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April 21st, 2014:

Texas insurance enrollment update

Enrollments are up and the number of uninsured are down, though both could have been a lot better.

It's constitutional - deal with it

It’s constitutional – deal with it

The sky-high rate of Texans without health insurance has dropped only slightly since the launch of the federal Affordable Care Act’s online health insurance marketplace, according to a new report from Rice University’s Baker Institute for Public Policy and the Episcopal Health Foundation.

During the open enrollment period from September through March, the rate of uninsured adults in Texas fell to 23.5 percent from 24.8. And most of that change was attributable to an increase in employer-sponsored health coverage, the report found, rather than new signups in the federal marketplace.

Texas’ decline in the rate of its uninsured was commensurate with those in other Republican-led states that elected not to expand Medicaid to cover poor adults. But while the number of Texans applying for coverage in the online marketplace — about 746,000, according to the report — pales in comparison to the more than 5 million who lack insurance, ACA proponents may see reason for optimism, the authors wrote. The 746,000 figure represents a significant increase in Texas enrollments from the 295,000 reported by the federal government as of March 1.

“You look at the absolute numbers and say, ‘Wow! This is a good start,’” said Vivian Ho, a co-author.

The report, which draws its conclusions from survey data rather than figures that are gradually being released by the U.S. Department of Health and Human Services, offers new insight into what kinds of people are signing up for insurance under the ACA.

For example, only about 30.2 percent of those seeking coverage in the online marketplace were previously uninsured, researchers found. Employer-provided health insurance seemed to be responsible for the biggest drop in the uninsured.

“If I had to guess, a large portion of that is just the upswing in the economy,” Ho said. “There are more people getting jobs.” But she added that some businesses are also preparing to comply with the upcoming coverage mandate for their employees, offering low-cost insurance options for low-wage workers, a trend that may be reflected in the data.

We also now have some specific information about Houston enrollments.

Meanwhile, in an unrelated report, the Associated Press found more than 177,000 Houston residents signed up for health coverage, exceeding expectations and indicating a last-minute enrollment push just before the March 31 deadline might have helped Texas meet projected targets despite months of lagging.

The news service, citing an email by Marjorie McColl Petty, the Department of Health and Human Services’ Dallas regional director, and obtained by the Associated Press, reported that as of April 5, some 177,825 Houston residents signed up for coverage. A previous email by Petty said that as of March 29, 149,273 Houston residents had signed up for insurance, the AP said.

The expectation had been that 138,000 Houston residents would sign up.

You can see the Baker Institute report here. This answers some of the questions raised in my earlier post, though the Kaiser numbers have not yet been updated. As noted, there’s no official tally of who does or does not have health insurance in Texas. We’ll have the healthcare.gov enrollment totals, and I presume HHSC has Medicaid and CHIP numbers, but beyond that it’s all estimates and speculation.

We all know how this has gone down in Texas, where the party line from the Republican leadership has been one of unrelenting hostility and obstacles. Not surprisingly, in states like Texas the ranks of the uninsured decreased at a lower rate than in states that are not run by heartless assholes. With the grace period for people who began but were unable to complete the enrollment process now over, the official tally for healthcare.gov enrollees is eight million. That doesn’t count state exchanges, Medicaid expansions, the under-26 set that can be on their parents’ insurance, or people who will now have insurance through their employers; the grand total is at least 14 million, and counting. And it could have been so much more.

Opponents of the ACA said the report spelled bad news for President Obama’s signature health law. John Davidson, a policy analyst for the conservative Texas Public Policy Foundation, called the number of previously uninsured people who signed up for coverage on the exchange a “drop in the bucket” compared to Texas’ total uninsured population.

“I believe that cost is driving these numbers,” Davidson said. “Coverage on the exchange is very expensive, and it’s expensive even if you get a subsidy, in many cases.” He compared the report’s projection that 746,000 Texans had enrolled in the marketplace to a recent HHS brief that estimated that 2.2 million Texans could qualify for subsidies.

“Something’s going on there,” Davidson said. “Why so few?”

I’m going to be charitable and not assume that the oft-quoted token Davidson is sufficiently stupid as to be genuinely baffled. The organization for which he is employed is a malignant force in Texas, but they are quite clear-eyed about their goals. He knows what the truth is, and he knows what his role in relation to it is. The real question is why the Tribune, or any self-respecting news organization, thinks there is value in including his disinformation. Why do you think it’s a good idea to let someone lie to your readers, Evan Smith? I can’t think of a good reason for that. The LA Times has more.

