Inmate advocates question state's commitment to prison healthcare

latimes.com

The judge who called California's medical care of inmates cruel and unusual punishment has ordered a plan to return control to the state. But inmates question if improvements will continue without U.S. supervision.

A guard escorts an inmate through a construction area to the medical ward at Deuel Vocational Institution in Tracy, Calif. (Luis Sinco / Los Angeles Times / January 26, 2012)

Reporting from San Quentin -- Fifteen years ago, Jackie Clark was so disgusted with the healthcare at San Quentin prison that she quit her job there as a nurse consultant.

"We didn't have sinks. We didn't have appropriate medical equipment," she recalled recently. "We were in converted offices and converted cells."

The care there and elsewhere in California's overcrowded lockups was so poor that in 2006 a federal judge, saying that an inmate was dying unnecessarily every week, put a receiver in charge of the health system. A cascade of court decisions that followed forced the state to begin lowering the country's largest state prisoner population by almost 25%.

Today, Clark is back at San Quentin Correctional Facility as its top medical official, overseeing a new $135-million clinic that is the showcase for six years of progress. The judge who once said California's dismal prison medical care constituted cruel and unusual punishment now says federal control could soon end.

"Many of the goals of the receivership have been accomplished," U.S. District Judge Thelton E. Henderson wrote last month, ordering up a plan for transferring control back to the state.

But advocates for inmates and some medical officials question whether the system will continue to improve without federal oversight. Despite San Quentin's new clinic, many of California's 33 prisons are still stuck with outdated or cramped facilities.

State officials say they are ready. Subpar doctors have been replaced with board-certified physicians. The state is converting reams of paper files into digital records, and aging computers have been tossed. Prescription drugs are no longer handed out haphazardly by overworked staff members with dangerously incomplete patient records.

Corrections Secretary Matt Cate said Gov. Jerry Brown's administration, not an unelected federal receiver, should be deciding how the state spends roughly $1.8 billion a year on inmate medical care.

Californians "voted for Jerry Brown, and that's who should run government," he said. The court should "have some faith that we'll be able to get this done without backsliding into conditions that were found unconstitutional to begin with."

But the receiver, J. Clark Kelso, isn't sure. The Brown administration has suspended plans for new medical buildings and $750 million in upgrades of existing clinics, and Kelso said that getting adequate facilities has been a constant challenge.

"I keep getting pressure from the state — 'Are you done yet, are you done yet?' " Kelso said. "Look in the mirror! I would have been done if you had just followed through on the things you said you were going to do."

Donald Specter, director of the Prison Law Office, the advocacy group that filed the lawsuit that led to the receivership, fears that the financially strapped state may stop investing in inmate healthcare.

"Jerry Brown has cut almost every social service for free people in order to balance the budget," Specter said. "So I'm concerned what he would do to the prison medical care budget without a court order."

Before the court took over in 2006, California's vast prison healthcare system was dangerous and unsanitary. Cate, who was state inspector general then, said it was substandard "for any human being, regardless of whether you're incarcerated."

In addition to the physicians' shortcomings, clinical space was decrepit and technology was inadequate. Ceilings leaked. Doctors and nurses had no reliable way to track patients.

Sam Johnson, who has been incarcerated at San Quentin for nearly 14 years for murder, said inmates waited months for a checkup and often didn't get the care they needed. He recalled a fellow prisoner who complained of chest pains, was given Pepto-Bismol for heartburn and was dead in his cell by the end of the day.

"We didn't matter to them," Johnson said.

State statistics show that prison deaths considered preventable or likely to have been preventable dropped from 18 in 2006 to five in 2010, a 72% decrease. Spending on inmate healthcare jumped from $948 million before the receiver arrived to a peak of nearly $2.3 billion in the 2008-09 fiscal year. Prison medical spending is projected at almost $1.8 billion in Brown's proposed budget for the next fiscal year, which begins in July.

The state is now working to reduce its inmate population by 33,000 by mid-2013 under a U.S. Supreme Court ruling last year. Low-level offenders now remain in county jails instead of being sent to state prisons.

Cate said he wants to continue upgrading medical facilities, but he questions the need for more building as the prison population drops. "How do we know we're not going to overbuild with a declining population?" Cate said.

The state and the receiver are examining the issue. But Kelso, who earned $280,000 last year, said some parts of the prison system still lack adequate facilities.

"I'd like to have hot water. I'd like to have clinic space that is actually clinic space and not a converted linen closet," Kelso said. "I'd like to see facilities that are designed to deliver healthcare. It's not an outrageous request, it seems to me. Unfortunately, to do any kind of construction in a prison is costly."

