(Fred/Flickr)

For you wonks out there, Kaiser Health News has a fascinating Friday afternoon read for you.

In a piece titled “Bloggers See Own Reflections in Oregon Medicaid Study,” reporter Jordan Rau describes how this week’s news about Oregon’s Medicaid Experiment quickly became “a Rorschach test for how partisans and health policy wonks view the health care law.”

To quickly recap, in a New England Journal of Medicine study researchers analyzed how 10,000 people who won Medicaid coverage have fared since they gained insurance. The highlights were: no apparent affect on physical health; rates of depression 30 percent lower than those without coverage; catastrophic out-of-pocket medical expenses essentially eliminated.

In his piece, Rau publishes excerpts from seven blogs, each with a different take on the study’s highly nuanced results. But he closes with something I hadn’t seen elsewhere: a view of the experiment by someone who says he was one of the winners of the Medicaid coverage. Rau found the post on the blog Robert’s Stochastic thoughts.

Here’s the post in its entirety:

I am one of the winners in the Oregon lottery [winners could get Medicaid]. Going from no insurance to insurance is very confusing. When you have no money every health question starts with “would I rather live with this problem and have electricity, or treat this problem and keep my milk in a cooler for a month or so?” Stepping back into healthcare was like hopping on a merry-go-round. The doctor wanted to do test after test to come up with baselines for me, and I had a hard time showing up at the lab, I hadn’t been going to the doctor to find out new things about what was wrong with me. A huge part of living without insurance is not thinking about your high blood pressure damaging your kidneys. It takes a while to change that. It took me 6 months to change my level of co-operation with my doctor, and she said I was faster than many. Most people got into the groove about their 2nd physical. Then we had year-to-year values for blood tests and weight and blood pressure. Those numbers getting better helped. I lost 40 pounds the first year, regained 15, and lost another 10 the next year. Now my doctor wants me to try for another 10 pound loss. I have gone from 3 blood pressure medicines to 1, and that’s at a half dose. This whole time my blood pressure stayed the same, but dropping 2 pills and keeping the same score is a health upgrade. My blood sugar is still pre-diabetic, but diabetes is a progressive disease. If you keep your blood sugar at the same level for 2 years, you are making progress with managing diabetes. The study would have found me to make no progress, but my doctor thinks I have improved.

The last point is that diabetes and cholesterol are both food-based diseases. The Oregon Medicaid project enrolled very poor adults, I think the income cutoff was much lower than the SNAP benefit limit. So none of us have access to unlimited fresh fruit and low fat meat. We still eat nothing but carbs for most meals.

The mental health benefits are enormous. Changing how you eat and exercise is hard for everyone, but most people can throw a bit of money at the problem and grease their way. With no money for better food, no money for good shoes to go on walks, no rain gear, no walkman for listening to music as a distraction while walking, change is harder.

What I would like to see is a study that shows the changes in these measurements over a 2 year period for people who have insurance. People with insurance for the last 20 years are not always improving their health, either.

So much in this post touches on the tough policy issues we’re facing today: health is about so much more than health care; it’s really hard to change habits and even harder if you’re poor; how mental health affects health. But that last line is really a zinger.

HHS Secretary Kathleen Sebelius, shown here speaking at a conference in Washington last week. (Chip Somodevilla/Getty Images)

The Obama Administration handed down a key rule Monday on its health care overhaul having to do with Medicaid, or Medi-Cal in California. States must expand to the federally mandated 138 percent of poverty in order to receive matching funds for those newly eligible for the program.

Because the Supreme Court ruling in June had struck down the requirement that states participate or lose existing match funds, some states thought there might be flexibility in the expansion. But the answer to that question is a clear “no” as Secretary of Health and Human Services Kathleen Sebelius explained in a letter to governors.

In a briefing last week, California’s Health and Human Services Secretary Diana Dooley indicated she was waiting for guidance from the feds about the Medicaid expansion and might not expand to the full 138 percent limit.

In an email, a spokesperson for the state’s department of health and human services said staff is currently evaluating the new information and declined to comment further at this time.

Consumer advocates said it was good to have the matter settled. “We thought that it was the case,” Anthony Wright, Executive Director of Health Access told me in a phone call, “but it’s good for the federal government to provide clarity and hopefully this allows the states to move forward with all deliberate speed.”

