Medicare Does Not Provide Long-Term Care in Nursing Homes

Let me say it again: Medicare does not provide long-term care in nursing homes. The idea that Medicare does provide long-term care in nursing homes is one of the greatest enduring myths about Medicare. And, here's the scary part: I encounter this myth in discussion groups at all income and educational levels. I have seen the individual look of astonishment on the faces of clients and their families when I have had to debunk this myth and I have surveyed the faces of  groups where, only gradually, did audience members come to accept the truth.

In its September-October issue, Harvard's alumni magazine published  "Coping With Alzheimer's" repeating the canard only to have to  correct itself in the next issue. Medicare only covers rehabilitation care up to 90 days following a three day hospitalization.

Harvard Magazine should not be burying the correction on page 6 of the Letters section, it should be broadcast as a cover story because, although it is not news, it is new information for many Americans.

12/10/13: As Buzzell points out in the comments, I overstate. I stand corrected and thank Buzzell for the comment. Here’s what I should have said:

Hospitals v. Insurers: Mississippi Version

I love the movie Cowboys & Aliens for its retro edge.  The story is ever the same, though the players may be altered slightly.

And so it is with the epic battles between hospitals and insurers over network participation and rates. I tell my students these battles are among the hardest fought and most continuous in all of health care contracting, whether or not what is going on behind the scenes is glimpsed by the public.

Occasional public glimpses over the bare-knuckled negotiations between hospitals and insurers occur when the negotiations threaten to blow up and plan enrollees are informed of impending changes to hospital "in-network" provider status. The issue can become quite heated.  People develop considerable loyalties to specific in-patient facilities, loyalties cultivated between and among friends and acquaintances (giving a whole new meaning to the idea of hospital "network"). You can read about a thought experiment probing patient acute care hospital selection here:  It may come as little surprise, then, to see Connecticut's Stamford Hospital, apparently trying to harness patient loyalty in opposition to the breakdown of their negotiations with Blue Cross & Blue Shield here:

What is going on in Mississippi takes one of these same kinds of disputes and writes it large. Negotiations have apparently broken down between the Blue Cross Blue Shield Network and Hospital Management Associates for-profit hospital chain over the in-network or out-of-network status of ten HMA facilities. After BCBS dropped these hospitals from their network, Governor Phil Bryant issued an executive order temporarily (for a maximum of 60 days) reinstating these ten HMA facilities into the BCBS network on contract terms based on the old contract rates. Yes, the facilities appear to have been commandeered and hospital-insurer contract rates have been set by the Governor.

Of course, this is already in federal district court.  Whether the Mississippi Patient Protection Act of 1995 requirement that insurers provide "reasonable access to care with minimum inconvenience" means that BCBS cannot walk away from what it says is a losing deal remains to be seen.  The real back story is that BCBS holds a near monpoly in some of  Mississippi's health insurance markets. You can see 2010 data on health insurance market concentration (looking at the individual insurance market) here:  And at least three of the hospitals are sole acute care providers in their rural settings, deeply dependent on reimbursement from BCBS.

This Mississippi story tells a tale of health insurance market concentration.  And it tells a story of the stark vulnerability of rural hospitals who need all the reimbursement they can get.  "Narrow networks" may be the topic of the month, when discussing cost-containment measures in the ACA but the possibility of non-existent rural networks has been out there for some time because of the high incidence of uninsurance in rural populations.

Governor Bryant is a well-spoken opponent of Medicaid expansion in Mississippi. In January he told a reporter, "I would rather pay extra to Blue Cross [to help cover uncompensated costs for the uninsured], rather than have to raise taxes to pay for additional Medicaid recipients." (You can read the text of that interview here:

It is beginning to look as if he may get his chance.

Variance in Insurance Rates for Products Sold Through the Exchanges

Comparing the newly announced insurance rates between and even within states is difficult. Comparing the status quo ante with exchange rates fails to account for the richer health insurance benefits found in the ACA created health insurance exchanges. Comparing an urban state with a rural state fails to account for higher labor and overhead costs in the urban setting and the price effects of precious little health insurer competition in rural settings.