At Deuel Vocational Institution in Tracy, inmates are examined in a sparsely equipped room once used for receiving packages. Drugs are sorted in a converted arsenal, and a closet became a nurses' office.

The prison's chief medical officer, Michael Kim, said a recent power outage forced pharmacists to throw out some drugs as they struggled to keep the refrigerator running.

"We're like a duct-tape institution," Kim said.

Inmates complained that the medical staff cuts corners.

"They try to save money in everything they do to treat you," said John James, 35, who is serving time for weapons possession. He said doctors delayed treatment he needed for a broken ankle for months and did not give him adequate painkillers.

"They're kind of callous to inmate suffering and pain," he said.

Cost hike blamed for immigrant kids losing public health insurance

LA Times

About 20% of low-income immigrant children in a public health insurance program in Los Angeles County lost coverage between 2009 and 2011 because of a premium increase, according to a study that appeared this week in the journal Health Affairs.

Nearly 4,500 low-income immigrant children dropped out of Healthy Kids, which was launched in 2003 and run by L.A. Care Health Plan. In 2008, Healthy Kids stopped taking new applicants ages 6 to 18. Two years later, the program raised its monthly premiums to $15 for each child in that age range. Researchers from USC and L.A. Care studied enrollment before and after the increase.

"Changes in federal, state and local government policies may force health plans to consider increasing premiums," co-author Michael R. Cousineau, who teaches at Keck School of Medicine at USC, said in a statement. "More research is necessary to determine the optimal level for premiums and to project what low-income families might do if they lose coverage."

American People Hate the Individual Mandate

FDL

Even after almost two years since the passage of the Affordable Care Act, the individual mandate continues to be as unpopular as always. An overwhelming 2/3rds of the county holds an unfavorable view of the mandate and the majority thinks the Supreme Court should strike it down. From
Kaiser Family Foundation poll:

"As for the public’s own views of the mandate, the January poll shows that the requirement that everyone obtain health insurance or pay a fine continues to be unpopular. This month’s poll finds the public more than twice as likely to have an unfavorable rather than favorable view of the provision (67% to 30%), very much in line with findings of previous Kaiser polls. Reflecting this dislike for a mandate, 54 percent of Americans say the Court should rule the individual mandate unconstitutional, while just 17 percent say they think it should be found constitutional. Roughly mirroring public views on the mandate, 55 percent of the public say they expect the Justices to find the mandate unconstitutional and 29 percent expect the Justices to find it constitutional."

The individual mandate was clearly politically toxic long before the Democrats voted for the law and it has remained politically toxic ever since. The Democrats had both ample warning and ample time to replace it with a less controversial and unquestionably constitutional alternative to encourage individuals to get insurance. Such a modest correction would have been easy to make right before passage to increase support for the law.

I don’t know if I can think of another policy that was ever viewed so unfavorably by the electorate yet was still very publicly pushed forward by one party. The disdain this move showed toward public opinion played an important role in driving the conservative energy that allowed the GOP to win a historic victory in the House. The fact that Democrats could have easily avoided this political problem yet actively choose not to makes it one of the greatest unforced political errors in American politics.

Given how many people actually expect the Supreme Court to strike down the mandate, it is hard to guess whether a favorable ruling for the administration would be a political positive or negative for Obama. On one hand, the court upholding the mandate could get people to resign themselves to the idea of the mandate and the new law.

On the other hand, most of the people who currently hate the mandate are expecting the Court to take care of it for them. They currently don’t think they need a Republican to win the Presidency for the highly unpopular mandate to go away. If the Court doesn’t get rid of it as these people expect, that could give many a new incentive to help elect Republicans in order for the GOP to get rid of the mandate with legislation.

More bad news about "essential health benefits"

Kaiser Health News: HHS Essential Benefits 'Bulletin' Draws Tide Of Comments

As the official window of time allowed for groups to react to the Department of Health and Human Services essential benefits proposal closed, a variety of objections, concerns and common themes became clear.

CQ HealthBeat: State 'Flexibility' For Essential Benefits Gets Cool Reception
A tide of objections and worries rolled in just before Tuesday's deadline for health groups to react to a Department of Health and Human Services proposal on essential health benefits. Input from health interests and consumers on the benefits "bulletin" is not being made public by the Obama administration, which asked that comments be sent to an email address rather than posted on a government website as would be the practice with a proposed regulation (Norman, 2/1).