It’s expected that more than four million Californians will be newly eligible for Medi-Cal. Under the Affordable Care Act, the federal government will pay 100 percent of the cost of those new eligibles from 2014 to 2017. After that, the match will phase down to 90 percent by 2020.

(Graphic: Kaiser Health News)

The so-called “fiscal cliff” is a package of automatic spending cuts and tax hikes set to kick in next month unless President Obama and Capitol Hill agree on a way to stop them.

Negotiations to avert the cuts are ongoing and both sides have exchanged offers. On one side, the president and congressional Democrats have said they will reduce spending on entitlements, including Medicare, if Republicans will agree to increase tax rates on the highest earners.

And on the other side, Republicans have agreed to more revenue — but by closing loopholes and eliminating some deductions. They oppose raising tax rates.

Here are answers to six questions about what could happen in health care before the end-of-year deadline.

Q: If no deal is struck, how would that affect Medicare patients as well as the hospitals and physicians and other providers who care for them?

A: Under the series of automatic spending cuts called “sequestration,” Medicare providers would be subject to an across-the-board 2 percent payment cut in fiscal 2013. That’s $11 billion. According to a September report from the Office of Management and Budget, hospitals would bear the largest share of the cuts, with payments reduced by about $5.8 billion.

Seniors would see no changes in their benefits.

Q:  How does that 2 percent cut in payments to physicians affect the 27 percent cut in Medicare payments to doctors already scheduled to occur in January? 

A: Physicians who accept Medicare patients would face the 2 percent cut on top of an already scheduled 27 percent reduction in January unless Congress steps in to stop it.

That payment formula was created in a 1997 deficit reduction law that called for setting Medicare physician payment rates through a formula based on economic growth. It’s known as the “sustainable growth rate” (SGR).

For the first few years, Medicare expenditures did not exceed the target and doctors received modest pay increases. But in 2002, doctors reacted with fury when they came in for a 4.8 percent pay cut. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size – and price tag – of the fix needed the next time.

A deal on the SGR could be part of a “grand bargain,” if congressional fiscal cliff negotiators decide to include it. To that point, Obama’s offer to Republicans included $25 billion to stop the scheduled cut. Congress could also pass separate legislation to stop the cuts. Some doctors say that if Medicare reimbursements are further reduced they may stop accepting Medicare patients.

Q: If negotiators do reach a deal, what could that mean for Medicare?

A: It depends on how large a role Medicare plays in a broader deal. Some of the proposals include raising Medicare’s eligibility age to 67, asking wealthier Medicare beneficiaries to pay more for their coverage and paying Medicare providers less. All are complicated and many Democrats have said that they do not want to make changes that harm beneficiaries or shift costs from the government onto seniors.  Republicans are insisting that entitlement savings play a large role in any deficit reduction deal.

Q: How is Medicaid affected, either way?

A: Medicaid does not face any automatic cuts starting Jan. 1. The Supreme Court’s ruling in June made the health law’s Medicaid expansion optional for states, so there’s concern that any reductions in federal Medicaid spending might make governors even more reluctant to expand the federal-state program.

Many Republicans, including GOP presidential nominee Mitt Romney and his running mate, Rep. Paul Ryan, R-Wis., favor changing Medicaid into a block grant, where states are given a set amount of money and more freedom to decide who is covered and what benefits they would receive. But the block grant concept is a non-starter with Obama and Democrats.

Q: If no deal is reached by Jan. 1, what happens to federal funding for medical research?

A:  The National Institutes of Health would see a $2.5 billion reduction in 2013, which means that the agency would “have to halt or curtail scientific research,” according to the OMB analysis. Other agencies would see cuts, too. For example, the Centers for Disease Control and Prevention would face cuts of $490 million, and the Food and Drug administration would see reductions of about $318 million.

Q:  If no deal is reached, what happens to health care for members of the military and veterans?

A: The TRICARE program for active members of the military system would also face an across-the-board 2 percent cut. The Veterans Affairs health system, however, is exempt from sequestration.

Alvin Tran contributed to this report.

President Obama's health care overhaul largely survived court challenges. The presidential election poses another hurdle. (Mark Wilson: Getty)

If Caroline Cunningham wakes up in her Studio City home on Wednesday morning to a President-elect Mitt Romney, she knows the first thing she will do. “I have to rush and get back surgery,” she says.

Cunningham, a 62-year-old mental health therapist with spinal stenosis, has health insurance coverage through a temporary program established for people with pre-existing conditions under the Affordable Care Act. The pre-existing condition insurance plans, mandated in every state and subsidized by the federal government, offer coverage to those deemed uninsurable.