But I am intrigued by an article that examines the spread within a state or a major region, comparing the prices of higher cost (richer) health plans sold through the exchanges with more modest health plans (thinner) sold through the same exchanges. You can see a great article here:

Why does this matter?  It gives us a useful snapshot of how the structure of the exchanges has influenced beginning rates. It probably is too soon to tell if choosing to have an active purchaser exchange model is really what drives the relatively small spread between plan levels in California but time will tell, especially when we consider that (at least as of June 1, 2013) several other states had also chosen the active purchaser exchange model.

The federally facilitated exchanges (FFEs) are, of course, clearinghouse-style, offering none of the rate reduction that may flow from the state using its exchange organizing power to drive health insurance rates for products sold within it to lower levels by requiring a kind of bidding process for the privilege of selling within the exchange.

When I look at the prices of exchange purchased health insurance in the California exchange, I have to wonder if — when all is said and done — it may end up being more expensive to purchase through Missouri's FFE than to purchase through California's state-sponsored health insurance exchange.

Finding the Uninsured

We all know people who lack health insurance. We just may not know that they lack health insurance. They know.

Of course, some people's need is obvious — they put it forward in disease groups or through pharmaceutical assistance programs. But the quietly uninsured, they have been in a kind of "don't ask, don't tell" place for some time. If we had asked regularly and recorded their responses and then thought about aggregating the data, we might have had to do something programmatic with what we knew.

Our deeply unprogrammatic safety net patch work for the uninsured comes back to haunt us now. How to find the uninsured, now that we (more so in some states, less so in others) want to do something programmatic?  Here's a fascinating article about how the state of Maryland is looking for tracings of uninsurance in things like emergency department overuse:,0,2157047.story.    Of course, those tracings are also somewhat  consistent with under-insurance. It ought to be interesting to see — now that we officially care to know — how we sort the two out.

Missouri’s Stealth Health Insurance Exchange

Glad the NY Times has spotted it.  That Missouri federally facilitated health insurance exchange is a tricky one. You can rarely spot it.  But you can read about it here:

Based, anecdotally, on the number of questions I receive via email as well as the number of speaking engagement requests I receive, I imagine that  most of Missouri's citizens are not only woefully underinformed about the ACA but also woefully underinformed about the choices the state has made that will shape the Missouri ACA experience.

In June, I suggested in remarks at a conference of health law professors, that we were in the midst of the largest health insurance counseling challenge of our lifetimes.  Missouri's stealth exchange may make ours particularly acute.

Missouri Ballot Measure Wars: Health Insurance Exchange

Late last week, a Missouri state court ruled that the Missouri Secretary of State-produced ballot measure summary on health insurance exchanges was not a fair and sufficient summary of the ballot measure submitted.  The court ordered that the following ballot summary be used instead: "Shall Missouri law be amended to prohibit the Governor or any state agency, from establishing or operating state based health insurance exchanges unless authorized by a vote of the people or by the Legislature?"  The ballot summary found wanting asked if "Missouri law be amended to deny individuals, families, and small businesses the ability to access affordable health care plans through a state-based health benefit exchange unless authorized by statute, initiative or referendum or through an exchange operated by the federal government as required by the federal health care act?"

What's the difference? Everything. 

The rejected ballot summary emphasizes the inevitability of health insurance exchange establishment in Missouri under the ACA, explicitly noting that the federal government is prepared to establish a health insurance exchange in any state that does not establish one (with or without a vote of the people).  The replacement ballot summary frames the issue in a narrower way: should anyone other than the people or the legislature retain the authority to decide to launch Missouri's health insurance exchange.

Both seem to me to be pretty accurate.  They are just talking about two different things.  The out-moded ballot summary about the inevitability of an exchange and hard choices about trying to shape Missouri's exchange or take what the federal government gives.  The replacement ballot summary about the necessary role the state legislative process would have to play in creating the health insurance exchange.  It is, in fact, this process that adds considerable time to the exchange roll out process and why any state planning on do-it-yourself exchange building will need to get legislation in place very soon.

That said, maybe turning all of this into a ballot measure is the real decision itself.  By the time of the November 2012 vote, it may well be too late to launch the first and necessary exchange-building steps.

Maybe Missouri has already opted-out of a state designed and operagted health insurance exchange under the ACA.