Joe, you forgot about lowering the Medicare age

For middle-income older Americans who have lost their jobs and no longer get health insurance through work, buying coverage through Obamacare is often unaffordable. 

Medicare at 60 would solve many of the health care problems facing this suffering cohort. It would make about 23 million Americans newly eligible for the program, including about 2 million who are currently uninsured.

Read more at Washington Monthly….

Cavity Country

Rural America has too few dentists – and too few patients who can pay.

Via the Washington Post.

Lynnel Beauchesne’s dental office hugs a rural crossroads near Tunnelton, W.Va., population 336. Acres of empty farmland surround the weathered one-story white building; a couple of houses and a few barns are the only neighbors. But the parking lot is full. Some people have driven hours to see Beauchesne, the sole dentist within 30 miles. She estimates that she has as many as 8,000 patients. Before the office closes at 7 p.m., she and her two hygienists will see up to 50 of them, not counting emergencies.

About 43 percent of rural Americans lack access to dental care, according to the National Rural Health Association, and West Virginia, among the poorest and most rural states, is at the center of the crisis.

Read more at the Washington Post.

The Dialysis Machine

Via Washington Monthly

On a sunny August day, an elderly, fragile-looking black man sits slumped in a wheelchair, eyes closed, outside the doors of a DaVita Dialysis center. The business takes up the corner of a run-down strip mall in Southeast D.C., in a heavily black neighborhood across the river from the Capitol. It’s next door to a liquor store and steps away from an ACE Cash Express check-cashing outlet, a barbershop, and a takeout place. A big sign on the glass warns visitors that firearms are not allowed inside. A handicapped-accessible public bus waits in the parking lot to take other patients home.

It’s midafternoon, but the shopping center is buzzing with knots of people hanging out by the takeout and the barbershop. Everybody seems to know someone on dialysis. One man in a barber’s smock out for a cigarette break says he had a friend who died at a dialysis center. He says ambulances are a constant presence at the DaVita clinic. It’s not unusual for people to die on dialysis: nationally, about one-fourth of patients die in the first year, and six in ten will be dead within five years.

As many as thirty million Americans have chronic kidney disease. If you’re one of them, and you’re white, well educated, and middle class or higher, odds are you’ll get the kind of medical care that will save your kidneys. You likely have private health insurance and get regular checkups. You probably caught your condition early and are taking medication to slow down the disease’s progression.

But if you are poor, less educated, and black, the odds are much greater that your disease will run unchecked and your kidneys will eventually fail. According to the National Institutes of Health, black people are nearly four times as likely to suffer kidney failure as whites. Then you will likely end up on dialysis, spending three days a week, four hours at a time, at a place like this one, as your blood is pumped out of your body, filtered, and pumped back in.

Farther down the sidewalk, waiting for her daughter at the takeout, is Sharon C., a soft-spoken sixty-two-year-old black woman in a sleeveless white dress and Jackie O sunglasses who doesn’t want to give her full name. She sits in a wheelchair, her left foot and ankle grotesquely swollen, the result of poor circulation caused by the diabetes she was diagnosed with in 2005.

Sharon goes to a different DaVita center for dialysis, one near Capitol Hill, where she spends every Tuesday, Thursday, and Saturday. “You can’t miss a treatment,” she says. “You can’t go anywhere.” She says she only got on dialysis two months earlier, when her one functioning kidney finally failed. She is not on the wait list for a transplant. “I need to find a donor,” she says, echoing what patient advocates say is a common misperception among dialysis patients: that you can’t get a transplant unless you find a donor for yourself. “I don’t want to be like this.”

The most tragic consequence of a system that incentivizes keeping people, especially poor people and minorities, on dialysis is that it also keeps them from getting what is beyond doubt the best treatment for kidney failure: a transplant.

