The following text contains the written testimony of Dr. Anne Scheetz that she presented to the Illinois House Special Committee on Medicaid Reform on Jan. 3, 2011, in Springfield, Ill.

Thank you for allowing me to address your committee on behalf of the Illinois chapter of Physicians for a National Health Program and the Illinois Single-Payer Coalition.

As I have listened to the proceedings of the University of Illinois Institute of Government and Public Affairs State Summit 2010, “Reforming Medicaid in Illinois: Managing Service Delivery and Controlling Costs,” and to those House and Senate special committee hearings that I have been able to attend, I have heard several recurring themes, among them, restoring public trust in government by eliminating fraud and abuse in the Medicaid system; controlling costs; and obtaining good value for taxpayer money.

Committee members have been assured that by privatizing Medicaid, that is, by turning over taxpayer money to private insurance companies, and forcing Medicaid recipients into HMOs, they can control Medicaid costs while improving recipients’ quality of care.

The Illinois chapter of Physicians for a National Health Program and the Illinois Single-Payer Coalition oppose forcing patients into HMOs. We work for a health care system in which every person has access to all necessary care without financial barriers and with complete choice of hospitals, physicians, and other providers. We note that the only health care system capable of controlling costs is, paradoxically, one in which everyone has access to care, because only a universal system is able to reduce the bureaucracy that consumes at least 30 percent of our health care dollars.

In regard to proposals for forcing people into Medicaid HMOs, we note that evidence from the Medicare program contradicts the assurances about cost and value that the committees have received.

Medicare was enacted in 1965 as a public program under which nearly all persons in the United States over age 65 were entitled to receive certain health care services on a fee-for-service basis. Beginning in 1972 there have been multiple forays into partial privatization. Currently, Medicare recipients are allowed to choose between the public program and private HMOs called Medicare Advantage Plans (MAPs). Insurance companies offering qualified MAPs receive capitated payments and assume full risk for covered services for their enrollees.

I will review briefly the results of partial privatization in terms of value, cost control, fraud and abuse, and public trust.

A report released by the U.S. House of Representatives Committee on Energy and Commerce on December 9, 2009, found the following: Traditional Medicare spends 1.5 percent of revenues on medical care and over 98 percent on health care. By contrast, the average MAP insurer spent 15 percent of premium revenue on profits, marketing, and other corporate expenses, and some insurers spent less than 75 percent on medical care in at least some years. MAPs spent nearly 10 times as much as traditional Medicare on administrative expenses per beneficiary. MAPs that spent less than 85 percent of revenues on medical care paid their executives over $1.2 billion, and one company that spent 83 percent of revenues on medical care spent $3.1 million for two executive retreats in Hawaii. In summary, the House report found that MAPs shift taxpayer money away from medical care into administrative overhead and wasteful executive benefits.

Dr. John Geyman in his 2006 book “Shredding the Social Contract: The Privatization of Medicare” provides further analysis of the effects of MAPs on beneficiaries’ health and on Medicare spending (pp. 103-106). MAPs received on average 13 percent more than the cost of traditional Medicare per patient. Medicare beneficiaries enrolled in MAPs were hospitalized at the rate of 66 percent of those in traditional Medicare during their MAP period of enrollment; but those who disenrolled from MAPs were hospitalized, during the first year after disenrollment, at 180 percent of the rate of traditional Medicare patients. Fifty-four percent of chronically ill Medicare patients in HMOs had declines in physical health during a four-year period compared to 28 percent in traditional fee-for-service Medicare. These are only some of the damning pieces of evidence listed in Dr. Geyman’s book; all were derived from articles published in Health Affairs and in top peer-reviewed medical journals. Furthermore, Medicare private plans engaged in both legal and illegal practices in order to enroll healthier beneficiaries and avoid sicker ones, despite their high level of payment (Geyman, pp. 69-70). Finally, between 1999 and 2002, about one-third of MAP enrollees lost their plans when insurance companies pulled out of certain markets due to low profitability or inability to enroll sufficient providers in their networks (p. 76).

A 2010 study by The Medicare Rights Center ( provides a beneficiary perspective on disenrollment from MAPs. Voluntary disenrollment occurred because of provider access problems for such services as cancer specialists, home health, and rehabilitation; misinformation and marketing abuse, including enrolling customers without their consent; coverage problems; cost sharing that was higher than expected; and data systems problems. Although the practice is illegal, some patients were disenrolled involuntarily when they received a diagnosis of cancer, through plans claiming that premiums had not been paid and refusing to rescind disenrollment even when proof of payment was presented.

