wants to become an active purchaser?

Posted by on Tuesday, Feb 9, 2016

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Will Get A California Makeover?

By Pauline Bartolone
Kaiser Health News, February 9, 2016

Experts say the California exchange uses more of its powers as an “active purchaser” than the vast majority of other states. That means it can decide which insurers can join the exchange, what plans and benefits are available and at what price.

The federal government — in pending proposed rules for 2017 — has signaled it too wants to have more of a hand in crafting plans. would be forging ahead on a path California already paved, swapping variety for simplicity in plan design.

“Not letting [health] plans define what’s right for consumers, but defining it on behalf of consumers … is a better model for the market,” said Peter Lee, executive director of Covered California.

“We want to make sure every consumer has good choice but not infinite choice,” said Lee.

Most other states, including those in the federal exchange, haven’t subscribed to that idea so far. They have a clearinghouse model, in which all health insurers and plan designs are accepted as long they comply with the Affordable Care Act. That can mean the same insurer offers multiple plans with slightly different premiums, deductibles and copays. Even within one metal tier, say silver, the same insurer might offer half a dozen slightly different plans.

Now, the federal government proposes to create standard cost-sharing designs in various metal tiers and make them easily accessible on And it’s considering how to improve “value” by being more selective about plans.

Covered California holds insurers to a higher bar than what’s required under the Affordable Care Act.

Covered California says it’s the only exchange in the country that requires all plans to be standardized (not just some, which the federal government is proposing).

But one of two health insurance regulators in California, the state Department of Insurance, said Covered California’s strict guidelines may not benefit consumers.

It has created a situation in which the exchange “has fewer carriers than would otherwise be the case,” said Janice Rocco, deputy commissioner of the California Department of Insurance.

Health insurers on a national level are “strongly” opposed to an active purchaser model for states served by, including standardized benefits.

“It could discourage many from enrolling if they can’t find a policy that works best for them,” said Clare Krusing from America’s Health Insurance Plans.

“Where there is competition and choice is where consumers benefit and where health plans benefit,” said Krusing.

Covered California – one of the more successful state-operated ACA insurance exchanges – has two features that are currently being considered for the federally-operated ACA exchanges: standardized cost-sharing designs and active purchasing of plans.

By creating standards for deductibles and other cost sharing, it makes it easier for plan shoppers to compare plans since the out-of-pocket expenses theoretically would be the same. After checking provider lists to see if their physicians are in-network, and checking formularies to see if their drugs are covered, shoppers can then select their plans based on the premiums.

Of course there are still some uncertainties. It is not uncommon to obtain care out of network, so another plan’s network may have turned out to be preferable. Also medical conditions change which might require drugs that are not in the plan’s formulary but may be covered by other plans.

In contracting with plans for the exchanges, Covered California decided to use active purchasing. In a non-transparent process, Covered California negotiates with the plans in an attempt to gain the best value for the plan beneficiaries. Under this process, not all plans are accepted, thus the insurers are motivated to offer better value than they might otherwise.

Active purchasing introduces more instability into the process. Plans moving into or out of the exchanges may face unprecedented changes in their administrative requirements which can be very disruptive to their business model. Changes required by the instability of contracts increase administrative expenses which are ultimately borne by the plan beneficiaries, adding to costs when the intent was to decrease costs. These disruptions apply not only to the private insurers but also to the physicians and hospitals who are included in the networks. Since active purchasing reduces the number of plans available, any change in plans covered would have a greater impact on the contracted providers thereby threatening insolvency.

To no surprise, the private insurers are not enthusiastic about either standardization of the plans or active purchasing. With standardization, the plans are less able to hide their innovations that improve the profits and competitiveness of the plans (i.e., the plans can be more competitive when the consumers do not know what they are buying). Active purchasing drives plan revenues down and exposes them to greater risk since the contract may not be renewed.

Clare Krusing of the insurance lobby organization, AHIP, says, “Where there is competition and choice is where consumers benefit and where health plans benefit.” Instead of plans competing for contracts with the ACA exchanges, they want to compete for individual patients. But the patients lose because there is less plan oversight when there is no active purchasing, and there is less transparency when the plans do not have to comply with standardized cost-sharing.

Cost-sharing standardization and active purchasing are the types of incremental reforms we can expect from those who say that we must build on what we have. These will do almost nothing for the problems that face us such as the 29 million uninsured, the tens of millions underinsured, the loss of choice of health care providers, and the interminable increase in health care spending.

We do have a better choice. Join the forces who are advocating for a single payer national health program. With single payer, we would no longer have to direct our health policies to maintaining a lucrative private health insurance infrastructure. Instead we could direct our health policies to taking care of patients, and that, of course, is what reform should be all about.

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Deloitte update of ACA Section 1332 state innovation waivers

Posted by on Monday, Feb 8, 2016

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

State health coverage innovation and Section 1332 waivers: Implications for states

By Anne Phelps
Deloitte Health Policy Brief

Executive summary

Although states and the federal government have implemented most Affordable Care Act (ACA) provisions, a few are scheduled to go into effect in the coming years. One such provision is Section 1332 State Innovation Waivers, (1332) which allows states to pursue alternative and innovative strategies for ensuring that residents have access to high-quality, affordable health insurance as long as they meet certain requirements. Within the constraints of Section 1332, states have numerous options for revamping their current approaches to providing health coverage to individuals and families. If approved, the waivers can go into effect beginning January 1, 2017. To implement reforms next year and take advantage of realizing innovative alternatives for health care coverage, states should consider acting now.

New guidance from the US Departments of Health and Human Services (HHS) and Treasury released at the end of 2015 indicates that waiver proposals from states using the federally facilitated health insurance exchange might not be considered feasible at this time because “the Federal platform cannot accommodate different rules for different states.” Instead, these states may want to consider establishing their own exchange platform and then apply for a 1332 waiver.

This health policy brief presents a number of potential waiver-associated coverage alternatives, including those being discussed by some states. While some options are mutually exclusive, states may include multiple innovative concepts in their applications. It is important to note that, even with the new HHS and Treasury guidance, the analysis required to support a 1332 waiver application may require states to leverage actuarial, policy, technology, and data expertise.

A final consideration

As the United States moves closer to the next presidential election, the health care landscape will continue to shift and evolve. Beginning in 2017, an Administration other than the Obama Administration will have stewardship over the ACA and its various provisions, including Section 1332 State Innovation Waivers, for the first time. States should be aware that – depending on where they are in the application process at the start of 2017 – approvals may depend on the goals of the new Administration.

