Tag: MedicaidMedicaid

Inaugural Speech, Part II

When President Obama delivered his first inaugural address four years ago, he was speaking to a nation mired in two wars and facing the worst financial crisis since the Great Depression. Yesterday, his second inaugural address focused less on economic issues and foreign policy, and more on social issues, ranging from gay rights to global warming to gun control.

He made clear his intention to help the middle class, including strong resistance to cutting entitlement programs – Medicare, Medicaid and Social Security. As an article in The Washington Post noted, “He embraced more clearly than he has in the past a liberal view of government activism” – which includes protecting policies and programs that “have reflected essential Democratic priorities for generations of voters.”

Obama’s tone suggested more partisanship and less willingness to compromise with Republicans during what will likely be a hard-fought effort to pass his agenda before leaving the presidency for good in four years.

Obama’s address has inspired a variety of reactions, depending on individual perspectives. For example, “as an economist focused on policy,” says Olivia Mitchell, Wharton professor of business economics and public policy, “I thought this was a key section: ‘We recognize that no matter how responsibly we live our lives, any one of us, at any time, may face a job loss, or a sudden illness, or a home swept away in a terrible storm. The commitments we make to each other – through Medicare, Medicaid and Social Security – these things do not sap our initiative; they strengthen us.’”

This statement, notes Mitchell, “emphasized only the benefits of social protection. But the President never acknowledged many programs’ negative influences on a variety of important economic outcomes. For instance, research has confirmed that the Medicaid program discourages most people from taking steps to save and insure against long-term care expenses. The structure of the Social Security program discourages private saving, and the program’s impending insolvency threatens retirement security for millions. The Disability Insurance program has made deep inroads into the nation’s labor market. Higher tax rates discourage people from working and encourage early retirement. In sum, I would have liked to have seen the President indicate his awareness of these counterbalancing factors.”

Wharton professor of health care management Mark V. Pauly says he was “a little disappointed in the treatment of health care and the Medicare and Medicaid programs. The President seems to want to defend them not only as programs that will provide benefits to those who need help, but to protect them from privatization of any sort.”

While that is a legitimate viewpoint, Pauly adds, “it seems more limiting than need be, though obviously congenial to the liberal base. [Obama] did imply he was going to control Medicare cost without recourse to any of the alternatives favored by his opponents. I don’t know how that can be done. We can hope and pray for lower rates of spending growth, but we still search for mechanisms that can bring it about without doing more harm than good.” At this point, Pauly adds, “I do not know of any magic in the pipeline of either party.”

Obama also emphasized the importance of all citizens participating in efforts to support his second-term agenda. Along those lines, he has endorsed the establishment of a nonprofit group called Organizing for Action, which will focus on reform in such areas as immigration and gun control.

One of the most oft-cited sections of Obama’s inaugural address was his comments on equal rights for women, African Americans and the LBGT community. “We, the people, declare today that the most evident of truths – that all of us are created equal – is the star that guides us still, just as it guided our forebears through Seneca Falls and Selma and Stonewall…. It is now our generation’s task to carry on what those pioneers began. For our journey is not complete until our wives, our mothers and daughters can earn a living equal to their efforts … until our gay brothers and sisters are treated like anyone else under the law – for if we are truly created equal, then surely the love we commit to one another must be equal as well. Our journey is not complete until no citizen is forced to wait for hours to exercise the right to vote….”

In comments directed to a large majority of Americans, Obama also noted that “our country cannot succeed when a shrinking few do very well and a growing many barely make it…. We are true to our creed when a little girl born into the bleakest poverty knows that she has the same chance to succeed as anybody else, because she is an American, she is free and she is equal, not just in the eyes of God, but also in our own.”

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When Fat Is No Longer Free

When Arizona governor Jan Brewer proposed that certain participants in the state’s Medicaid program — specifically obese people and smokers who don’t take steps to change their unhealthy behaviors — should pay a fine of $50 a year, it didn’t take long for the reactions to come rolling in.