To summarize, partial privatization of Medicare has resulted in the opposite of cost control, increased value, and elimination of fraud and abuse. Instead, privatized Medicare as compared with traditional public Medicare has resulted in the following: increased per beneficiary cost to Medicare; increased beneficiary out of pocket costs; higher overhead; disruption of continuity of care; decreased choice of providers; denial of services; and poorer health outcomes. Furthermore, insurance companies break the law and waste taxpayer money.

Privatized Medicaid, as I have heard it presented during these hearings, will be different in some respects from privatized Medicare. For instance, recipients who cannot access the providers and other services they need, such as cancer care and rehabilitation, will not be able to switch to a public program. We do not know what will happen to these patients, but we can anticipate that their needs will not be met. On the other hand, we can anticipate that insurance companies will demand that the state pay them enough to ensure their profitability, regardless of the loss to patients and to taxpayers; if they do not get the profits they want they will withdraw, in itself an expensive process for the Medicaid program and for patients and providers. We can expect multiple disruptions of continuity of care. We can expect the insurance companies to engage in illegal practices. We can expect poorer health outcomes among Medicaid recipients.

At the same time that Physicians for a National Health Program and the Illinois Single-Payer Coalition foresee these problems for Medicaid recipients, we acknowledge that every person in the contemporary U.S. health care system faces the risk of denial of services, disruptions of care, and financial devastation in the event of serious illness. Thus, we work for true reform of the entire U.S. health care system in the form of Expanded and Improved Medicare for All. We urge all of you to support H.B. 311, the Illinois single-payer bill, when it is reintroduced during the next legislative session.

Thank you.

Financial disclosures: none. I receive no reimbursement, including for expenses, for my work for PNHP and ISPC.

Anne Scheetz, M.D., F.A.C.P., is board certified in internal medicine with added qualifications in geriatric medicine. She resides in Chicago.

Moody’s reports negative outlook for private insurers

Posted by on Wednesday, Jan 5, 2011

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.

Outlook negative for insurers: Moody’s

By Melanie Evans
January 4, 2011

Health insurers’ outlook continues to be negative as the sector faces new regulations, heightened political pressure and a weak economy, which are expected to squeeze earnings, one major ratings agency said.

Moody’s Investors Service said in a report that insurance provisions of the Patient Protection and Affordable Care Act that go into effect this year could limit insurers’ income. Analysts described 2011 “as a transition year” for insurers as companies grapple with new medical-loss ratio regulations, which require 85% of large group premiums and 80% of small group and individual premiums to be spent on patient care.

Flat Medicare Advantage reimbursement levels for 2011, to be followed by cuts next year, could squeeze insurers’ margins, the report said. Insurers have moved to diversify to increase revenue and income not affected by changes under the reform law, analysts said. The sector also faces greater oversight and political pressure regarding insurers’ premium increases.

Insurers also face threats to enrollment from the economy, according to the report. The weak job market and possible further layoffs in the public sector this year could leave more households without employment, the source of health insurance for many, the report said. Struggling employers and households may not be willing or able to pay for care even as providers seek pay increases to increase revenue.


US Healthcare Insurers: Outlook Remains Negative

Moody’s Investor Service
December 29, 2010

…Despite better than expected results in 2010, Moody’s has maintained its negative outlook for the U.S. healthcare insurance sector due to regulatory, political, and economic threats that combine to place downward pressure on future earnings. Our expectations for 2011 for the sector as a whole include lower earnings, flat-to-low membership growth, and strategies increasingly focused on diversification. The negative sector outlook represents our view of credit conditions facing health insurers over the next 12 to 18 months; it provides a framework against which to consider issuer-specific ratings and research. 1. Regulatory Issues ¡ The healthcare reform law passed in early 2010, has already imposed a number of challenges for health insurers. During 2010, most changes required insurers to provide additional benefits while allowing them to adjust premiums appropriately. However, in 2011, two key provisions of the law — minimum medical loss ratio (MLR) regulations and changes to Medicare Advantage…

The remainder of this 9 page report can be purchased for $550.00 at this link:—PBC_129845

We hear much about the private health insurance industry from Health and Human Services (HHS) and from America’s Health Insurance Plans (AHIP) and the private insurers themselves. This report is of interest because it provides a perspective on for-profit health insurers from a consulting firm for investors.

