Yesterday, jumping into a discussion an individual who saw their costs rise after ACA, I made a comment about the lack of competition in the Pennsylvania health care market. The person I was responding to had noted that their friend only had two plans to choose.  Pennsylvania has long had an unholy alliance between providers, insurers and government that sustains a poor competitive environment and high prices. UPMC dominates western PA, and just a few insurers compete in many other parts of the state. Our per capita costs are more than 13 percent above the U.S. average. While some of that is our older population, even our Medicare costs per capita are above the national average. My comment wasn’t directly about ACA, but I guess at least one person immediately interpreted it as a harsh criticism of the law–noted health policy blogger Maggie Mahar. Our subsequent twitter discussion was disorienting.

The subsequent reaction by Maggie Mahar included wildly off-base accusations about my politics. (No, I am not a subsidy-hating Neanderthal. I am a registered Democrat, two time Obama voter, and proud of what ACA is and has accomplished). It demonstrated to me that even people well-versed in health policy still seem to miss critical parts of the problem.

To start with the subsidies, they have made a dramatic and immediate impact on improving insurance coverage and access to care for millions of Americans, especially the low to middle income Americans who have been excluded from coverage in the past. Nothing I wrote in twitter or here or in my past suggests anything different.

The progress those subsidies have made and will make in the future, however, is and will be limited by the current high prices and growing high costs of care in America. That’s not support for getting rid of those subsidies. It’s a rational and reality-based recognition that reining in prices and costs are a necessary part of the solution to improving access to health care, too.

It’s widely recognized that a fundamental difference between the U.S. and other health systems is the high prices charged by our health care providers.  A good reference is Gerald Anderson’s 2003 paper from Health Affairs. A just as good and entertaining one is Uwe Reinhardt’s New York Times work. At one point in discussion on twitter Ms. Mahar makes reference to overtreatment being the problem. Yes, there’s overtreatment in the U.S. system. There’s also undertreatment (that’s what the uninsured have received forever). On balance, the difference between us and the rest of the world on a population basis is not that we receive more care.  We don’t.  The difference is we pay more per service received.  That’s, in large part, our cost problem.

And it is those large and rising costs that have to be controlled for those ACA subsidies to reach full effect. Even now, the impact of the subsidies is muted because under the current high prices, a large number of the plans being offered on the exchanges have high deductibles and/or limited networks. The goal is not making sure people have insurance. It’s making sure they can afford needed care.  High deductibles and limited networks that result from high provider prices limit the protection provided by ACA and limit access to some needed care.

And, in the longer term, ACA subsidies will ultimately lose the battle on access to care if prices and cost growth are not reduced.  If health care costs rise in excess of incomes, the purchasing power of those subsidies will be consistently eroded. Plans will have to further narrow networks or raise deductibles to remain affordable. People may have insurance, but the gaps and weaknesses in that insurance will harm access. Governments, of course, could raise those subsidies, but if costs are rising faster than national income, that is also a long run on a treadmill going faster than we can manage.

Support for reducing health care prices and reducing health care cost growth is not opposition to ACA.  In fact, it’s a fundamental part of necessary health reform to support the subsidies in ACA. Massachusetts new effort on price transparency shows one part of what is needed. Vigilance in examining health care consolidation is also needed, as work by Martin Gaynor and others shows. From the federal government to the state government to individual plans and providers, we need to address this part of the problem.

So, Maggie, I’m not your enemy.  I’m your ally.

So, after finishing our presentation Thursday, I got back to my hotel at about 8:30 and had a quick dinner of more peanut butter sandwiches, celery and fruit.  I was exhausted and went straight to bed, since I had to drive home to State College the next morning.

Friday I was up at 5 am, and on the road to State College by 6:30, after answering a few emails and packing.  Breakfast was cheerios (4th time out of 5 days).  I was so happy that my cooler kept my milk cold. I’m not sure I could have faced dry cheerios for breakfast with a long drive ahead.

Sustained by coffee, I made it back to town before 10 am, and headed right into the office.  I prepped for a meeting, caught up on a few emails and phone calls, and checked to make sure everything was ready for my class in the afternoon.  Lunch after my meetings was a nice pasta salad with tuna (no peanut butter for lunch–hooray!!), and I caught up on a few things with Dean Nan Crouter, as we ate.

My class was great–two alumni guest speakers who did a a great job sharing their experiences.  It doesn’t always happen this way, but their stories reinforced several of the topics on health care leadership that we’ve been discussing.  After a long chat with one of them, I raced home to grab a quick dinner–scrambled eggs with green pepper and some fruit.  I added a peanut butter sandwich for good luck, because I was headed to an alumni dinner, and then a church youth group “lock-in”–a sleepover at the church.

At both events, temptations were everywhere. The dinner roll in front of me called my name. The surf and turf with potatoes was mouthwatering. I was warned that our alumni relations director, Abby Diehl, had gone all out on dessert–chocolate fudge cake with a salted caramel drizzle. I did not touch a bite, and I got to share about SNAP with everyone at the table.

