A new paper came out that looked at individuals with depression who were covered by Medicaid. ** The paper looks at breaks in coverage and what happens to people when they get back onto Medicaid. It is both a painful humanitarian diseaster and expensive as hell.
Outcome Measures: Emergency department (ED) visits, inpatient episodes, inpatient days, and Medicaid-reimbursed costs.
Results: Approximately 29.4% of beneficiaries experienced coverage disruptions. In instrumental variables models, those with coverage disruptions incurred an increase of $650 in acute care costs per-person per Medicaid-covered month compared with those with continuous coverage, evidenced by an increase in ED use (0.1 more ED visits per-person-month) and inpatient days (0.6 more days per-person-month). The increase in acute costs contributed to an overall increase in all-cause costs by $310 per-person-month (all P-values<0.001).
The cost side is pretty straightforward. Making sure that people with depression have continual, low or no cost access to their prescriptions and other useful clinical support services saves money. The savings pathway is through far less inpatient utilization and a dramatic drop in emergency room utilization. Churn is expensive if the people being cut loose to fend for themselves without adequate resources have complex chronic conditions.
From a humanitarian point of view, the cost pathway is because people are suffering. I am lucky, depression is a monster I don’t have to fight. Several of my family members do struggle with depression and other mood disorders. They are able to maintain themselves but it is a continual struggle when they have resources. A downswing is not a good spot for them, it is not a good spot for the people that they live with, it is not good. And it is not good even without regard to economic costs. Churning people in and out of Medicaid means more people go into avoidable downswings that last long and go deeper than they otherwise should experience.
The current Senate bill will increase Medicaid churn. It will increase it in a variety of ways. First it will reduce Medicaid Expansion quickly and kill it over the long run. As people’s incomes move, they will earn out of Medicaid faster. Secondly, the Senate bill is allowing more frequent eligibility redeterminations. People will need to prove their eligibility more often which means people will fall out more frequently.
Churn is a cost killer. It also has incredible costs to the people who are being bounced in and out of coverage.
** Ji, X., Wilk, A. S., Druss, B. G., Lally, C., & Cummings, J. R. (2017). Discontinuity of Medicaid Coverage. Medical Care, 55(8), 735-743. doi:10.1097/mlr.0000000000000751
Humdog
Is it possible to create a bill more cruel than what these people are attempting?
From Both Sides of the Pond
I can speak to this, with a close family member suffering from depression. Due to a boss attempting to cover up their extramarital activities, a close family member of mine with depression was run out of their job and lost health insurance; the result was the loss of medication and treatment, which leads to a spiral of anxiety and depression that makes getting another job and back on treatment incredibly difficult. Americans have this stupid obsession with the idea that maladies must have physical manifestations to be taken seriously, and the dependency on employer-based coverage leads to dire outcomes when there are abuses in the workplace.
Laura
The wreckage, the physical manafestation of untreated mental illness is on full display on our streets. Homeless and untreated mental illness go hand in hand.
My dad’s side of the family has lots of what used to be called manic depression and is coupled with extremely high intelligence -and we’ve always referred to it as the Jonathon Winters wing of the family.
My grandmother’s experience was a forced hysterectomy at 28. Instant menopause. Didn’t help at all. She was fortunate to have the Napa State Hospital for long periods of time and was able to live a highly functioning life as an LVN while on daily thorazine.
A certain Ronald Reagan closed or sharply reduced state hospital services and promised that care would be provided in the communities. He fucking lied. The so called services are few and far between.
And so it goes.
jacy
Depression and mood disorders can wreak havoc with your life. Access to medications and therapy is vital. I’ve been fortunate to have access that’s been unbroken, even when I had to drop my private insurance and spend a year on Medicaid (ironically, because mood disorders disrupted my life so much that I had trouble working and my income fell precipitously.) I know people who have found a medication that helped their mental health problems, then had that medication dropped from their insurance coverage, and become suicidal as a result. There really needs to be a lot more attention put into mental health in this country.