Although the regulatory changes that the insurance industry faces as a result of the Patient Protection and Affordable Care Act bring bad news to investors, in a sense this is good news for patients because some of the greed has been squeezed out of the system. Moody’s seems to be an expert on greed since they charge $550.00 for a 9 page report that apparently only tells us what we already knew. (I must confess that I made an exception in not reading the full report that was used as the source of today’s quote since I couldn’t bring myself to pay that fee.)

We could have had better news. The savings that is good news for patients is only minuscule when you consider the much larger amount that we could have saved by changing to a single payer national health program – an improved Medicare for all.

California and New York lessons for Medicaid expansion under PPACA

Posted by on Tuesday, Jan 4, 2011

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.

Cuomo Targeting Medicaid Spending

By Jacob Gershman
The Wall Street Journal
January 4, 2011

Gov. Andrew Cuomo is aiming to reduce the state’s Medicaid spending by billions of dollars, exceeding the size of cuts to the program proposed in past years, according to individuals with knowledge of his budget.

The Cuomo administration is considering a cut of about $2.1 billion out of the state’s projected spending on Medicaid in the upcoming fiscal year. With federal matching funds, the cut comes to more than $4 billion.


Brown to propose broad list of budget cuts

By Kevin Yamamura
The Sacramento Bee
January 3, 2011

(Gov. Jerry Brown) will propose Medi-Cal (Medicaid) savings by requiring patients to provide co-payments for services, limiting doctor visits and reducing rates paid to health providers. In Healthy Families (CHIP), which provides subsidized care for low-income children, he wants participants to pay more in premiums and co-payments while eliminating vision care.

“These would be shocking cuts if we hadn’t seen them before, but we have seen them before,” said Anthony Wright, executive director of Health Access California. “This is what’s left to cut outside of the wholesale dismantling of core programs. These are bad cuts that will impact millions of Californians.”

A substantial increase in eligibility qualification for the Medicaid program is a crucial measure in the Patient Protection and Affordable Care Act (PPACA), designed to decrease the numbers of Americans without insurance coverage. Now the newly-elected Democratic governors of the two most populous states in the nation intend to sharply reduce funding of their Medicaid programs. What does this say about the wisdom of the PPACA policy of using Medicaid to expand coverage?

Gov. Brown’s proposal to impose financial penalties for accessing care, placing caps on doctor visits, and further slashing payments in this already critically underfunded program can only be disastrous for the low-income patients enrolled.

Once again, this is not change we can believe in. We desperately need an improved Medicare that covers everyone.

Drug firms providing kickbacks for co-pays and coinsurance

Posted by on Monday, Jan 3, 2011

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.

Coupons for Patients, but Higher Bills for Insurers

By Andrew Pollack
The New York Times
January 1, 2011

With drug prices rising and many people out of work, pharmaceutical companies are increasingly helping patients with their co-payments.

Drug companies say the plans help some patients afford medicines that they otherwise could not.

But health insurers and some consumer groups say that in many cases, the coupons are just marketing gimmicks that are leading to an overall increase in health care costs. That is because they circumvent the system of higher co-pays on costlier drugs that insurers use to encourage consumers to use less expensive products.

Any shift to brand-name drugs can have a big impact on health care costs.

At District Council 37, a union representing public employees in New York City, 59 percent of claims for statins in the year ended in June 2009 were for brand-name products that cost the plan $17.3 million. The other 41 percent of claims were for generic statins, which cost only $179,000. A year ago, the health plan eliminated the co-pay on generic statins to encourage more use of them.

For very expensive drugs, co-pay assistance is almost de rigueur, because in some cases co-payments can be up to 20 percent of the price of the drug. Novartis’s new pill for multiple sclerosis, Gilenya, costs $48,000 a year, compared with $30,000 to $40,000 for rival drugs, which are injected. Novartis is offering to cover the entire co-pay, up to $800 a month, which is 20 percent of the drug’s monthly cost.

Jazz Pharmaceuticals has quadrupled the price of its narcolepsy drug Xyrem, to about $30,000 a year, over the last five years, according to a recent report from the securities firm Jefferies & Company. To cushion patients, the company recently increased its co-pay assistance to as much as $1,200 a month.