After that, the lock-in was easy. The only thing there was candy, popcorn, potato chips, pretzels, etc., etc. I calmly munched my dry cheerios for my snack.  It was fun to explain what I was doing to the kids, and we had a good time!

I’ll try to close later today with my Saturday and Sunday.

The combination of a trip to a conference, a college alumni awards dinner, and a church youth group sleepover has made it difficult to give an update.  Here’s a quick, somewhat sleep-deprived, disoriented recollection of the last 3 days.

Wednesday started with a nice scrambled egg sandwich for breakfast, following by some tuna pasta salad for lunch (leftovers of the noodles I made for noodles with peanut sauce on Tues night). Tues night was interesting. Since my wife came down with something, I had to cook for my son, too. I succeeded in not sampling his pasta with alfredo/bacon sauce.

After a busy day of meetings and teaching, I hoped in the car to drive to DC for the Gerontology conference.  In addition to my luggage, I had my bag of food and cooler of milk/veggies/fruit. Stopped at the Midway Travel Plaza on the PA Turnpike for a banana, celery and peanut butter sandwich.

For my trip, I took a coffee mulligan. I didn’t see any way to make coffee without transporting my coffee maker with me, and I was not willing to risk falling asleep and crashing (reasonable, right?).  So, I did spend extra dollars for caffeine. This, of course, just brings up the challenge part of this. What if I simply did not have that cash to spend? So many of us are accustomed to our $3 Starbuck’s that it’s difficult to consider what life is like without that indulgence. Could I have made the trip without it? Maybe.  But, those on SNAP don’t get that choice.

Avoiding the conference food was fine. Walking past several restaurants with delicious smells was harder. Between sessions on Thursday, I grabbed another PB sandwich and some fruit. I gave into a few moments of weakness and joined my grad school mentor, Steve Crystal, for a beer after our paper presentation.

I’ll add more later on the drive back, awards dinner and sleepover…

Day 2 of my SNAP Challenge, and I’ve walked the dog, put to the trash, and am ready for breakfast.

I feel a little tired, not from the meals yesterday, but because I’ve had a little trouble sleeping the last 2 days.  When I get stressed, I tend to wake up 2 or 3 times a night, and that’s what has happened Sunday and Monday. As I walked this morning, I was reflecting on what it might be like to know real stress-not the worries I have about a presentation or a busy week–but the fear of not having food on the table or keeping your kids safe in a dangerous neighborhood or working 2 or 3 minimum wage jobs to survive.

I find it hard to imagine the chronic stress that creates and the long-term effects that must have on health and well-being.  I’m dragging after 2 days of poor sleep. What must it feel like to live in poverty day after day after day?  Not sure I can even imagine the tired that means. I’m reminded of my resolution to re-read some of Studs Terkel’s books which I read in high school and college. The stories of lives lived at the margins of our society were a major impact on my thinking.

Now, time to eat.  Hello, Cheerios!

Today, I am starting the SNAP Challenge, an exercise designed to gain an understanding of the difficulties of living on the food support we provide the poorest Americans.  One of the faculty in our Department of Health Policy and Administration, Dr. Patricia Miranda, did the challenge last year to illustrate its lessons for students in her Public Health class.  This year, she has challenged all of her students (and me) to try it.

On Sunday, I went out to make my purchases–less than $30 to buy food for the week. Tricia had shared some basic tips, but I did not take time to consult the handy guides provided by the government. I had hoped to stretch my dollars by getting some day old food, but a busy weekend meant I had to rush for my purchases later on Sunday, when many of the best deals were gone. I’ll see if those two mistakes will come back at me later this week. My final purchases totaled a little more than it should $33, in large part because the on sale peanut butter I had planned was sold out, so I grabbed the next bigger size.

Looking over my plan for the week, I think breakfast and lunch will be easiest. The menus don’t look much different than what I usually eat, though much more monotonous–peanut butter and tuna rule lunch, cereal and bananas dominate breakfast. Afternoon snacking–no more nuts and chocolate to keep me going; Dinner–my wife, Allison, prepares some great dinners and they are off the plate; And, my end of the evening beer and occasional snack is history. These will be the hardest times for me.

I bring some advantages to the table.  As a former high school and college wrestler, I am pretty familiar with an empty stomach.  My senior year in high school, I was dropping about 20+ pounds to get to my wrestling weight of 100 pounds. I’m not generally prone to cravings, so I think I’m OK on that score.

The week, however, will bring some big challenges. In fact, you probably could not pick a worse week for me to do this.  On Wednesday, I’ll be heading to DC for the Gerontology Society meetings, and returning Friday morning. On Friday, I have both a college alumni board dinner AND a church youth group “lock-in”.  The temptations at both will be difficult to resist. On Saturday, my son will be at his lock-in, so my wife and I were talking about going out to dinner, when I realized I would still be on my challenge.  I’m not sure my offer of a rain check was the best move.

Wish me luck, and even if you never do the challenge, I’d encourage you to try to shop for a week’s worth of groceries on $30!!