PDF of report (8 pages):

Section 1332 of the Affordable Care Act allows states to pursue waivers allowing alternative approaches to implementation of the Act as long as they comply with certain minimal requirements. In December, HHS released an advisory which gives guidance to what sort of innovations might be approved. This Deloitte health policy brief includes this guidance in updating the description of Section 1332 waivers and how the states may use them.

A few points:

*  Section 1332 does allow innovations that can improve access and equity and thus should be considered by state activists who wish to improve their health care systems, though the innovations are quite limited.

*  Section 1332 does allow innovations that might rely more heavily on market dynamics and thus could threaten the social insurance gains of ACA, though those innovations are also quite limited, but state activists should be on guard to help protect what gains have been made.

*  States with federally facilitated health insurance exchanges will not be able to receive waivers because of the administrative complexity: “the Federal platform cannot accommodate different rules for different states.”

*  States that have not accepted federal funds to expand their Medicaid programs may find that the political climate may inhibit any efforts to improve their systems through waivers.

*  The December 2015 advisory indicates that HHS will be quite rigid in the interpretation of what innovations would be allowed. This will protect states from efforts to dismantle the gains of ACA, but it will also prevent states from using Section 1332 to establish a state-based single payer system. Nevertheless, improvements such as all-payer systems may be allowed, although the administrative requirements may be overwhelming.

*  The Deloitte report emphasizes the importance of politics: “Beginning in 2017, an Administration other than the Obama Administration will have stewardship over the ACA and its various provisions, including Section 1332 State Innovation Waivers, for the first time. States should be aware that – depending on where they are in the application process at the start of 2017 – approvals may depend on the goals of the new Administration.”

So this report does further confirm the fact that states can improve their health systems through Section 1332 waivers. Until we can enact a single payer national health program, state efforts should be pursued.

This report also confirms that state efforts alone are grossly inadequate and that federal legislation for a national health program is an imperative.

This year, single payer is back in the political arena. Although state reform efforts are encouraged, we cannot allow these efforts to displace or even dilute the drive for national single payer. Even if it is difficult to see the political path to immediate enactment, at a minimum, through education, grassroots and coalition efforts we can move much closer to the political threshold required to make single payer inevitable.

Read the Deloitte policy brief, give thought as to how far short Section 1332 waivers will leave us, and then join the national political movement that will finally bring health care justice to all.

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Why it is difficult to make sense of the claims and counter-claims of single payer financing

Posted by on Friday, Feb 5, 2016

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Single-payer health plan wouldn’t cost U.S. more

By Steffie Woolhandler and David U. Himmelstein
Philadelphia Inquirer, February 5, 2016

In our “read my lips/over my dead body” political culture, the threat of tax increases usually shuts down proposals for single-payer national health insurance. Lately, conservative pundits – and even liberals like Hillary Clinton – have been repeating the mantra that single-payer insurance would break the bank.

Never mind that Canadians, Australians, and Western Europeans spend about half what we do on health care, enjoy universal coverage, and are healthier. Their health-care taxes are higher.

Or are they? According to our study in the current issue of the American Journal of Public Health, American taxpayers picked up 65 percent of the total health-care tab last year – a figure that will soon rise to 67 percent.

We paid $2.1 trillion in taxes to fund health care – $6,560 per person. That’s more per capita than Canadians or people in any other nation pay. Indeed, our tax-financed health-care bill is higher than total health spending (private as well as public) in any other nation except Switzerland.

Official accounts from agencies like the Department of Health and Human Services peg taxpayers’ share of U.S. health spending at about 45 percent, a figure that includes Medicare, Medicaid, the Centers for Disease Control and Prevention, and Veterans Affairs. However, this kind of tally omits two important items.

First, it leaves out government spending to buy private health coverage for public employees like teachers, firefighters, and members of Congress. Indeed, government employers account for 28 percent of all employer health spending.

Second, it excludes tax subsidies for private employer-paid plans and other privately paid care – $326 billion last year – that mainly benefit affluent families.

Omitting these government expenditures from the official health-spending tabulations obscures the fact that our health-care system is already about two-thirds publicly funded. In contrast, the Office of Management and Budget, not to mention most health-policy experts, considers tax subsidies for private insurance to be tax expenditures.

Even many uninsured families pay thousands of dollars in taxes for the health care of others.

More than one-third of these tax dollars meander through private insurers on the way to the bedside. These private insurers siphon off 12 percent for their overhead and profits (vs. 2 percent in the Medicare program) and also inflict huge paperwork costs on doctors and hospitals. A shift to single-payer national health insurance would save at least $400 billion annually on paperwork alone, enough to cover all of the uninsured and eliminate co-payments and deductibles for the rest of us.

That means a national single-payer plan wouldn’t cost Americans any more than we’re currently spending. Moreover, the taxes to pay for it would be fully offset by the savings from eliminating private insurance premiums.

Moving from our current level of tax financing, 65 percent, to Canada’s 70.7 percent would mean a tax increase of about $185 billion per year. But Americans would save at least that much on premiums. The vast majority of American households would come out ahead financially, and everyone would be covered.

Drug and insurance firms that would lose billions under single-payer health coverage generously fund its detractors (including Clinton, who has gotten more health-industry dollars than any other presidential candidate). These naysayers suggest that a single-payer plan (or “Medicare for all,” as Bernie Sanders likes to call it) would downgrade Americans’ coverage, and they also raise the specter of big tax increases.

But a national single-payer plan would give all Americans the first-dollar coverage enjoyed by Canadians and Brits, and guarantee them a free choice of doctors and hospitals – a choice that private insurers currently deny to many of us.

Surprisingly, American taxpayers already pay enough to fund national health insurance. We just don’t get it.

Steffie Woolhandler, M.D. and David U. Himmelstein, M.D. are professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School.

There are two important reasons for distributing this update on how much we spend in taxes for the health system. One is that most people do not realize how much they are already spending for health care through mostly opaque tax policies – approaching two-thirds of our national health expenditures! Right now the more important reason is that people are bashing single payer reform with reports and articles based on selected taxes drawn from single payer financing proposals – particularly countering the brief single payer proposal from a leading candidate for the Democratic nomination for President. Misinformation is rampant.

A big part of the problem is that most people have no idea what they are currently spending on health care, especially since most of it is hidden in our taxes. So when people “analyze” the single payer proposals by pulling out the various taxes, adding them up, along with recalculating upward what the expenditures would be under single payer, ignoring the savings that are already firmly established in the policy literature, then calculating the deficits in the federal budget that would result, and then projecting that out over ten years – the cumulative total is in the trillions – an almost incomprehensible number. Scary.