Drug companies cannot offer co-payment assistance for patients in federal programs like Medicare because such offers are considered an inducement to use a drug and in violation of anti-kickback laws. Some companies have responded by contributing to, or even helping to set up, charitable foundations that can provide co-payment assistance legally.

Executives at insurers and pharmacy benefit management companies say they would like to counter the cards and coupons but are not sure exactly how to do so. One problem is that the information they receive from pharmacies does not specify whether the co-pay was made by the patient or by the drug company.

“The payer doesn’t know, and the P.B.M. doesn’t know,” said F. Everett Neville, chief trade relations officer at Express Scripts, a pharmacy benefits manager. “We have no ability to stop it and no ability to prohibit it.”

Should a health care system be designed to ensure that patients receive appropriate medications that they should have to relieve symptoms or cure disease? Of course. Yet co-payments (a dollar amount) and coinsurance (a percentage of the cost) impose on the patient financial barriers to the medications – barriers which frequently are not surmounted, and thereby may result in impaired health outcomes.

With our fragmented system of financing health care those seeking greater profits will always find another way to achieve their goals. In this instance, the pharmaceutical manufacturers have found a way to reduce or eliminate these financial barriers to their products.

In providing cost-sharing assistance to the patient, the manufacturers are not specifically removing barriers to the most appropriate products, but rather are removing barriers to their most profitable products, irrespective of whether or not they are the best choice. Since these are more expensive products, that increases the drug costs of the private insurers. Those of us paying premiums to private insurers that cover drugs are paying for these excess costs.

These practices do not require collusion with the physicians and pharmacists since their marketing practices are effective in creating a demand for their products regardless of the appropriateness.

Note that these pharmaceutical industry subsidies of co-payments and coinsurance are illegal in federal programs such as Medicare because they are the equivalent of kickbacks. If we had a Medicare program that covered everyone and eliminated the private intermediaries such as the insurers and pharmacy benefit managers, then these kickbacks wouldn’t exist. Drugs would be prescribed based strictly on appropriateness, and would be priced to provide fair profits for the pharmaceutical firms and fair costs for Medicare.

Republican rules threaten health care

Posted by on Thursday, Dec 30, 2010

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.

Deficit Hypocrisy

The New York Times
December 29, 2010

On Dec. 22, just before they left town for the holidays, House Republican leaders released new budget rules that they intend to adopt when they assume the majority in January and will set the stage for even more budget-busting tax cuts.

The new Republican rules will gut pay-as-you-go because they require offsets only for entitlement increases, not for tax cuts.

It gets worse. The new rules mandate that entitlement-spending increases be offset by spending cuts only — and actually bar the House from raising taxes to pay for such spending.

Even worse, they direct the leader of the House Budget Committee to ignore several costs when computing the budget impact of future actions.

For example, the cost to make the Bush-era tax cuts permanent would be ignored, as would the fiscal effects of repealing the health reform law. At the same time, the new rules bar the renewal of aid for low-income working families — extended temporarily in the recent tax-cut deal — unless it is fully paid for.

Rules draft (33 pages):

Although long, the new Republican rules for the House of Representatives read somewhat like those jokes that are circulated around the Internet. When the fact sinks in that this is no joke but that these rules are very real, the inhumanity implicit in these new rules induces a feeling of despair.

Think of what these rules do for public funding of health care under the Patient Protection and Affordable Care Act. Because health insurance is too expensive and out-of-pocket costs are also unaffordable, government subsidies are necessary, but those called for in the act are inadequate. Many people who will need health care will face financial hardship unless the subsidies are increased.

Under the Republican rules, increases in these subsidies cannot be paid for by increasing taxes. Only reductions in other programs can be used. This is not unlike the prohibited act of cannibalizing one military vehicle to get another one up and running, when both vehicles are essential. Just as we have a responsibility to pay our taxes, our government has a responsibility to ensure that appropriate publicly-financed services will be there when needed, whether it’s maintaining our military vehicles, supporting transportation services in major snowstorms, or ensuring that everyone always has access to affordable health care.

Although the Republicans display a decidedly uncaring attitude toward the financing of important public services shared by most of us, they have an almost sacred devotion to protecting higher-income individuals from the need to pay their equitable share of the taxes to fund those services.