David Anderson
@Humdog: Yes — #holdmybeer
Ms. D. Ranged in AZ
@From Both Sides of the Pond: But there are very real manifestations of depression. The problem is they often present as something else like migraines, eating disorders, insomnia, and diagnoses of exclusion that are hard to understand like IBS, Fibromyalgia, etc. And it doesn’t help that Americans are woefully ignorant about mental illness and do not make the connection. I’ve had depression and anxiety since childhood and have managed to be high functioning for the majority of that time even though I did not have continuous coverage. I did have some rough patches though and they ALWAYS coincided with times when I had no insurance. Your description of the spiral is right on point. When someone is feeling hopeless and they can’t get the medication they need, it feeds into the hopelessness and desperation. Those rough patches resulted in financial hardship, ruined relationships and bad personal decisions, which in turn made both my mental problems worse and as a result my physical symptoms worse. Multiply that economic damage by the number of people who suffer from mental illness without coverage and it will add up to a pretty penny. Collectively and individually we are best served by having basic services for mental illness. Hell just having affordable prescriptions available would make a HUGE difference. I get that reforming Health Care is complicated but justifying economically shouldn’t be the hard part. One would think the cost/benefit analysis should be enough to move conservatives, but that presumes they’re rational and we know how that goes.
Patty Penglase
@jacy:
It is really long past time for our society to recognize that:
1) depression and other mental illness are physical illnesses
2) people suffering them can’t just “buck up” and fix themselves, and that does not mean that they are “weak” or morally inferior
3) same applies to addiction
Oh, and while we’re at it, people who are rich aren’t rich because they are morally superior.
amygdala
Another element of churn that’s especially vexing is the demand it puts on people to advocate for themselves. Not easy to do when you’re not feeling well for any reason, but especially so for anyone trying to keep the black dog at bay. For folks who don’t speak English, haven’t finished high school, and come from a background where being deferential is valued it’s only worse.
The VA has made headway in making its system easier to negotiate for its patients. Our entire health care system needs to do this, too.
Aleta
The changes Obama brought about for mental illness coverage made a profound difference for my relative. Not only much better daily life and feeling happiness, but he’s stayed out of the hospital for the last 7 years. Which also means he hasn’t had to go through the (necessary but cruel) trauma of that experience and the lead-up to it. Which then reactivates his ptsd. And was very traumatizing each time for the children.
Before, his insurance wouldn’t allow consistent preventative care until he had reached the point of a serious breakdown. Then when hospitalized they would force his discharge before he was better, so he would get much worse at home. Sometimes be in so much pain he’d try to end it, and then, fully broken, he could be readmitted.
Many effects on the lives of his immediate family, who’ve had stabilization because of his stabilization. Kids have been able to do their best work in school again and recover some from the bullying and shame they used to get when he was acting weird. Took years for him to regain their trust, but they feel love for him again now and his illness doesn’t run their lives. He’s able to be aware of their needs again which of course they need for their health.
The small change in basic patient support (which people with money don’t have to do without) has made him able to stay home alone a few times a year, caring for the animals so mom and kids can take overnights to do something special. He andI I now have phone conversations where we just joke around and express love instead of ones dominated by his personality on less effective medications.
Lack of coverage for regular outpatient care led to his illness being treated by too many difficult med changes; that all stopped thanks to the ACA. His previous shoddy care just wrote him off. I fear he will lose this better care and changes will be forced on him. He’s newly of medicare age now.
Didn’t mean to go on; I started out to write one sentence. I get worked up on this and want to explain how it matters when the nervous system is treated like an equal part of the body.
gene108
@jacy:
Untreated mental illness can be life threatening. This needs to be mentioned more often.
@Patty Penglase:
I agree with what you wrote.
But I think we need to further. When someone is depressed, they tend to isolate. We need to be a bit more proactive in getting people to seek treatment.
Ruckus
@amygdala:
The VA has made it a lot easier, not necessarily a lot better. Because making it better means spending money they don’t have. Ironically that’s the same problem that public mental health care has. Conservatives want control, not freedom. That’s why they talk about freedom all the time, it’s misdirection.
Aleta
@Ruckus:
That’s it in a nutshell.
ETA (in a nutshell–kind of an odd phrase. Maybe a folk saying?)
Ruckus
@Aleta:
Talk all you need to.
Not talking about this type of thing is part of the problem. We humans have illnesses, we are not strong beings that never have a bad day or a bad life. Mental illness is a bigger part because it affects all the other parts. Mental illness is not just a 5 minute exam followed by take these pills and don’t call in the morning. And it’s not just a broken arm, that can be x-rayed and set, anything and everything can be a setback. Or a breakthrough. The causes can be from an experienced event to physical deficits in the brain to all of the above.