When individuals compare those enormous numbers with what they know they are currently spending – employee share of the premium for employer-sponsored plans, deductibles and copayments, and Medicare payroll taxes – they do not realize that this is only a small part of what they are actually paying, so the single payer taxes appear to be horrendous to them. Little do they realize that, with our current system, we will be spending about 43 trillion dollars on health care over the next decade, and much of the spending will be opaque to individuals and their families (since, again, two-thirds is paid through the tax system).

We now have claims on one side that the costs of single payer are egregiously high, and on the other that the savings for individuals and families will be phenomenal – conclusions that are reached by playing with these numbers. In fact, well designed single payer models save typical individuals and families an average of about 5 percent from their current total spending (including the hidden costs). Only very high income individuals would pay more.

By losing people in the fog of these incomprehensible numbers, the opponents are able to suppress discussion of the more important reasons why we should enact a single payer system: absolutely everyone is covered, deductibles and other financial barriers to care are greatly reduced or eliminated, free choice of health care professionals and hospitals is returned to patients, central planning ensures adequate but not excessive capacity in the system, excessive prices are reduced to fair levels, and economic policies are put in place that slow health care inflation to sustainable levels.

Do not get hung up on the numbers, Just remember that most people will see better numbers, whether they recognize them or not,  while everyone will see a superior health care system. And that is what single payer is all about.

Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

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Insurers avoiding some of the sickest patients by using broker disincentives

Posted by on Thursday, Feb 4, 2016

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Licking Wounds, Insurers Accelerate Moves To Limit Health-Law Enrollment

By Jay Hancock
Kaiser Health News, February 4, 2016

Stung by losses under the federal health law, major insurers are seeking to sharply limit how policies are sold to individuals in ways that consumer advocates say seem to discriminate against the sickest and could hold down future enrollment.

In recent days Anthem, Aetna and Cigna, all among the top five health insurers, told brokers they will stop paying them sales commissions to sign up most customers who qualify for new coverage outside the normal enrollment period, according to the companies and broker documents.

Last year, these “special enrollment” clients were much more expensive than expected because lax enforcement allowed many who didn’t qualify to sign up, insurers said. Nearly a million special-enrollment customers selected plans in the first half of 2015, half of them after losing previous coverage.

In addition, Cigna and Humana, another big health insurer, have ceased paying brokers to sell many higher-benefit “gold” marketplace plans for individuals and families while continuing to pay commissions on more-profitable, lower-benefit “bronze” plans, according to documents and interviews.

Gold plans typically enroll sicker members than do less comprehensive policies, say insurance experts. As of June, more than 695,000 people had enrolled in gold plans.

But the retreat from broker sales, which includes last year’s decision by No. 1 carrier UnitedHealthcare to suspend almost any commissions for such business, erodes a pillar of the health law: that insurers must sell to all customers no matter how sick, consumer advocates say.

By inducing brokers to avoid high-cost members — whether in gold plans or special enrollment — the moves limit access to coverage and discriminate against those with greater medical needs, said Timothy Jost, a law professor at Washington and Lee University and an authority on the health law.

“The only explanation I can see for them doing this is risk avoidance — and that is discriminatory marketing and not permitted,” he said. “When people wonder why we’re not getting millions more enrollees in Affordable Care Act health plans, one reason is, the carriers are discouraging it.”

The insurance industry says it is not discriminating but adjusting to market realities including higher-than-expected medical claims and the failure of a government risk-adjustment program called “risk corridors” to cover much of that cost.

“Without making necessary changes to coverage and benefits, there was no way for health plans to remain in the market or to offer the kind of coverage as they had in the past without sustaining huge losses,” said Clare Krusing, spokeswoman for America’s Health Insurance Plans, an industry lobby.

The nonpartisan Congressional Budget Office estimated as recently as last March that 21 million consumers would be enrolled by now in private health insurance plans sold through online marketplaces. Now CBO forecasts 13 million will sign up this year.

Brokers are critical to sign-ups and the success of the health law. For 2014, 44 percent of Kentucky enrollees bought through brokers. So did 39 percent of the California enrollees. No similar figures are available for the marketplace that serves most states,

With varying commissions, brokers will be tempted to promote only plans they make money on, even if those aren’t the best for some customers, said John Jaggi, an Illinois broker and consultant.

“Now they’re really forcing the agent to think only of the plan that he gets compensated for,” he said.

No matter what legislation, regulations, rules or advisories our government produces, the private insurance industry will always find ways to skirt the intent of this oversight in order to maximize their business goals, usually at a cost to patients and public and private payers. The current efforts of insurers to manipulate the brokers are a prime example of how they will continue to work the system to advance their own interests.

As the Affordable Care Act was being crafted and then implemented, there was a push to include brokers as intermediaries who would provide customer access to the exchange plans. The argument was that brokers were highly qualified to provide guidance on what the best plans would be for their clients. But little was said about how insurers might  find ways to use the brokers to to their own advantage.

As this article shows, insurers can heavily influence broker behavior through the commissions they grant. The insurers found that people who were signed up during special enrollment periods had greater health care needs and also were more likely to drop out after their needs were met. That’s easy. The insurers stopped paying commissions for most of the plans sold during these special enrollment periods. Also, people enrolling in gold plans, with their higher actuarial values (covered more of the costs), were also using more health care. Again, no problem. Many insurers quit paying commissions for gold plans but continued to pay them for lower actuarial value plans that required patients to pick up more of the costs of health care. Will the broker sell plans without a commission, when an insurer offers a commission for selling their more profitable plans?

Discrimination in the offering of private insurance plans is prohibited, but AHIP – the insurance lobby – says that insurers are not discriminating but rather are merely adjusting to market realities. Clare Krusing – AHIP’s spokesperson – said that there was no way “to offer the kind of coverage as they had in the past (gold or platinum plans) without sustaining huge losses.” It really is about profits, not patients.

And now many politicians and progressive pundits are telling us to build on Obamacare. Forget about single payer because it will “never, ever come to pass.” Instead let’s control costs through higher deductibles and other cost sharing, narrower networks, greater administrative hassles through ACOs and EHRs that keep professionals from tending to their patients, more opaque obstructions that keep sicker patients out of the private plans, more managed care that reduces access, especially to specialized services, *** **** ****, ***** ** ****, and ** ****** *****.