Any increases in spending for the public good must be offset by reductions in other services that would then no longer be available for the public good. Yet, under the new Republican rules, any tax reductions which would accrue primarily to the benefit of the wealthy do not have to be offset at all. Instead, those deficits are added to our debt burden and the debt burden passed on to our progeny.

Is the tax burden in the United States so great that we must sacrifice our public services while burdening ourselves with more debt simply to provide tax relief for the wealthy? The following chart provides that answer. The United States has one of the lowest tax burdens of all nations. The Republicans are catering to the rich at a great cost to the rest of us. What is really tragic is that it seems that, rather than electing representatives who care, the American voters would rather attend tea parties.

If the following OECD chart was not transmitted in this message, it can be accessed by scanning down to Chart A at this link:,3343,en_2649_37427_46661795_1_1_1_3742…

Total tax ratio as percentage of GDP, 2008

Private insurers depending on Medicaid for growth

Posted by on Wednesday, Dec 29, 2010

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.

Insurers Bid for State Medicaid Plans

By Avery Johnson
The Wall Street Journal
December 29, 2010

Health insurers are preparing to capitalize on $40 billion of new opportunities to run privately managed Medicaid plans for the states, which would position insurers to benefit from the health overhaul’s expansion of Medicaid in 2014.

Medicaid is one of health insurers’ few bright spots, as their margins are pressed by regulatory crackdowns on premiums in their traditional policies. Gail Boudreaux, UnitedHealth’s executive vice president, told investors last month that: “The Medicaid space is a significant long-term growth opportunity for us. It’s a big market that’s getting even bigger.”

Budget crises mean cash-strapped states are more willing than ever to outsource their programs to private companies.

When you hear that the nation’s largest (in revenue) investor-owned insurer is looking at taxpayer-financed Medicaid as “a significant long-term growth opportunity,” be afraid. Be very afraid.

Reagan and Churchill – contrasting views on health care

Posted by on Tuesday, Dec 28, 2010

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.

Two Views of Health Law

Letters, The New York Times
December 27, 2010

To the Editor:

Re “In Health Law, Old Arguments Get New Airing,” by David Leonhardt (Economic Scene, front page, Dec. 15):

It is interesting to compare Ronald Reagan’s argument opposing Medicare as “socialized medicine,” a program that would take away the freedom of “our children and our children’s children,” with the words of one of his heroes.

In 1944 Winston Churchill, while still prime minister, said that “our policy is to create a national health service in order to ensure that everybody in the country irrespective of means, age, sex or occupation shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

Humphrey Taylor
New York, Dec. 15, 2010

The writer is chairman of the Harris Poll.

“In Health Law, Old Arguments Get New Airing,” by David Leonhardt:


Actually, Reagan Wasn’t So Proud of That 1965 Medicare Speech

By David Weigel
The Washington Independent
August 21, 2009

In the last month, there’s been a rediscovery of Ronald Reagan’s 1965 recording “Ronald Reagan Speaks Out Against Socialized Medicine.” Something that’s largely been forgotten, though, was that a much more famous Reagan quote — his “There you go again” dismissal of President Jimmy Carter in the 1980 presidential debates–came when Reagan denied that he really meant this, or that he was “opposing the principle of providing care for” seniors in 1965.

Winston Churchill represented the view of most conservative politicians in recent history when he said that “everybody in the country irrespective of means, age, sex or occupation shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

Even Ronald Reagan tried to erase his personal history of opposing Medicare by stating during the debate with President Carter, “I happened to favor the other piece of legislation and thought that it would be better for the senior citizens and provide better care than the one that was finally passed.”

So what has happened? Why are conservative politicians in the United States implicitly paying homage to the Chicago school of economics when their policies result in tens of millions of Americans being denied equal opportunities to benefit from the best and most up-to-date medical services that Winston Churchill spoke of? Does the faith in the abstraction of free market ideology really trump the actual health and welfare of the citizenry?

It would be too much of a stretch to classify this as a folie en masse. However the feigned obliviousness toward the unmet needs of fellow citizens can hardly be interpreted as anything other than heartless neglect driven by greed.

The conservatives and their moderate co-conspirators have updated Russell Long’s famous quotation: Don’t tax you, don’t tax me, and above all don’t even consider taxing that rich man behind the tree even if it means destroying social justice and common decency along with it.