Burnam challenge awaiting appeal

Another update on the ongoing legal challenge by State Rep. Lon Burnam, who wants his loss in the primary to Ramon Romero thrown out on the grounds that some applications for absentee ballots by Romero voters involved the use of iPads, which are not included as permissible devices in the relevant state law.

Rep. Lon Burnam

In a hearing earlier this month, attorneys representing Burnam asked that county election officials release all the applications turned in for mail-in ballots in this race to investigate potential illegalities such as an “illegal computerized-signature vote-by-mail operation.”

State District Judge Robert McFarling of Denton, the visiting judge appointed to the case, turned down the request. Burnam’s attorney, former Tarrant County Democratic Party Chairman Art Brender, has filed an appeal, asking the Fort Worth Court of Appeals to overturn that ruling.

McFarling on Monday agreed to delay the trial until the Court of Appeals rules. The case was scheduled to go to trial Tuesday.

Brender said he was glad for the delay.

“We are continuing our investigation every day,” he said. “And we are investigating other aspects of the election — and have been the whole time.”

Romero’s staff said they believe the final ruling will go their way.

“We are confident in the legal system,” said Michael “Mikey” Valdez, Romero’s campaign manager. “We feel the right decision will be made and it will confirm our victory.”

See here, here, and here for the background. I presume that’s the Fourth Circuit Court of Appeals and not the “Fort Worth Court of Appeals” since as far as I know there is no such thing. I don’t have anything to add to this story, but on a related note both Campos and Michael Li complained about an email Burnam sent out, presumably as an update on his case and as a fundraising appeal. Burnam is litigating a technicality, and technicalities don’t have much fundraising appeal. Trying to make it more than that risks alienating supporters and handing Republicans political ammunition. Burnam may win his challenge, but I’ll say again that I see nothing wrong in what Romero’s campaign did, nor do I see any reason why the law shouldn’t be amended to specifically allow it. Don’t lose sight of who you are in your quest to stay in office, Lon.

Retail medical clinics

I for one think they’re a good idea.

Here’s a prescription for pediatricians fighting to keep easy-to-treat, well-paying patients: Expand after-hours and weekend services to serve desperate parents in search of quick remedies for their kids’ late-night sore throats and upset tummies. Otherwise, parents will continue choosing the closest CVS, Walgreens or H-E-B clinic.

With the store-based medical clinic business projected to double between 2012 and 2015, analysts and doctors say pediatricians must change their business model to fit parents’ needs. Otherwise, they risk losing their relatively lucrative patients and relying more on chronically ill ones who take longer to diagnose and treat and thus reduce the number of people that doctors can see in a day.

“Well-baby cases help compensate for a Medicaid enrollee who takes half an hour,” said Devon Herrick, senior fellow at the Dallas-based National Center for Policy Analysis. He added that the speed and convenience of retail clinics attract many of the better-paying cases, and doctors are working to keep from losing them.

Despite clear demand in the market, doctors have for years targeted retail clinics for criticism. They argue that doctors best understand their patients’ needs and provide the best care. Most recently, the American Academy of Pediatrics urged parents to avoid store-based health clinics, saying they don’t provide the high-quality care children need.

However, the nation’s leading professional organizations for doctors repeatedly have said there aren’t enough doctors to treat everyone now and won’t be in years to come. The American Academy of Family Physicians projects a shortage of 40,000 doctors nationwide by 2020. Texas already has a ratio of about 165 doctors for every 100,000 residents, which falls below the national average of 220 physicians for every 100,000 people.

“It’s about competition,” said Dr. Kaveh Safavi, global managing director of Accenture health business, adding that retailers came up with the idea for “embedded clinics” because people needed them.

He described pediatricians’ concerns with retail clinics as a “short-term skirmish” that doctors have been waging for years.

[…]

Texas Children’s Hospital’s chief medical officer, Dr. Stan Spinner, recently posted in a hospital website blog that retail clinics employ providers who lack proper training and experience treating children.

“As a pediatrician for more than 25 years, I’ve seen firsthand the inadequate care these clinics can provide,” Spinner wrote. “Numerous patients have come into our Texas Children’s pediatrics practices after visiting a retail-based clinic the night before questioning the medication or dosage they had received.”

When asked to elaborate later, Spinner said he didn’t know how many such incidents had occurred. He said parents waste time and resources at retail clinics and then follow up with pediatricians to ensure children received the correct treatment.