And those asterisks? They are the hidden future policies of the insurers that will further enhance their business models – policies that we can’t even conceive of since they can only be conjured up by the nefarious minds that are currently in control of our health care financing system. Do we really have to have a health care future that will eventually reveal to us what is behind the magic asterisks? Or shall we tell them on their way out the door where to put their asterisks, as we take over and set up our own single payer national health program?

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Disabled on Medicare may not be eligible for Medigap

Posted by on Wednesday, Feb 3, 2016

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Buying Supplemental Insurance Can Be Hard For Younger Medicare Beneficiaries

By Susan Jaffe
Kaiser Health News, February 3, 2016

Federal law requires companies to sell Medigap plans to any Medicare beneficiary aged 65 or older within six months of signing up for Part B, which covers doctor visits and other outpatient services. If they sign up during this guaranteed open enrollment, they cannot be charged higher premiums due to their medical conditions.

But Congress left it to states to determine whether Medigap plans are sold to the more than 9 million people younger than 65 years old who qualify for Medicare because of a disability.

In 20 states and the District of Columbia, home to more than 2 million disabled Medicare beneficiaries, insurers are not required to sell Medigap policies to customers under 65. In other states, insurers cannot reject applicants if they enroll when they first join Medicare. Companies in some states, including Virginia, can still charge higher premiums to younger beneficiaries or those with kidney disease, often making policies unaffordable.

In California, Massachusetts and Vermont, insurers are required to sell Medigap policies to anyone with Medicare, except to people… who are under 65 and have end stage renal disease.

The federal health law provides no relief for these younger Medicare beneficiaries. One of its most popular provisions prohibits discrimination by insurance companies in the non-Medicare market based on pre-existing conditions or age, but the law is silent on Medigap.

Prospects for a nationwide solution are dim because expanding Medigap coverage could lead to these beneficiaries with disabilities receiving more care and raising costs for the Medicare program. Congress is looking for strategies to curb Medicare spending, not increase it.

The health insurance industry’s trade association opposes expanding Medigap to include all Medicare beneficiaries younger than 65 with end stage renal kidney disease. Since treatment for those patients can be so expensive, adding them could increase Medigap premiums for everyone, said Cindy Goff, a vice president at America’s Health Insurance Plans.

Older adults are “super price-sensitive” and raising premiums “would basically price them out of being able to get the Medigap protection they want,” said Goff.

It has long been recognized that the benefits of the Medicare program are inadequate, leaving too many exposed to financial hardship and impaired access due to financial barriers. Some are protected with retiree health benefit plans or with backup by the Medicaid program, but for others, the private Medigap insurance plans were developed. This article shows that the rules for Medigap plan eligibility may still leave vulnerable those who quality for Medicare based on a disability – some of the most neediest of Medicare beneficiaries.

Medigap plans are a poor solution for the inadequacies of Medicare coverage. They are overpriced when considering the benefits received, and are usually unaffordable for those who do not quite qualify for dual Medicare/Medicaid coverage. They add significantly to the administrative complexity of administering Medicare, wasting funds that would be better spent on health care. It would be far more efficient to roll the Medigap benefits into the Medicare program. That would be an important component of the “Improved” in an “Improved Medicare for All” which could be the basis of a single payer national health program.

Congress has left to the states decisions on whether or not private insurers selling Medigap plans must do so on a guaranteed issue basis (plans must be sold to any applicant regardless of medical status), and also if the plans can be subject to medical underwriting (charging higher premiums for those with greater health needs). Just as we see with Medicaid, states under the rule of heartless politicians frequently decide to turn these disabled patients over to the marketplace – further exposing them to a life of physical suffering and financial hardship.

Generally, individuals must purchase their Medigap plans soon after enrolling in Medicare. This applies to both those over 65 and those under 65 with disabilities. The high premiums charged for these plans are one of the many reasons that individuals decide to forgo initial enrollment and then become ineligible later on when medical needs may be even greater. This is yet one more example of a policy that prevents individuals from having access to coverage when our national policies should be designed to achieve the opposite – ensuring enrollment of absolutely everyone, throughout life.

Medigap is another bad idea brought to us by the private insurance industry. It works well for insurers, but not so well for too many patients. We should dump it along with the rest of the private insurance industry and establish our own equitable, publicly-funded and publicly-administered single payer system. How can we leave so many of our disabled residents hanging like we do?

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Meaningful Use Program Officially Shelved

By News Staff
AAFP News, January 14, 2016

CMS Acting Administrator Andy Slavitt recently took center stage during the J.P. Morgan 34th Annual Healthcare Conference in San Francisco for what could have been a routine speech about upcoming health care policies aimed at an interested stakeholder audience.

However, a few minutes into his remarks, available in their entirety in a CMS blog ( posted on Jan. 12, Slavitt rocked the U.S. health care world with these words:

“We are now in the process of ending meaningful use and moving to a new regime culminating with the MACRA (Medicare Access and CHIP Reauthorization Act) implementation. The meaningful use program, as it has existed, will now be effectively over and replaced with something better.”

Judging from the immediate media interest, Slavitt’s announcement caught many people off guard.

On January 11, CMS’s acting administrator, Andy Slavitt, stated at a health care “investment symposium” sponsored by J.P. Morgan that the awful “meaningful use” program inflicted on doctors by the High Tech Act of 2009 is “over.” He was quoted in Family Medicine News saying, “The meaningful use program as it has existed will now be effectively over and replaced with something better.”

Slavitt went on to say, “We have to get the hearts and minds of physicians back. I think we have lost them.”

I give Slavitt, a former employee of UnitedHealth Group, credit for having the courage to state clearly that “meaningful use” has infuriated doctors. Better late than never.

But Slavitt has put himself in a box. He has admitted that Obama’s and Congress’s decision to force doctors to use the clumsy electronic health records (EHRs) sold by the American computer industry was bad policy, but he has no idea how to fix that problem. All he can do is talk like Donald Trump – he’ll come up with “something better.”

It sounds like Slavitt wasn’t prepared for the publicity his remark generated. The next day, January 12, he and Karen DeSalvo posted a comment on both the CMS blog and The Health Care Blog seeking to temper expectations among doctors that their days of torment will soon be over. Slavitt and DeSalvo claimed that the 2015 Medicare Access and Chip Reauthorization Act (MACRA) (the bill that repealed the Sustainable Growth Rate formula), authorized CMS to improve upon the “meaningful use” law and they intended to do that. I quote:

While MACRA also continues to require that physicians be measured on their meaningful use of certified EHR technology for purposes of determining their Medicare payments, it provides a significant opportunity to transition the Medicare EHR Incentive Program for physicians towards the reality of where we want to go next.