But the high risk pools, as they are known, have an expiration date. They are slated to shut down in January 2014 when, under the federal health law, people with pre-existing conditions can buy plans from private insurers through newly created insurance exchanges.

If Romney follows through with his pledge to dismantle President Barack Obama’s signature domestic legislation and Congress is unable to quickly enact a meaningful alternative, Cunningham worries she will, once again, be uninsured. “I called the Romney campaign and asked them what they’re going to do,” said Cunningham. “I hope they wouldn’t dump us.”

Medicaid Expansion

More than any other state, California has wagered heavily on the Affordable Care Act. It has moved quickly to erect an insurance exchange and establish the high risk pool. It has also put federal consumer protections into state law.

In 2010, the state signed a $10 billion Medicaid waiver with the Obama administration that allowed counties from Democratic Los Angeles to Republican San Diego to enroll as many as 500,000 low-income adults into a ‘Medicaid-lite’ program — years ahead of the Medicaid expansion required by the act. Similar to the high risk pool, ‘Medicaid-lite’ — officially called the Low Income Health Plan — is a temporary measure until January 2014. That’s when California would open up its Medicaid program to millions of poor people, an expansion paid for largely by the federal government.

But if a Romney Administration follows through with its vow to undo the health law, that deadline could come and go without an expanded Medicaid program or a health insurance exchange in place.

“It’s the ballgame at stake,” said Anthony Wright, executive director of Health Access California, an advocacy group. “We go from the major reforms to a salvage operation.”

The various provisions in the health law and California’s Medicaid waiver were all designed to work in concert. “The fundamental design of health reform in California was a layering of stuff,” said Peter Harbage, a policy analyst who has advised Republican and Democratic administrations on health issues. “Phase one, phase two and phase three, and if one of the later phases doesn’t materialize, then people could be left without insurance.”

California’s health insurance exchange, ‘Covered California’

As for California’s nascent health insurance exchange, now called Covered California, spokesman Oscar Hidalgo said in an email, “We are moving forward with our mandate to implement the California exchange.”

The oversight board and staff of Covered California have been busy putting into place the state’s online insurance shopping portal and vetting the menu of a la carte insurance products. But there is widespread agreement that the online marketplace would falter if a Romney Administration were to cut off the federal subsidies aimed at helping working-class and middle-income individuals and families to buy coverage on the exchange.

Yet even in beleaguered California, there remain some who are optimistic that a Romney Administration would not signal the end of a comprehensive plan to deal with the uninsured.

Michael Cousineau, an associate professor of family medicine at the Keck School of Medicine at the University of Southern California and a long-time advisor to state and county officials on health care financing, said Romney’s preference for state control could mean his administration might allow California to extend its Medicaid waiver and coverage expansion of low-income adults. “The question is how much money would the federal government put into it?” said Cousineau.

Gov. Brown’s Prop. 30 to fund education has health insurance ramifications, if it fails 

But a new administration in Washington turning off the spigot is not the Golden State’s only worry. On Tuesday, Californians will weigh in on a ballot measure, Proposition 30, that would increase the state’s sales tax by .25 percent and raise income taxes on high-income earners. The initiative’s biggest backer is California Gov. Jerry Brown who has said if the measure fails, he will be left with an $8.5 billion budget hole. That deficit will largely be closed by cuts to public schools, Brown and Democratic lawmakers argue, since the legislature has already slashed $23 billion in funding for health and welfare services, criminal justice and other programs.

Still, health care leaders here say if Proposition 30 fails, and Obama holds onto his job and the Affordable Care Act, the state will nonetheless enter a grim era of budget austerity. In that scenario, where the state is likely to cut weeks off the school year for public school children, Brown might be unwilling, they say, to move ahead with California’s planned Medicaid expansion. “It would be very hard,” said Wright, “to move forward with anything that even costs a dime.”

(Su-Lin: Flickr)

Whatever the outcome on November 6th, officials in Washington will still have to deal with a looming “fiscal cliff” before the end of the year.

What’s coming is a perfect storm of expiring tax cuts, scheduled budget cuts, and various other spending changes scheduled to take place Jan. 1 unless Congress and President Obama (who, no matter what, will still be president until next Jan. 20) agree on a way to avert them.