Keep talking, talking can really help, bit by bit.
Ruckus
@Aleta:
I always though “in a nutshell” came from having to open the nuts to get into the good part. Even avocados have a shell. Easier to remove than say a walnut or almond but still has to be done to enjoy the edible part, which of course isn’t the all the way inside nut part.
sherparick
@Aleta: For Conservative Freedom is control by the 1%. Their sense of freedom and right to do as they will are made all the greater by the contrast with the lack of freedom and misery of as many of the 99% as possible.
amygdala
@Ruckus: I’m embarrassed that I haven’t said before how much I appreciate your insights about the VA. My friends who work there are among the most satisfied docs I know. The EHR works, the bureaucracy can be circumvented when patients need things, and there’s a sense of mission.
I always wonder how things are for vets in places like the UK and Canada, especially those from the recent wars. In the US, the VA has systems of care for polytrauma survivors. I’ve had this argument with people who try to make a case for privatizing VA care, that civilian medicine doesn’t do such a great job at taking care of someone missing 3 limbs with a TBI and/or PTSD on top of it.
And yeah, I’ll start believing Republicans care about vets when they stop trying to slash the VA budget. Ok to create disabled vets; not ok to cough up the funds to care for them properly. That should be part of the cost estimate of any proposed war.
Ruckus
@Patty Penglase:
There are actually many things that aren’t counted as heath issues. Dental or vision. A blind person without teeth is not a healthy person. They may exist and survive well enough but they are not healthy. All systems are not go. Mental heath is the same. A person with mental health issues has a malfunctioning organ. A rather important one at that. The causes can be experienced based or physically based or both. They can’t be addressed by dropping coins in a fountain or wishing upon a star. They take work and effort and sometimes medication. When the brain is malfunctioning it can take many forms, physical pain, physical disability, mental issues of coping with everyday life, depression and loss of the will to live, etc, etc.
Ruckus
@amygdala:
As well, people like me had a contract with the rest of the people that we would be provided health care when we needed it if we gave up a part of our lives and served our country. And of course we aren’t mercenaries so the pay is crap. Conservatives are violating that contract. Of course it’s not just the contract with vets that they are willing/trying to violate. drumpf is just the epitome of the worst of them, violating contracts for his own personal gain is the basis of his life. I’d bet that’s one reason why a lot of people voted for him. Employers who do the same to their employees to make an extra buck at everyone else’s expense, that’s the conservative way. It’s the me society at it’s worst.
TenguPhule
@Humdog:
Yes, SATSQ.
Boussinesque
David,
I don’t have anything substantial to add, but as another sufferer of depression, I just wanted to thank you for bringing attention to this particular aspect of the consequences of the Republican Wealthcare bill.
Aleta
@Ruckus: Thanks. I think you’re very skilled about this reassurance. I appreciate it a lot.
Nutshell got me thinking: ‘In a nutshell’ seems to mean to sum up the whole thing up perfectly and concisely, to contain the heart of the matter, essential to understand. The simple small nut, the potential tree inside the shell. The good nutritious meat that’s worth going after. And essential harvest.
Ruckus
@Aleta:
Been on this rock for a while, had/having my ups and downs. I’ve had a few health downs, more of them and them more critical so now as I slide into geezerdom. Actually it feels like a free fall rather than a slide but that’s just my perspective.
I always try to look at the big picture first and then break it down into it’s component parts, to see how it was made or how to make it or how to fix it and make it better. Sometimes you have to walk all around a problem to see how one piece affects the others. Sometimes your answer is wrong. Sometimes it’s a sideways move rather than better or worse. Sometimes you can’t fix the problem at all and need assistance. When that happens it’s nice to have someone/something to give you that.
A question I’ve heard a lot is why can’t we have nice things. Because a portion of the country is fucking cheap and doesn’t want to pay for them. This concept that we are all in this together is foreign to a large segment of the people. It’s been beat out of them with phony bullshit in the guise of freedom, while it’s real purpose is to enrich the lives of the providers. We all have to provide a fair but not necessarily equal share, because not everyone can provide any. Those politicians in bed with the Russian mafia? They are soul mates, that’s why they don’t see it as a problem or even an issue to discuss.