That sentence is a severe test of your ability to decipher gibberish. What does “the reality of where we want to go next” mean? That’s a rhetorical question. Please don’t try to answer it. To paraphrase Humpty Dumpty’s explanation to Alice, it means whatever CMS says it means.

I’m quite sure the reason Slavitt and DeSalvo selected such patently obvious weasel words is that they don’t have any idea how they’re going to “get back the hearts and minds of physicians.”

Slavitt’s problem is that he isn’t free to concoct his own solution. He has to enforce one of the craziest laws ever passed – MACRA. MACRA takes the “meaningful use” and “pay-for-checked-boxes” craze to new heights. MACRA is to “meaningful use” as Ebola is to the flu. MACRA forces doctors who treat Medicare patients to choose between two byzantine payment systems  –  the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs) system. Both systems are insanely complex (see my description of the MIPS system here). Either system alone would infuriate doctors and frustrate CMS administrators.  The two programs together will drive everyone around the bend.

If you read the Slavitt-DeSalvo essay on The Health Care Blog, be sure to read the comments by Dr. Maralit Gur-Arie. She posts frequently on that blog and others about health information technology. At the end of one of her comments she asks, “Just out of sheer curiosity, and I most certainly don’t expect answers, is there anybody up there [at CMS] who considered even for one fleeting moment that maybe, just maybe, we should gather some hard evidence to guide our next steps, if any?”

This is the MOST fundamental question one can ask of those who peddle the EHR and pay-for-performance fads. Can you provide evidence for your claim that these fads are worth their costs in money, damage to physician morale, damage to quality of care, and damage to patient privacy?

Kip Sullivan, J.D., is a member of the board of Minnesota Physicians for a National Health Program. His articles have appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.

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The lesson of BC/BS of NC on special enrollment periods

Posted by on Tuesday, Feb 2, 2016

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Obamacare Pummels Blue Cross Blue Shield Of NC–What Can We Learn From This?

By Chris Conover
Forbes, January 30, 2016

Blue Cross and Blue Shield of NC is expecting to lose more than $400 million on its first two years of Obamacare business. In response to its bleak experience with the Obamacare exchange, the company has decided to eliminate sales commissions for agents, terminate advertising of Obamacare policies, and stop accepting applications on-line through a web link that provides insurance price quotes–all moves calculated to limited Obamacare enrollment.

BCBSNC reported an operating loss of $50.6 million in 2014–the first such loss in 15 years. Why? Because its Obamacare policies lost $123 million despite $343 million in various insurer bailouts (the so-called “Three R’s“–risk adjustment, reinsurance, and risk corridors).

What makes this shocking is that BCBSNC is the state’s dominant insurer, covering 72% of the large group market. If a deep-pocketed insurer such as this cannot make a go of Obamacare, that does not bode well for many smaller carriers who do not have large profits on other lines of business with which to absorb whatever losses are generated by policies sold on the Obamacare exchanges.

The fact that one of the nation’s largest insurers, UnitedHealthcare also has raised doubts about its ability to carry plans on the healthcare law’s exchanges beyond 2016 makes clear that this problem is not unique to North Carolina.

The Problem is Getting Worse, Not Better

A large carrier such as BCBSNC can afford to absorb a temporary hit to its profits. But the evidence in NC is that Obamacare losses are growing over time rather than shrinking–a clearly unsustainable business model.

Because of its enormous losses, BCBSNC was able to convince the state’s insurance commissioner to allow a 32.5% average increase in its rates for the 2016 Obamacare policies now being sold.

Special Enrollment Period Enrollees Are a Problem

The special enrollment period is open to people whose circumstances have changed, such as getting married, having children, losing/changing jobs or similar situations. However, many such individuals evidently are staying insured only for several months, generating a lot of medical bills and then discontinuing their coverage.

People who buy their coverage during these special enrollment periods cost twice as much as Obamacare customers who secure their coverage during open enrollment.

Again, this is not unique to NC: earlier this month, in response to complaints by insurance companies, Obamacare administrators eliminated six additional conditions that allowed people to sign up for health coverage outside of the general enrollment period.  According to UPI, these steps will ”make it more difficult for persons without health coverage to financially manipulate or abuse the Affordable Care Act.”

These steps presumably will be good news for the bottom line of insurers such as BCBSNC. But they by no means eliminate various ways in which people have figured out to game the system.

University of Minnesota economist Stephen Parente has calculated that the cost of the least expensive policies on the Obamacare exchanges will more than triple in NC between 2016 and 2017!


Insurer Aetna Lays out Concerns About ACA Exchange Business

By Tom Murphy, AP
ABC News, February 1, 2016

Aetna has joined other major health insurers in sounding a warning about the Affordable Care Act’s public insurance exchanges.

The nation’s third-largest insurer said Monday that it has been struggling with customers who sign up for coverage outside the ACA’s annual enrollment window and then use a lot of care. This dumps claims on the insurer without providing enough premium revenue to counter those costs.

Both Aetna and UnitedHealth Group Inc. said the exchange customers they get outside the annual enrollment window use more health care than those who sign up within it. This includes some cases where it appears that a customer bought coverage, used it and then dropped it.

“Insurance systems tend to get stressed when people can buy coverage when they know they need it and then drop it when they know they don’t,” Chief Financial Officer Shawn Guertin told The Associated Press.

The Centers for Medicare and Medicaid Services recently outlined several changes it said it was making to help shore up exchange enrollment windows.

Blue Cross-Blue Shield insurer Anthem Inc. also is paying close attention to how the government deals with special enrollment periods as it judges how sustainable the exchange business will be in the future, CEO Joseph Swedish said recently.

UnitedHealth Group has said it will decide this year whether to participate in the public exchanges in 2017. CEO Kevin Counihan said in a Jan. 19 blog post that special enrollment periods will not be available for “the vast majority of consumers.” HealthCare.Gov operates public insurance exchanges in 38 states.

“For example, special enrollment periods are not allowed for people who choose to remain uninsured and then decide they need health insurance when they get sick,” he wrote.


Sustaining the marketplace for a healthier America

By former Sen. Tom Daschle (D-S.D.)
The Hill, January 29, 2016

To ensure the affordability of healthcare services, we must help individuals not only access health insurance coverage, but also stay covered.
Instead, our current regulatory framework seems to be having the opposite effect.

For example, there are over 30 “special enrollment periods” – more than that of any other federal government program, including Medicare Advantage.  Rightfully so, these periods are intended to help individuals seek coverage outside of the normal enrollment period due to certain qualifying life events, such as relocating or losing prior coverage.  However, there is little oversight in place to ensure that special enrollment period requirements are satisfied. The unintended consequence is that special enrollment periods enable individuals to only seek coverage when they need care the most – a more costly proposition for the patient and the health care system.