As two of the largest spending items in the federal budget, the Medicare and Medicaid health programs are expected to play a role in how the deal gets done. Under the provisions of the law that created the budget deal Congress will attempt to undo, Medicare is subject to a two percent cut in provider payments, while Medicaid is exempt.

But two new studies and a proposed class action lawsuit settlement suggest a lot of dollar signs could change as lawmakers start to think about how to address the impending mess.

A proposed settlement in a long-running dispute between advocates for Medicare patients and the federal government is actually likely to increase Medicare spending — although how much remains unclear.

The suit was brought by the Center for Medicare Advocacy on behalf of a class of patients with chronic conditions. these patients had been denied Medicare coverage for home care, nursing home care or other services on the grounds that the patients’ conditions were not expected to “improve” with care.

The settlement – assuming it is approved by the judge in the case — means that “the Medicare Benefit Policy Manual will be revised to correct any suggestion that continued coverage is dependent on the beneficiary improving,” said the organization in a statement. The change is expected to affect as many as tens of thousands of beneficiaries with conditions ranging from multiple sclerosis to Parkinson’s to diabetes, arthritis, and heart disease.

But while it will boost spending for Medicare by preventing many of those patients from spending themselves into poverty, it could well end up saving money for Medicaid, which is jointly financed by the federal government and the states.

A new survey from the Kaiser Family Foundation finds that after one of the fastest growing years for that program, Medicaid spending growth slowed dramatically in 2012.

Total state Medicaid spending grew by an average of two percent in fiscal 2012, “among the lowest rates of growth ever recorded,” according to the study. By contrast, spending in fiscal 2011 rose by 9.7 percent.

Part of the slowdown was due to a recovering economy, which made fewer additional people eligible for the program, the survey found. Part was also due to states imposing their own cost controls on the program, in part stemming from the end of additional temporary federal funding that came as part of the 2009 stimulus law.

That spending could go down more – a lot more – if Mitt Romney is elected and implements his plan for Medicaid, according to yet another study out this week.

This one, commissioned by the Kaiser Family Foundation and done by researchers for the Urban Institute, looked at the potential impact of implementing the plan approved by the Republican-led House. That’s similar to the one Romney is proposing.

The study found that the combination of repealing the Affordable Care Act (which calls for a major expansion of Medicaid) and limiting federal payments for Medicaid could together reduce federal Medicaid spending by $1.7 trillion from 2013 to 2022. That represents a 38 percent cut in federal funding for the program.

The study estimated a range of how many people would lose coverage, depending on how states react. The estimates, however, range from a low of 31.3 million fewer people being covered to 37.5 fewer million people being covered.

It turns out Republicans and Democrats do have something they can agree on this election season – they’re worried about how to pay for long-term care when they or a family member can no longer live at home.

A new poll released Wednesday by The SCAN Foundation and the UCLA Center for Health Policy Research found that half of California voters say they’ll need long-term care for a close family member in the next few years, but won’t be able to afford it.

Anxiety over the cost of long-term care, like the price tag of a nursing home stay, is going up. The percentage of California voters who said they couldn’t afford more than three months of nursing home care increased to 73 percent from 66 percent in 2011, and 46 percent said they didn’t have the money to cover a single month in a nursing home, about $6,800 in California. For Latinos, the prospect of paying for long-term care is even more grim: nine in 10 Latino voters said they couldn’t afford more than three months of nursing home care and 86 percent couldn’t afford more than three months of part-time care at home.

Long-term care costs can surprise many families who expect Medicare to cover their needs. After a hospital stay, Medicare will pay for 100 days of nursing home care, but after that, families are on their own or are forced to spend down their assets to become poor enough to qualify for Medicaid. Latino voters in California, the poll found, were the most confused about Medicare: 31 percent assumed the federal program would pay for long-term, nursing home care – more than twice as many as white voters.

What is certain is that there will be many more people spending their golden years in the Golden State. Over the next two decades, the population of seniors aged 65 and older is projected to double to 8 million. And Californians want their state government in Sacramento to find a solution. The vast majority of Republicans (81 percent), Democrats (94 percent) and independents (85 percent), the poll found, said that despite the fiscal calamities in California, figuring out affordable options for long-term care should be a top priority.

The poll surveyed 1,667 registered California voters age 40 and older and was conducted by Lake Research Partners and Chesapeake Beach Consulting between Aug. 15-22, 2012.

Learn More:

Live Long and Pay for It: America’s Real Long-Term Care Cost Crisis (The Atlantic)