot of time on, because this is the law of the land. We in California, across the political spectrum and range of stakeholders, are working together phenomenally well, recognizing that Californians don’t have the coverage they should have. And I’m confident that the spirit of collaboration and partnership that we’ve seen in standing up to the exchange would continue in California irrespective of what might happen at the national level.
Some critics have expressed concern over the exchange having an iron grip over the market.
The exchange will represent somewhere between 5 and 10 percent of the health care market. That is far from having an iron grip over anything. We look forward to helping create marketplace dynamics that will put consumers in the drivers' seat. The charge and charter of the exchange is to enable consumers, those that are choosing health plans, doctors, hospitals, with the information and ability to make the choice that’s right for them. For many, many years we had a healthcare system that [in some ways] hasn’t put consumers in the center of it. The exchange is putting consumers in the center of health care. And that’s not an iron grip, that’s putting the right hand on the steering wheel.
Any thoughts on Senator Mark Leno’s, D-San Francisco, Single Payer Option bill?
I have no comment on that. I’m not familiar with the legislation. Our focus at the exchange is implementing a program which is moving California and the nation, as part of the Affordable Care Act, toward close-to universal coverage through market-based reforms that we think have enormous promise. Whether there are legislative efforts to dismantle exchanges or start single-payer options, I’ve got a day job and it’s a pretty big one and that’s what I’m focusing on.
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