Fortunately, the Centers for Medicare & Medicaid Services (CMS) is already taking an important first step to help address these concerns.  CMS is eliminating six special enrollment periods that are either no longer needed or subject to abuse.

The marketplace will also require greater opportunity for innovation.

The Affordable Care Act has demonstrated great potential for establishing a high quality, affordable health care market.  Now is the time to leverage that progress and ensure its sustainability by removing barriers that discourage market participation and incentives that make it easier to not seek care.

The losses experienced by Blue Cross and Blue Shield of North Carolina represent a problem prevalent throughout the nation wherein patients, when they become ill, enter the system during special enrollment periods and then exit once their health care needs are met. The insurers along with CMS have diagnosed the problem. There is nothing wrong with our system of private insurers. It is the patients who are to blame because they are gaming the system.

The solution? Reduce special enrollment periods that were designed to assist patients who fell through the cracks. Instead, protect the insurers by preventing these people from getting coverage for the care that they need. Bankrupt them. That’ll show them.

Reducing special enrollment periods is being touted as one of the improvements that we need in the Affordable Care Act – the type of incrementalism that we should pursue as we reject overtures to establish a single payer national health program. We should pay no regard to the fact that this incremental tweak is designed to assist the private insurers and enhance their profits, at a cost of impairing access and affordability for far too many patients.

Wasn’t the Affordable Care Act designed to provide everyone with affordable access to health care? No. Single payer has such a design, but that was rejected to the benefit of the private insurers.

So now we are supposed to tweak the system to make it work better for patients? No. We are tweaking it to make it work better for private insurers. Damn those patients who try to cheat the insurers by gaming the system.

Oh wait. Under single payer the goal is to deliberately include absolutely everyone. The idea that someone is cheating by trying to sneak into the system is totally foreign to the stewards of egalitarian universal systems. How could anyone even think about devising methods of keeping people out? Perhaps it’s American Exceptionalism at work.

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Paul Song on the real debate we should be having

Posted by on Monday, Feb 1, 2016

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The Real Healthcare Debate Democrats Should Be Having

By Paul Y. Song, M.D.
HuffPost Politics, January 31, 2016

Recently, a fierce debate has been ignited within the Democratic Party regarding the merits and feasibility of a single-payer Medicare-for-All universal healthcare system. Some liberal commentators have summarily dismissed Senator Sanders’ proposal as politically unrealistic or as greatly lacking in details while championing a slightly improved status quo, and other political surrogates have spread GOP-like untruths that have no place in any honest discussion.

Regardless of ones’ individual beliefs on Medicare-for-All, it is crucial to note some indisputable facts regarding the Affordable Care Act (ACA) and the current status quo:

1.  While the ACA did indeed do some very positive things like end lifetime caps on medical coverage and do away with discrimination for pre-existing conditions, it was never intended to cover every uninsured individual. In fact, after the ACA is fully implemented, the Congressional Budget Office estimates that up to 29 million residents will still remain uninsured.

2.  The only area of the ACA that both Democrats and Republicans found mutual agreement on was to exclude our undocumented brothers and sisters.

3.  The average insured family still pays an extra $1,017 in premiums (hidden tax) to cover the cost of care for the uninsured.

4.  A recent Commonwealth Fund study revealed that 31 million people with insurance had such high out-of-pocket costs or deductibles relative to their incomes that they were UNDER-insured and that 51% of these adults reported problems with their medical bills, while 44% of all adults reported not getting care because of high co-pays and deductibles despite being insured.

5.  Even after a significant decrease in the total number of uninsured, there were still 1.7 million medical related bankruptcies in 2014 of which 75% were actually insured, and this is only expected to get worse.

6.  Most individuals in the U.S. cannot afford an annual deductible of $6,850 and most families of four cannot afford an annual deductible of $13,700.

7.  Despite premiums increasing over 150% over the past 9 years, there is no federal insurance rate regulation.

8.  Despite the fact that average branded drug prices have increased 127% during the past 8 years to the point that 73% of Americans now find the cost of drugs unreasonable, there was no mechanism to control drug prices.

9.  Many states have huge underfunded retiree healthcare liabilities. California’s alone is $150 Billion.

10.  Healthcare costs are currently 17.5% of GDP with over 1% of GDP spent on Prescription drugs alone, and will only continue to climb as mandatory federal health spending is projected to double in the next 10 Years.

11.  Recent data from the American Journal of Public Health found that tax-funded expenditures accounted for 64.3% of all U.S. health spending. U.S. health spending for 2013 was $9,267 per capita, with government’s share being $5,960.

12.  Prior to the bailout, GM spent more on healthcare for its employees than it did on steel. Rising healthcare costs are making U.S. companies less competitive and taking money away from wages and capital investments.

13.  Most Americans continue to get employer-sponsored healthcare but worker’s contributions to premiums have increased 212% since 2000 while wages have only increased 54% during the same period.

14.  Healthcare benefits have become the biggest source of labor negotiation strife.

So if anything, most health policy experts believe that our current healthcare system is unsustainable for individuals, businesses, states and our federal government, and to continue this status quo is what is really unrealistic.

The real debate Democrats should be having should not be about whether single payer, a highly successful proven system in so many industrialized nations, is the solution, but rather how we can collectively come together to overcome the corporate forces that derailed the ACA from providing a public option, drug price controls and insurance rate regulation, and how we get to the ultimate goal of Medicare for All.

Back in 2003, then Illinois State Senator Barack Obama said in a speech to the AFL-CIO, “I happen to be a proponent of a single payer universal healthcare plan…but first we need to take back the White House, then the Senate, then the house”.

Sadly, when Barack Obama became President and had a supermajority in the Senate and House, single payer was never even introduced as an option. In fact, well before the ACA was even written, the pharmaceutical industry under the guidance of former congressman and Medicare Part D architect, Billy Tauzin, negotiated a sweetheart deal that would provide industry support for the administration’s health reform agenda in exchange for no significant reform of the pharmaceutical industry.

At the same time there were over 3,300 registered healthcare lobbyists for the 535 members of congress who spent more in total than what was spent on the entire Bush-Kerry election to influence the legislation. Many of these lobbyists were former congressional staffers including two former chiefs of staff to then Finance Committee Chairman Senator Max Baucus. Many legislators from both sides of the aisle received lots of money, but it was Baucus who received over $1.4 million and held up the legislation in his committee for so long that Senator Ted Kennedy was not alive to vote for it.