Politico Pro: EHB Comments Show Some Common Themes
Believe it or not, businesses, insurers and consumers do see eye to eye on essential health benefits — well, on some parts, anyway. They're at odds on some of the bigger issues, which doesn't exactly come as a surprise. The comments submitted to HHS on its essential health benefits approach shows a wide divide between consumers ... and businesses and insurers, who don't see enough safeguards to keep the essential health benefits package affordable (Millman, 2/2).


Comment:
By Don McCanne, MD

Yesterday we reported that some of the most politically powerful organizations in the nation have joined together in a coalition to try to weaken the package of "essential health benefits" that will be required of health plans under the Affordable Care Act. Excerpts from two new articles covered in the Kaiser Daily Health Policy Report should have us even more concerned.

In Politico Pro, it is reported that businesses and insurers "don't see enough safeguards to keep the essential health benefits package affordable." The proposal already has reduced the required benefits down to the relatively austere level of small group plans offered in the various states. These plans leave patients facing financial hardship when they must access health care.

Yet the powerful businesses and insurers want an even lower standard of benefits in order to keep the health benefits package affordable. The insurers want to protect their markets by keeping the insurance premiums affordable, and businesses also want the lowest premiums they can negotiate. Low premiums equate with higher out-of-pocket expenses for those with medical needs. In trying to make the health insurance plans more affordable, actual health care for the patients will be even less affordable.

As we have seen, the process has always been about powerful interests, with only a passive concern for patients.

In CQ HealthBeat, we see that comments on the proposal are being "sent to an email address rather than posted on a government website as would be the practice with a proposed regulation," and are "not being made public by the Obama administration."

The White House gave these special interests carte blanche with secretive access during the reform process. Secrecy continues. Should we be surprised when the final rule on "essential health benefits" pleases business and insurance interests, at a cost of exposing those with health care needs to greater financial hardship? No, not surprised. Outraged is more like it!

‘Sorry for your loss — here’s your bill’

(Canadians, who enjoy single-payer national health care, are appalled that the family of deceased Canadian skier Sarah Burke was handed a medical bill for $550,000 to cover her nine days of intensive care in Utah. "Burke’s case should be a sobering reminder to Canadians of what could happen in a privately-insured market, rather than a public system where everyone is insured against a catastrophic event." What's even more appalling is that Americans tolerate our own disastrous private health insurance system, and many even believe it's superior to health care in Canada. Nor will this situation change under Obamacare. -- Scott McLarty, Green Party Media Coordinator)


Calgary Herald

With the family of deceased Canadian skier Sarah Burke facing a U.S. medical bill topping the value of an average Calgary home, I was reminded Friday of a quote by the late Justice Emmett Hall, a crusader for Canada’s public health-care system.

“We as a society are aware that the trauma of illness, the pain of surgery, the slow decline to death are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability,” Hall wrote in a 1979 review of publicly funded health insurance.

To help Burke’s husband Rory Bushfield pay an expected $550,000 medical bill for nine days of intensive care in Utah, a website was set up by Burke’s agent asking for donations. The site had reached nearly $200,000 as of this writing Friday afternoon, prompting the Canadian Freestyle Ski Association to announce that the amount was enough that her family “will not have any financial burden related to her care.”

The association’s statement seemed odd, considering that the website was $350,000 short of its intended goal, but not if you understand the vagaries of a private health system dominated by big private insurers.

In the U.S. health system, “nobody pays the sticker price, except for those who are squeezed, which is normally the uninsured,” says Steve Morgan, a health policy analyst with the University of British Columbia’s Centre for Health Services and Policy Research.

“Big insurance doesn’t pay retail,” Morgan says of the U.S. health system. Typically, he says a hospital will present a bill big enough to choke a horse and the insurance company will negotiate it down. Individuals without insurance, or those who are under-insured, have little or no negotiating power and often end up paying bills that are financially devastating, Morgan said.

Burke was apparently not adequately insured in the U.S. Her ski association only covers sanctioned events. Because the event at which she was injured and subsequently died was an unsanctioned competition put on by her sponsor, Monster Energy Company, the ski association’s insurance did not cover her.

It was not clear if Burke’s family thought she was adequately covered, or if Monster had insurance for her. The company did not say if it would help cover her medical bills, which Morgan says is not surprising.

Monster, he said, could have negotiated behind the scenes to get the price down. The Canadian Freestyle Ski Association said the family had not yet received a final bill for her hospitalization, but that it is expected to be approximately $200,000, roughly the amount that had already been collected.

