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Wednesday
Apr242013

Government Health Care: What You Get Will Depend On Your Political Clout

One of the biggest drawbacks of any government-run health care system is that the health care you get is more likely to be determined by political clout than medical need.  That’s a problem because the the sickest people are the ones who are most in need and most likely to lack political clout.

The reasons they lack such clout are:

1. The very sick are relatively few in number, which means they amount to a very limited number of voters, too limited to have much impact on elections.

2. They are too sick to engage in the type of political activities such as organizing, protesting, etc., necessary to bring about change in health care policy.

3. They may be completely unaware of how government health care policy has affected their plight, in which case they will not feel a need to vote or organize to change health care policy.

4. They’re dead, in which case they definitely won’t be organizing and, unless they are laid to rest in Chicago, they won’t be voting.

For today, let’s look at an example involving one and two, saving three and four for tomorrow.

Until recently, Medicare would only pay for physical, occupational or speech therapy if the therapy satisfied the “improvement standard.”  The improvement standard required that the patient must be showing improvement while undergoing therapy.  If he wasn’t, therapy would be discontinued.

At one time, the improvement standard may have made sense.  Most patients who received therapy underwent it for an injury, say, to a knee or hand.  The rationale for the therapy was that it was might succeed in improving the function of the injured body part, possibly restoring it to its pre-injury state.

But medical professionals often find that over time a treatment intended for a particular illness has multiple uses.  Therapy is no exception.

In the last 20 years or so studies have found many uses for therapy.  According to a review of the medical literature, no therapy treatment has yet proven effective in stopping multiple sclerosis (MS), but some treatments have proven useful in treating the symptoms.  For example, a recent article examining primary-progressive MS found that therapy and other rehabilitative treatments can slow its progression by minimizing problems that result from decreased mobility or by compensating for a loss of function.  A “meta-analysis” of the effect of occupational therapy on MS patients found that it was generally effective in improving muscle strength, range of motion, walking, and daily tasks like bathing and dressing.  Another study of MS patients found that extensive therapy did little to improve patients’ impairment but did help them maintain their activity level.

Other studies have shown that therapy benefits patients suffering from Alzheimer’s Disease.  Alzheimer’s patients in a walking program showed improvement in activities of daily living and a slower decline in mental activities.  Another article showed improvements in balance and a slowing of cognitive decline using physiotherapy, occupational therapy and physical education.  Various types of speech therapy also improve health outcomes for dementia patients.

The results of such studies offer hope, but many of the benefits listed above do not necessarily satisfy the improvement standard.  Improving muscle strength or the ability to carry out daily activities might qualify.  But things like “slowing the progression,” “treating the symptoms,” and “slowing cognitive decline,” probably would not.

Case in point was Clay Bell, a Detroit-area man who suffered from primary-progressive MS, the worst form of the disease.  Being disabled, he was covered by Medicare. By the time I interviewed him, he was paralyzed from the neck down.  About a year prior, he still had some limited mobility in his arms and legs, thanks to physical and occupational therapy.  However, therapy was not going to improve his condition.  It would only slow the decline, so Medicare cut it off.  After he was cut off, his decline came very quickly.

Patients with primary progressive MS are some of the most likely to run afoul of the improvement standard.  Estimates vary, but somewhere between 250,000 and 400,000 Americans suffer from MS.  Primary-progressive accounts for 10 to 15 percent of those, or 25,000 to 60,000.  Even if their physical limitations didn’t present serious obstacles to political organization, their numbers at most average to about 137 per congressional district and 1,200 per state—hardly enough to have much impact on House or Senate elections.

There are far more Alzheimer’s patients, an estimated 5.4 million in the U.S.  Exactly how many of them run afoul of the improvement standard is not known, but if it was even one-fifth, they might have the numbers to influence Congress.  But, of course, Alzheimer’s patients also suffer from mental impairment.  People who suffer from confusion, memory loss, and problems with attention and language difficulties, sadly, aren’t going to be a political force to be reckoned with.

Fortunately, the “improvement standard” was recently overturned.  The Center for Medicare Advocacy filed a class action lawsuit against it, arguing that the standard was not based on any actual legislation or regulation. Apparently the Centers for Medicare and Medicaid Services realized that it did not have a case.  CMS settled, and now qualifying for therapy will be based “on whether the beneficiary needs skilled care.”

Unfortunately that came too late for Clay Bell, who passed away in May 2012.  How many other people with MS or dementia saw their health decline or died prematurely because of the improvement standard?  That’s something that may never be known.  What will be the next treatment that could help a group of Medicare beneficiaries that Medicare won’t pay for because the group lacks sufficient political clout?  We don’t know, but given the way Medicare functions it is inevitable.

Photo: iStock Photo

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