In the end, despite some positive aspects, the ACA looks like it was essentially written by the pharmaceutical and insurance industry. It is not socialism, but rather a $475 billion corporate welfare program that mandated uninsured Americans buy a product from a for-profit industry that only makes money by denying care, and this is why we still have so many of the problems stated above.

Paul Krugman is correct when he says that Senator Sanders’ Medicare-or-All plan is not politically feasible today. As long as we have Democrats who are consistently beholden to the Insurance and Pharma cartels, we will definitely continue the status quo. As long as we do not fight to reverse the awful cloud of Citizens’ United and the grossly disproportionate influence of money in politics, we cannot achieve any meaningful progress in healthcare or any other critical challenge facing our country and world.

Far beyond any Medicare-For-All proposal, what the Senator is really calling for is a transformational movement, much larger than any one individual, which can come together to fight against the Super PACs and suffocating corporate influences. His campaign is the personification of this fight.

58 percent of Americans currently favor Medicare-for-All once they learn more about it, and 81% of Democrats already believe it is the best solution. So, rather than demonize it with lies and scare tactics, we should be educating more and more people who are disillusioned with their current healthcare so that more and more of us can demand something better from our representatives.

Sadly, the biggest major insurers also recognize the benefits and efficiencies of a single payer system and have begun to rapidly consolidate through huge mergers, which further eliminates what little competition consumers have. So the question is not whether we will have single payer, but whether it will be administered by one ruthless for-profit entity that will keep all realized savings for its shareholders while continuing to gauge, deny, and shortchange its patients. Or whether it will be a Medicare-for-all, which will use the cost savings of administrative efficiency and bulk purchasing power to increase coverage and benefits for everyone, to provide the humane and comprehensive health care system we as a society truly deserve and already pay for.

Above all, we need to remember that we ARE the party that rejected the status quo and created a very bold disruptive new program called Medicare at a time when 44% of seniors were uninsured and 1/3 were living in poverty. We are the party for the least among us and for those without a voice. We are the party of “Yes, we can”.

Paul Y. Song, is a board certified radiation oncologist and the Executive Chair of the Courage Campaign, Co-Chair for a Campaign for a Healthy California, and Board Member of Physicians for a National Health Program.

Currently the two leading candidates for the Democratic nomination for president are debating whether or not a single-payer Medicare-for-All universal healthcare system is politically feasible. Paul Song provides us with evidence that our current system is inadequate and unsustainable, so the real debate we should be having is whether we should leave our health care system under the control the industries and policies that are responsible for much of what is wrong, or if we should initiate a transformational movement that will include Medicare-for-All so that we can have “the humane and comprehensive health care system we as a society truly deserve and already pay for.”

This debate is not just for members of the Democratic Party. It is a debate that the entire nation should be having. It is important that the debate be informed with facts such as those presented here by Paul Song.

Physicians for a National Health Program (PNHP) is a nonprofit, nonpartisan, educational and policy research organization that neither supports nor opposes any candidate for public office nor any political party. Although Paul Song is a board member of PNHP, any partisan views expressed in this article are his own and not those of PNHP.

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Himmelstein and Woolhandler set the facts straight on Thorpe’s analysis

Posted by on Friday, Jan 29, 2016

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

On Kenneth Thorpe’s Analysis of Senator Sanders’ Single-Payer Reform Plan

By David Himmelstein and Steffie Woolhandler
Huffpost Politics, January 29, 2016

Professor Kenneth Thorpe recently issued an analysis of Senator Bernie Sanders’ single-payer national health insurance proposal. Thorpe, an Emory University professor who served in the Clinton administration, claims the single-payer plan would break the bank.

Thorpe’s analysis rests on several incorrect, and occasionally outlandish, assumptions. Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform (see this study, for example, or this one).

We outline below the incorrect assumptions behind Thorpe’s current analysis:

1. He incorrectly assumes administrative savings of only 4.7 percent of expenditures, based on projections of administrative savings under Vermont’s proposed reform.

However, the Vermont reform did not contemplate a fully single-payer system. It would have allowed large employers to continue offering private coverage, and the continuation of the FEHBP and Medicare programs. Hence, hospitals, physicians’ offices, and nursing homes would still have had to contend with multiple payers, forcing them to maintain the complex cost-tracking and billing apparatus that drives up providers’ administrative costs. Vermont’s plan proposed continuing to pay hospitals and other institutional providers on a per-patient basis, rather than through global budgets, perpetuating the expensive hospital billing apparatus that siphons funds from care.

The correct way to estimate administrative savings is to use actual data from real world experience with single-payer systems such as that in Canada or Scotland, rather than using projections of costs in Vermont’s non-single-payer plan. In our study published in the New England Journal of Medicine we found that the administrative costs of insurers and providers accounted for 16.7 percent of total health care expenditures in Canada, versus. 31.0 percent in the U.S. – a difference of 14.3 percent. In subsequent studies, we have found that U.S. hospital administrative costs have continued to rise, while Canada’s have not. Moreover, hospital administrative costs in Scotland’s single-payer system were virtually identical those in Canada.

In sum, Thorpe’s assumptions understate the administrative savings of single-payer by 9.6 percent of total health spending. Hence he overestimates the program’s cost by 9.6 percent of health spending — $327 billion in 2016, and $3.742 trillion between 2016 and 2024. Notably, Thorpe’s earlier analyses projected much larger administrative savings from single-payer reform — closely in line with our estimates.

2. Thorpe assumes huge increases in the utilization of care, increases far beyond those that were seen when national health insurance was implemented in Canada, and much larger than is possible given the supply of doctors and hospital beds.

When Canada implemented universal coverage and abolished copayments and deductibles there was no change in the total number of doctor visits; doctors worked the same number of hours after the reform as before, and saw the same number of patients. However, they saw their healthy and wealthier patients slightly less often, and sicker and poorer patients somewhat more frequently. Moreover, the limited supply of hospital beds precluded the kind of big surge in hospitalizations that Thorpe predicts. In health policy parlance, “capacity constraints” precluded a big increase in system-wide utilization.

Thorpe bases his estimates on what has happened when a small percentage of people in a community have had copayments eliminated or added. But in those cases there are no capacity constraints, so it tells us little about what would happen under a system-wide reform like single-payer.