Morgan says Burke’s case should be a sobering reminder to Canadians of what could happen in a privately-insured market, rather than a public system where everyone is insured against a catastrophic event.

In 2000, the U.S. health policy journal Health Affairs wrote about the issue under the heading “Gouging the Medically Uninsured: A Tale of Two Bills.”

“Overcharging the uninsured is one of the many unintended and largely overlooked results of our decade-long obsession with curbing health-care costs,” it said. “Powerful interest groups — government, employers, insurers, hospitals, medical equipment vendors, and health care professionals — have fought vigorously to protect their interests. The uninsured, with no organized voice, emerge as losers.”

Since 2001, family health insurance premiums in the U.S. have increased 113 per cent, according to the Kaiser Family Foundation, with annual premiums for employer-sponsored family health coverage growing to $15,073 in 2011. Due to the economic downturn, the number of Americans going without insurance has grown by one million to 49.9 million people.

We complain of health-care costs and outcomes in Canada, but the U.S. ranks behind Australia, Canada, Germany, the Netherlands, New Zealand and the U.K. in five areas of health system performance: quality, efficiency, access to care, equity and mortality, according to a report by the Commonwealth Fund.

“Our failure as a country to ensure basic health care for all of its citizens is in part to blame,” Glenn D. Braunstein, chairman of the Department of Medicine at Cedars-Sinai Medical Center in Los Angeles, wrote Friday in the Huffington Post.

It is, indeed, a sobering reminder to Canadians how lucky we are. As one commentator wrote of the Burke family’s experience with the U.S. system: “We are sorry for your loss. Here’s your bill.”

Green Party presidential candidate Jill Stein Embraces Dr. King’s Call to make Health Care a Right, Promote Economic Justice and End War

From Jill Stein for President:

Dr. Jill Stein, running for president as a Green Party candidate, said if elected she would honor Dr. Martin Luther King Jr.’s legacy by not only embracing his call for civil rights and racial equality but continuing his struggle for peace, economic justice and universal health care.

Dr. Stein, a graduate of Harvard Medical School, said she would make health care a right and enact a single payer, expanded and improved Medicare for All. In 1968, Dr. King said that “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

“All Americans are entitled to quality health care. We need to also control the excessive costs of health care, starting with eliminating the expensive and wasteful practice of health insurance, where profits are increased by denying access to health care. It is a scandal that President Obama, who has long admitted that single payer is the best solution, instead copied Milt Romney and mandated that all Americans buy health insurance,” stated Stein.

The last major speech Dr. King delivered, “Remaining Awake Through a Great Revolution”, was on poverty. Speaking at the National Cathedral in Washington D.C., King talked about how the poor were invisible in America. When he was killed in Memphis four days later, while supporting the striking garbage workers, King was organizing a massive march in D.C. to launch a new campaign to end poverty.

Said King, ”There is nothing new about poverty. What is new is that we now have the techniques and the resources to get rid of poverty. The real question is whether we have the will.”

King called for “a campaign for jobs and income, because … the economic question was the most crucial that black people and poor people, generally, were confronting.”

Strikingly, a recent report has included that nearly 50% of Americans live in conditions of actual poverty, meaning that they are not self-sufficient and cannot afford food, transportation, and shelter, or are just one paycheck away from that falling into that condition. Income inequality in America is worse than it has been since 1927. The richest 1% own 40% of the nation’s wealth and get 24% of the income.

“We need economic policies that seek income equality. We need to guarantee access to the fundamentals of life, these being quality housing, food, transportation, education, and health care. We need a progressive tax system that requires the wealthy and Wall Street speculators to pay a higher share of the tax burden. We need to focus on providing a decent life for the 99%, not excessive wealth for the 1%,” said Stein.

Dr. King had concluded that a guaranteed annual income was needed as the prime step to ending poverty in our country. “I am now convinced that the simplest approach will prove to be the most effective — the solution to poverty is to abolish it directly by a now widely discussed measure: the guaranteed income.” Surprisingly, this was actually proposed a number of years later by President Nixon as a replacement for welfare, but Congress rejected it.

Stein said that she agreed with King on the need to end war and reinvest the military budget to fund domestic needs. Stein said she would also use the peace dividend to fund a Green New Deal to provide jobs while curbing climate change.

“I will bring our troops home not only from Afghanistan and Iraq and Africa and South America, but from the more than one hundred countries where we have bases. The best way to protect the security of Americans is to rebuild our economy and stop using our military and economic might to exploit other countries and enrich corporate war profiteers,” noted Stein.