Those in favor state that people who eat to the point of obesity or who smoke should have to contribute to covering the costs of that behavior. In addition, they note that any money collected through these fees will help the state’s financially strapped Medicaid program and allow it to expand current coverage. Opponents of the proposal say that for some individuals, obesity is the result of occurrences beyond their control, such as accident or illness.

An article in The Wall Street Journal notes that 25.5% of Arizona residents were considered obese as of 2009, and about 46% of the state’s Medicaid participants smoke daily, according to a 2006 survey. Moreover, the Journal added, “Unlike private insurers, which often charge different premiums based on customers’ health status, Medicaid must enroll all those who meet its eligibility requirements.”

Knowledge@Wharton asked two Wharton professors — Katherine Milkman, professor of operations and information management, and Kevin Volpp, professor of health care management — for their thoughts on three issues raised by the Republican governor’s proposal.

First: Is this proposal fair?

Volpp: Many of the people in question likely have a BMI (body mass index) far above 30, the cutoff for being considered obese. It is unlikely that people with BMIs much above 30 would be able to successfully lose enough weight to avoid this penalty.

Differential premiums based on weight are tricky from an ethical standpoint; to the extent that weight is based on genetic factors or larger social/environmental factors that individuals can’t control, adjusting premiums based on weight undermines the concept of risk pooling that is the basis for insurance. To the extent that weight is based on behaviors that an individual can control, it is arguably fairer to adjust premiums than not to do so, since otherwise, people with healthy lifestyles subsidize unhealthy behaviors of others. We don’t really know, for a given individual, how much of their obesity is due to their behaviors vs. genetics/environmental factors.

Another important factor is that reasonable accommodation should be made to those who can’t meet a particular incentive; for example, those who are in wheelchairs.

Milkman: It is no surprise to me that people are concerned about the fairness of this proposal. Classic judgment and decision making research about what people perceive as fair shows that any loss relative to our current reference point is viewed as extremely unfair. In this case, the reference point is no surcharge (in spite of higher medical costs) for obesity and smoking, and the change relative to that reference point (a $50 fee) is experienced as a loss. 

We know from prospect theory (a Nobel-prize winning theory describing human behavior) that losses loom larger than gains, so in spite of the gains associated with this new program (coverage of more people, etc.), it is no surprise that the losses are getting more attention. I do think it’s wise that those who are obese or who  smoke will be offered actionable steps (and hopefully realistically achievable ones) to avoid the fee. 

2. Would this proposal be effective? Is $50 enough of an incentive?

Volpp: It is unlikely that this will be effective in making people lose weight. Losing weight and maintaining weight loss is extremely difficult for most people, and a one-time $50 penalty, once paid, will not provide sufficient motivation throughout the year. Most people are very focused on the present; a once-a-year incentive will not likely be effective in sustaining weight loss.

Milkman: $50 may not be enough to make a significant dent in the problem, but it should affect some people meaningfully. The question is, how many? It would be very interesting to calculate that percentage if the program is implemented.

3. Do you think this proposal will be passed, given its controversial nature?

Volpp: A similar provision is part of the Affordable Care Act (Section 2705), which stipulates that starting in 2014 employers can adjust health insurance premiums based on outcome-based wellness incentives using measures such as BMI by up to 30% of the total employer/employee premium. Employers currently are allowed to adjust premiums by up to 20% using outcome-based wellness incentives. Few use this full amount but clearly there is precedent for these types of approaches to be used more widely.

Milkman: I think it is likely that proposals like this will become increasingly common. I think that could be a good thing to the extent that these incentives help educate people about the risks associated with obesity and smoking and help motivate them to take steps to lose weight or quit smoking. However, there is also the risk that these types of programs will simply function as regressive taxes.

 From Incentives to Penalties: How Far Should Employers Go to Reduce Workplace Obesity? Knowledge@Wharton

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