Of the 661,000 Americans with kidney failure, about 468,000 people—more than a third of whom are black—are on dialysis. In the District of Columbia, where the prevalence of kidney failure is the highest in the nation, according to the Centers for Disease Control, there are twenty-three dialysis centers, mostly in Northeast and Southeast Washington, the predominantly black parts of the city that are also ground zero for diabetes and high blood pressure, the two conditions most linked to kidney disease. Another 100 dialysis centers are within a twenty-five-mile radius of the city, again concentrated in the suburbs with the largest minority and low-income populations. In District Heights, Maryland, a DaVita center dominates the busy intersection of Pennsylvania Avenue and Silver Hill Road. In a strip mall just across the street is a clinic run by U.S. Renal Care.

Like check-cashing outlets and payday lenders, dialysis centers—the vast majority of which are for-profit, like DaVita and U.S. Renal Care—are now fixtures in the urban commercial landscape. “We used to say there’s a liquor store on every corner,” said Clive Callender, a transplant surgeon and professor of surgery at Howard University. “Now we say there’s a dialysis unit on every corner.”

The prevalence of dialysis centers in minority neighborhoods is a reflection of policy failures that encourage—indeed institutionalize—class and racial disparities in American health care. These failures include more than just disparate access to the primary and preventive services that could help high-risk patients stave off kidney disease. Public policy effectively steers low-income and minority patients with kidney disease toward dialysis and away from superior options, particularly transplants.

Everyone with kidney failure, also called end-stage renal disease, is covered by Medicare. And Medicare guarantees payment for every dialysis session. As a result, the treatment of kidney failure is a volume-centered business aimed at keeping dialysis centers running. “You fill up a facility with so many stations, you make sure somebody is sitting in each of those chairs around the clock,” said Dennis Cotter, president of the Medical Technology and Practice Patterns Institute. “It’s the Henry Ford production model.”

This system creates an incentive for clinics to keep patients on dialysis until they die.

Continued at the Washington Monthly

How Obamacare Is Winning Young Invincibles

More than 5.7 million young Americans have become insured since 2010.

When the Affordable Care Act (ACA) passed in 2010, one of the biggest unknowns was this: Would enough young, healthier Americans sign up for Obamacare to keep the fledgling health insurance marketplace viable?

“Young invincibles,” many believed, were critical for balancing out the older, sicker – and more expensive – enrollees who would otherwise dominate the market. Without enough younger participants, experts feared, the market would see a “death spiral” of rising premiums that could lead to its eventual collapse.

But since 2010, more than 5.7 million young Americans ages 19-to-25 have gained coverage, according to government figures, including significant numbers of African-Americans, Latinos and other minorities. And of the 8.84 million Americans who chose a plan during the most recent open enrollment period, 28 percent were millennials ages 18-to-34. These figures are all the more remarkable given that in 2010, the uninsured rate among 19-to-25 year olds was 34.1 percent – more than double the uninsured rate among the population as a whole.

How is Obamacare winning millennials?

Continued at the Washington Monthly…

The Long Term Care Time Bomb

America’s biggest demographic challenges might be posed not by the very young, but by the very old.

In 1900, according to the U.S. Census, just 122,000 Americans were age 85 and older. Today, it’s 6.1 million.

Americans 85-plus now account for about 13 percent of all Americans over age 65, and more than 1 in 4 seniors (26 percent) are now over age 80. By 2050, says the Robert Wood Johnson Foundation, the number of Americans over age 85 is expected to reach 19 million nationwide.

Millennials may continue to grab the demographic limelight – they’re now officiallythe largest generation in U.S. history – but the rapidly-growing cohort of very old Americans demands as much attention, if not much more concern. Particularly worrisome: The exploding cost of long-term care.

Here’s a simple but stunning fact: Public policy has made no provision to finance the growing long-term care needs of aging Americans in a fiscally sustainable way. In fact, a bipartisan commission convened by Congress in 2013 failed to agree on a viable solution to pay for Americans’ increasing long-term care needs. The result: A looming social and economic crisis that threatens both middle-class finances and well-being.

Continued at the Washington Monthly…