Thorpe does not give actual figures for how many additional doctor visits and hospital stays he predicts. However, his estimates that persons with private insurance would increase their utilization of care by 10 percent and that those with Medicare-only coverage would increase utilization by 10 to 25 percent suggest that he projects about 100 million additional doctor visits and several million more hospitalizations each year – something that’s impossible given real-world capacity constraints. There just aren’t enough doctors and hospital beds to deliver that much care.

Instead of a huge surge in utilization, more realistic projections would assume that doctors and hospitals would reduce the amount of unnecessary care they’re now delivering in order to deliver needed care to those who are currently not getting what they need. That’s what happened in Canada.

3. Thorpe assumes that the program would be a huge bonanza for state governments, projecting that the federal government would relieve them of 10 percent of their current spending for Medicaid and CHIP — equivalent to about $20 billion annually.

No one has suggested that a single-payer reform would or should do this.

4. Thorpe’s analysis also ignores the large savings that would accrue to state and local governments — and hence taxpayers — because they would be relieved of the costs of private coverage for public employees.

State and local government spent $177 billion last year on employee health benefits – about $120 billion more than state and local government would pay under the 6.2 percent payroll tax that Senator Sanders has proposed. The federal government could simply allow state and local governments to keep this windfall, but it seems far more likely that it would reduce other funding streams to compensate.

5. Thorpe’s analysis also apparently ignores the huge tax subsidies that currently support private insurance, which are listed as “Tax Expenditures” in the federal government’s official budget documents.

These subsidies totaled $326.2 billion last year, and are expected to increase to $538.9 billion in 2024. Shifting these current tax expenditures from subsidizing private coverage to funding for a single-payer program would greatly lessen the amount of new revenues that would be required. Thorpe’s analysis makes no mention of these current subsidies.

6. Thorpe assumes zero cost savings under single-payer on prescription drugs and devices.

Nations with single-payer systems have in every case used their clout as a huge purchaser to lower drug prices by about 50 percent. In fact, the U.S. Defense Department and VA system have also been able to realize such savings.

In summary, professor Thorpe grossly underestimates the administrative savings under single-payer; posits increases in the number of doctor visits and hospitalizations that exceed the capacity of doctors and hospitals to provide this added care; assumes that the federal government would provide state and local governments with huge windfalls rather than requiring full maintenance of effort; makes no mention of the vast current tax subsidies for private coverage whose elimination would provide hundreds of billions annually to fund a single-payer program; and ignores savings on drugs and medical equipment that every other single-payer program has reaped.

In the past, Thorpe estimated that single-payer reform would lower health spending while covering all of the uninsured and upgrading coverage for the tens of millions who are currently underinsured. The facts on which those conclusions were based have not changed.

Drs. David Himmelstein and Steffie Woolhandler are professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School. The opinions expressed here do not necessarily reflect the views of those institutions.

In the political battle over Bernie Sanders’ proposal for a single payer national health program, it is unfortunate that the perspective of just how much single payer would benefit Americans is being lost in all of the clamor.

This is not an issue with two opposing sets of facts. There is only one truth and that is that a well designed single payer system would bring comprehensive health care to everyone, while removing financial barriers to care and making our national health expenditures sustainable well into the future.

It is not at all clear why so many progressives have decided to attack Sanders’ single payer proposal. Most of them do understand the clear advantages in improving access while controlling costs, but they seem fixated on opposing it based on the alleged lack of political feasibility. It is fine to condemn the politics, but that should give us even more reason to advance a clearly superior model of health care financing reform.

The latest attack that is being circulated widely is that by Kenneth Thorpe, a highly respected Emory University professor. David Himmelstein and Steffie Woolhandler lay the record straight. It is crucial that we not be caught up in the numbers being bandied about – the trees – when we need to see the forest – the fundamental principles of the single payer model.

Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

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Some employers exclude outpatient surgeries from their health plans

Posted by on Thursday, Jan 28, 2016

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Check The Fine Print: Some Work-Based Health Plans Exclude Outpatient Surgeries

By Jay Hancock
Kaiser Health News, January 25, 2016

Last year regulators blocked companies with millions of lower-wage workers from claiming that coverage with no inpatient hospital benefits met Obamacare’s strictest standard for large employers.

Now that those so-called “skinny plans” aren’t allowed, insurance administrators and many cost-conscious employers are purporting to meet the rules with a new version that excludes another major category: outpatient surgery. The new plans may not survive regulatory scrutiny any more than the old ones did, some experts believe.

For 2016, such insurance has been marketed primarily to staffing companies, home health agencies, hoteliers and other lower-wage employers that had historically never provided major medical coverage. Those are the same firms that were sponsoring skinny coverage a year ago, industry consultants say.

“I really wonder whether they can do that,” said Timothy Jost, a law professor at Washington and Lee University in Virginia who is an authority on the health law. “Refusing to cover any outpatient physician surgical services is arguably a violation.”

Unlike insurance sold to individuals and small businesses through online marketplaces, large employers are not required to offer a list of “essential health benefits.” Instead, they must offer minimum value — roughly comparable to that of a high-deductible, “bronze” marketplace plan — as determined by an online calculator and regulatory guidance, or face a penalty. There is also a lesser standard for large employers — “minimum essential coverage” — that triggers different fines for noncompliance. But nearly all workplace-based plans that offer some types of preventive care meet this requirement.…

One of the arguments made for choosing the incremental policies of the Affordable Care Act  (ACA) over a comprehensive single payer model of reform was that the politicians wanted to avoid disrupting the part of health care financing that was working well – particularly the employer-sponsored health plans. So are employees being assured of adequate health care coverage?

The onslaught of higher deductibles and narrower networks indicates that maybe these plans are not working so well after all. But you cannot underestimate the conniving behavior of some of the private sector employers in shirking their responsibilities for providing adequate coverage, as supposedly was intended by the architects of ACA.

Since the employers are allowed considerable flexibility in plan design, some thought that they could exclude inpatient hospital benefits. That, of course, would be disastrous for anyone requiring hospitalization. Fortunately that loophole was closed.

Now they claim that they can exclude outpatient surgery. Considering that now about two-thirds of surgeries are done on an outpatient basis, that too will lead to financial disaster for far too many patients. It is likely that our federal stewards will also disallow the exclusion of outpatient surgery. But then what scheme will they think up next?

Leaving the private sector in control inevitably leads to devious behavior designed to save money for the employers or insurers at a cost to the patients. That is the way the private sector and their markets work. In contrast, responsible public stewards act in the interests of patients, and part of that means ensuring an adequate health delivery infrastructure to take care of the patients.

We really do need to dismiss private managers of health care funds and replace them with our own public administrators. That’s precisely what a single payer national health program would do.

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