King ended his speech at the Washington Cathederal four days before he was murdered with a day with a call for America to end the Vietnam War, and a call for a peace dividend. “Every time we kill [a Vietcong soldier] we spend about five hundred thousand dollars while we spend only fifty-three dollars a year for every person characterized as poverty-stricken in the so-called poverty program, which is not even a good skirmish against poverty.”

Dr. Martin Luther King Jr. also stated, “A nation that continues year after year to spend more money on military defense than on programs of social uplift is approaching spiritual death.”

Next civil rights frontier? It surely has to be health care

The Charlotte Observer

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane."

–Martin Luther King, 1966

In the exam room, the patient recounted her complicated illness. When she described symptoms related to her surgery, I suggested she see her surgeon.

She had spoken calmly until this point, but now tears came to her eyes. When she lost her job because of her illness, she lost her insurance and could no longer see any of her trusted physicians. Then followed months without needed care. Hers was just one of the sad money-related stories I hear daily.

Injustice we still tolerate

On Martin Luther King Day, it is easy to congratulate ourselves on our progress in moving beyond segregated schools, lunch counters and drinking fountains. The hard question is this: what injustices do we still accept that should, in fact, be intolerable?

Surely Dr. King would find the next civil rights frontier in health care, with nearly 50 million uninsured, almost 45,000 deaths annually due to lack of insurance, and more than half of all personal bankruptcies linked to illness and medical bills.

While the Affordable Care Act will bring improvements, such as decreasing the ranks of the uninsured, supporting community health centers, and investing in prevention, it leaves many gaps. At least 23 million people will still be uninsured in 2019. Tens of millions will be underinsured, one serious illness away from financial ruin. Most people who suffer medical bankruptcy had private insurance before getting sick. And medical bankruptcy is a cruel double whammy. Already beset with pain, anxiety and fear - due to serious illness - families find themselves financially devastated.

This doesn't happen in other industrialized countries, which have high-quality health systems that cover everyone.

The U.S. spent $7,960 per person for health care in 2010. Most developed countries spent less than half that amount and yet have better health outcomes and, in many cases, similar or better access to technical advances, such as hip replacements, bone marrow transplants, and MRIs.

How is this possible? As a nation, we waste about $350 billion in unnecessary paperwork and bureaucracy, thanks to our fragmented system of financing care through multiple insurers. And, although all countries are suffering from health care inflation, our rise in costs is far higher.

What to do? We should move to an Improved Medicare for All system, in which we share the cost of covering everyone, as we do for other valued services such as education, police, and the fire department.

How could we afford it? Our current public expenditures for health care that don't cover everyone are already greater than the total expenditures of countries that do.

First, we would save by cutting out the insurance company middlemen. Second, we would negotiate lower prices for medications and supplies. Finally, by abolishing private insurance premiums and substituting revenues from taxes based on ability to pay (a mixture of taxes on payroll, personal, and unearned income as well as stock and bond transactions), we would easily cover the uninsured.

Concerned that this is socialized medicine? Not at all. The U.S. has a high-performing socialized medicine system in the Veterans Administration, which owns hospitals and employs doctors and enjoys high patient satisfaction. Improved Medicare for All is not socialized medicine. The bills would be paid by one source, but medical practices and non-profit hospitals would continue to be independent.

Worried about the solvency of Medicare? Medicare actually operates economically, with administrative costs well under half those of private plans and with better cost control. In addition, Medicare has been considerably less inflationary. If billions of dollars were freed up in administrative costs nationally, that could go a long way toward comprehensive (not minimal) coverage for all, as well as fair (and not constantly threatened) payment for doctors and hospitals.

What are those expenses? Insurance companies incur them for designing plans, marketing, and deciding who is - or often isn't - eligible. Hospitals and providers also have excessive costs. While medical practices in Ontario spent $22, 205 per physician annually interacting with Canada's single payer agency, American practices spent $82,975 per physician dealing with health plans.

Use health care dollars to help

Consider the possible savings. This money could be used for actually providing health care.

My dream is to take care of patients and not have the specter of financial issues an unwelcome presence at every visit. I dream that there will be no tears in my office due to the unaffordability of needed care. And I dream that my time - and our health care dollars - will be spent helping people, not mired in bureaucracy.

Do you want to pay a real tribute to Martin Luther King? Be bold and visionary as he was. Fight "the most shocking and inhumane" injustice - and support Improved Medicare for All.


Jessica Schorr Saxe is a Charlotte physician and a board member of the Health Care for All NC.