“(Pediatricians) should have seen them the very first time,” Spinner said, adding that some pediatricians are expanding their office hours and working weekends to accommodate patients.

All due respect, Doc, but there are bad physicians out there, too. I’d take your complaint more seriously if we had a more effective means of policing them, but between tort “reform” and the impotence of the Texas Medical Board, there ain’t much that can be done. Be that as it may, my own anecdotal evidence favors the retail clinics. A few years back, what I had figured was an insect bite on my left foot had turned into something painful and alarmingly swelled on a Saturday morning. With my alternatives being a visit to the emergency room and a fervent wish that it wouldn’t get any worse by Monday, I visited a clinic at the HEB on Bunker Hill. They prescribed some meds that did the trick, and by the time I did see my doctor on Monday, my foot looked mostly normal again, and he agreed with their diagnosis. Faced with the same situation again, I’d have no hesitation to pay them another visit.

One more thing:

Retail clinics revolve around a high-volume, low-complexity business model. Services usually range from $59 to $99. They include convenient and basic care – physicals, disease monitoring, vaccinations, and illness and infection diagnosis and treatment. The clinics usually employ nurse practitioners and physician assistants, who are less expensive than doctors.

[…]

Retail clinics will hold nearly 11 million visits annually, saving about $800 million in unnecessary emergency care costs, Accenture said.

One of the dirty secrets of health care and the amount that we spend on it is that controlling our health care costs necessarily means paying less money to doctors. It’s more complex than that, of course – prescription drug costs and a lack of transparency in pricing are other big factors – but in the end, less money being spent by consumers means less money being paid to providers. Given that there’s a shortage of general practice physicians anyway, more retail clinics and a greater use of advanced practice nurses are both modest steps in the right direction. Doctors are going to have to learn to live with that.

City asks court to let Ashby Highrise be built

Interesting.

Sue me!

The city on Friday asked a judge to let the Ashby high-rise project go forward after seven years of wrangling and a recent jury verdict in favor of nearby residents who oppose the 21-story tower planned for 1717 Bissonnet.

City Attorney David Feldman said halting construction of a project that satisfied the regulations in place at the time it was granted a permit would “irreparably impair future developments in the city.”

“The uncertainty surrounding the outcome of such lawsuits would hinder developers from financing, leasing and constructing real estate developments in Houston, which require long-term secure contracts,” Feldman wrote in a letter delivered to state District Judge Randy Wilson. “We urge the court to consider the serious public policy considerations involved.”

[…]

“We’re not endeavoring to take a position in this specific situation,” Feldman said Friday. “It’s a broader question of whether, in a city such as ours without zoning, development can reasonably be expected to occur if a developer that complies with all laws and deed restrictions can be enjoined from building … What kind of effect would that have on development in a city such as ours? That’s the point that we felt was important to raise with the court.”

The city’s stance surprised Earle Martin, one of the residents who brought the suit. He said that even when the city settled a separate lawsuit with Buckhead in 2012, Mayor Annise Parker continued to insist the project was not suitable for the area.

“The letter is completely inconsistent with what the mayor has said so far,” Martin said. “I cannot understand this. I’m sure there is pressure from the development community.”

[…]

Expert testimony presented during the monthlong trial showed the building would severely damage several homes, causing walls to lean, foundations to crack and pipes to shift. The jury also heard evidence that the project would cause significant traffic problems, and that it is out of place and abnormal in the neighborhood.

Residents’ attorney Jean Frizzell said Friday that the city letter ignores evidence presented at trial that the developers misled the city to obtain permits, and that an ordinance enacted after the battle began ensured similar projects could not be built so close to existing homes.

“This letter appears to ignore that,” Frizzell said.

Josh Sanders, executive director of Houstonians for Responsible Growth, a nonprofit organization that represents developers, said the city weighed in on the court case because stopping the project would have a major impact on development. His group submitted a friend of the court brief, which Feldman referenced in his letter, that argued against permanent injunction.

“The city is stepping in and saying, ‘Why are you overriding our regulatory structure?’ ” Sanders said. “If a permanent injunction is granted, it throws all the rules out the window.”

See here for the last update. I’m really not sure what to make of this. I get where the city is coming from, and as you know I never really believed the plaintiffs had a case, but neither do I think the regulatory structure is sacrosanct. If this lawsuit has shown it to be fatally flawed, then let the court do its job and allow for a remedy. I’m skeptical this is the case, but let’s let the judge sort it out. Final arguments are today about whether the project can go forward, and I’m sure whatever the judge says it will be appealed. What do you think?