Only 8,000 enroll in health plan for preexisting conditions

Posted by on Monday, Dec 27, 2010

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.

Only 8,000 enroll in health plan for preexisting conditions

By Geri Aston
American Medical News
December 27, 2010

As of Nov. 1, only 8,011 people were enrolled in the Pre-Existing Condition Insurance Plan, numbers from the Dept. of Health and Human Services show.

People who have been denied coverage by private insurers because of a preexisting condition and who have been uninsured for at least six months are eligible to participate in PCIP. The idea is to give patients who have no access to private coverage because of their condition a way to get insurance while they wait for the state-based health insurance exchanges to launch in 2014.

Almost 6 million Americans are potentially eligible for the program, which runs through 2013.

One of the highly touted transitional programs of the Patient Protection and Affordable Care Act is the temporary high risk health insurance pool program designed to provide health insurance for individuals with preexisting conditions. Until the state insurance exchanges are in operation in 2014, this program provides a source of insurance coverage for eligible individuals who have been rejected by private insurers because of preexisting conditions.

How successful has the program been so far? After four months of this three and one-half year program, 99.9 percent of eligible individuals have not yet been enrolled. Only 8,011 out of about 6,000,000 eligible have.

Several explanations have been advanced as to why participation is so low, but they are trivial compared to the most fundamental reason. Our fragmented, dysfunctional health financing system based on private insurance plans will never be capable of bringing everyone in and making the premiums and out-of-pocket spending affordable. As this program demonstrates, trying to apply patches to a rickety financing infrastructure will never be adequate to provide health security for everyone.

We need to dump the crumbling financing infrastructure based on the obsolete model of private plans and replace it with the sturdy structure of an improved Medicare that covers everyone.

George Annas on the constitutionality of Medicare

Posted by on Friday, Dec 24, 2010

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.

Can Congress Make You Buy Broccoli? And Why That’s a Hard Question

By Wendy K. Mariner, J.D., M.P.H., George J. Annas, J.D., M.P.H. (corresponding author), and Leonard H. Glantz, J.D. (From the Department of Health Law, Bioethics, and Human Rights, Boston University School of Public Health)
The New England Journal of Medicine
December 22, 2010

The continuing uncertainty over the constitutionality of the Affordable Care Act (ACA), illustrated by conflicting trial court rulings and scholarly commentaries, raises the question of why this constitutional question is so hard to answer. There are at least four reasons.

(The four reasons are discussed in the article.)

A much easier question to answer is why we’re facing this constitutional turmoil. Why, for example, is there no constitutional fuss over Medicare, Medicaid, or veterans’ health care? These programs raise no constitutional issue because they are government benefit programs funded by taxes, and the Constitution explicitly authorizes Congress to tax and spend for the general welfare. Had the ACA expanded Medicare eligibility to everyone, or created a new government health benefit program, there would be no constitutional issue. The constitutional controversy is the direct result of the insistence by conservative legislators that any health insurance reform must preserve the private insurance industry, which necessitated the addition of the individual mandate that is now being fought in the courts by similarly conservative forces.

Although these views on the constitutionality of Medicare have been discussed by others, including PNHP’s leadership, this NEJM article is of prime importance in the continuing health reform debate because it represents the views of respected ethicist George Annas and his colleagues.

The editor’s decision to use broccoli in the title stems from the comments of Florida’s Judge Vinson who questioned whether Congress could require everyone to buy broccoli. Cute. But that distracts from the fundamental issue that should have been selected for inclusion in the title.

Our founding fathers drafted a Constitution that recognizes the primacy of government in the establishment of benefit programs, and explicitly authorizes Congress to tax and spend for the general welfare. That does not extend to taxing and spending for the welfare of the private insurance industry, especially when that is the most expensive and least efficient model of reform – one that leaves so many out, and creates financial hardship for many more.

Is anyone else ready for a national movement to petition Congress to grant us our right to a government health benefit program for everyone – an improved Medicare for all?

Is HHS serious about controlling insurance premiums?

Posted by on Tuesday, Dec 21, 2010

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.

Rate Increase Disclosure and Review

Department of Health and Human Services
Filed December 21, 2010

This document contains proposed regulations implementing the rules for health insurance issuers regarding the disclosure and review of unreasonable premium increases under section 2794 of the Public Health Service Act. The proposed rule would establish a rate review program to ensure that all rate increases that meet or exceed an established threshold are reviewed by a State or HHS to determine whether the rate increases are unreasonable.

Under this approach, if a proposed rate increase equals or exceeds a defined threshold, it would be considered “subject to review.” The review process would then determine if the increase is, in fact, unreasonable.

Rates above the threshold would not be deemed or otherwise determined to be unreasonable in advance of this review. As discussed below, for rate increases filed in a State on or after July 1, 2011, or effective on or after July 1, 2011 in a State that does not require a rate increase to be filed, the threshold for whether rates are subject to review would be whether the average weighted increase in the rate filing, alone or in combination with prior increases in the preceding 12 month period, is 10 percent or more.

In establishing the 10 percent threshold for determining which rates are subject to review, HHS has balanced the wide range of available data on rate and medical trend increases. Our review of the limited data available suggests that the majority of increases in the individual market exceeded 10 percent each year for the past 3 years.

These yearly increases significantly exceed some national measures of medical cost inflation, such as the medical component of the Consumer Price Index, whose inflation has typically ranged from 3.7 percent to 4.4 percent. The Centers for Medicare and Medicaid Services’ National Health Expenditures (NHE) data is another measure of health care cost trends based on overall national health care spending. The five most recent years of available NHE data suggest that overall health care expenditures have increased at an annual rate between 4.4 percent to 6.9 percent. Some commenters suggested using these indices as thresholds for a review of rate increases. Another national index, the Standard & Poor’s Healthcare Economic Commercial Index, also measures insurance rate trends.  The S & P Index measures trends in provider claims costs, which encompasses both unit cost and utilization changes; the trend in that index from September 2009 to September 2010 was 8.5 percent.

The 10 percent threshold established in this regulation exceeds these major indices and in doing so balances industry concerns that any threshold would be over-inclusive with the competing concern that it would subject to review too few rates that may be unreasonable. As we discuss below, when better and more specific data on trends in insurance rates in individual States can be collected, State-specific thresholds would be established.

This approach does not provide for the review of every proposed rate increase, no matter how small, to determine whether it is unreasonable. We recognize that the choice of any threshold makes it inevitable that unreasonable rate increases below the threshold will not be reviewed, and that a proposed increase of less than 10 percent would be unreasonable if the actuarial assumptions underlying the increase were invalid or unreasonable. In proposing this approach, HHS also has taken into consideration the fact that many States, as discussed below, conduct a rate review process for all rate increases without regard to the magnitude of the increase. We expect the number of States conducting such reviews to increase in light of additional resources provided under the rate review grants and passage of State legislation. Therefore, as a practical matter, in a growing number of States, there is even less likelihood that an unreasonable increase below the threshold would be implemented.

In establishing an initial 10 percent threshold for whether a rate increase is subject to review, as discussed below, HHS recognizes that rates, underlying costs, and health care trends vary from State to State.

As discussed below, the State-specific threshold would be based on the same analysis used to develop the initial 10 percent threshold, but would be based on data from the specific State, rather than the national data we analyzed in selecting the proposed 10 percent figure.

Applying this regulation to the large group market would result in a process that is not closely aligned with most State processes upon which the regulation is modeled. In addition, many issuers are not accustomed to submitting proposed rate increases for review in this market. Finally, purchasers in the large group market have greater leverage than those in the individual and small group markets, and therefore may be better able to avoid imposition of unreasonable rate increases. For these reasons, under this proposed regulation, rates in the large group market would not be subject to the rate review process we are proposing.

Proposed regulation (136 pages):

Besides being sure that everyone is covered by a comprehensive system of financing health care, the other important goal of reform was to slow down the intolerable increases in health care costs. The token cost containment measures included in the legislation will likely have little impact, so attention was given to the false proxy of health care costs: the increases in insurance premiums. So how effective will the proposed regulations be in controlling the inexorable rise in insurance premiums?

To begin with, the regulations cover only the individual market, leaving out the much larger market of employer-sponsored health plans. Since the increases in health care costs have placed an undue burden on employers, and indirectly on their employees, this is a serious omission.

As far as setting a threshold for selecting the level of unreasonable premium increases which would be reviewed, Health and Human Services (HHS) has decided that plans with less than 10 percent premium increases would not be reviewed. That is a level well in excess of measures of medical cost inflation. Imagine compounded premium increases of 9.99 percent per year on top of premiums that are already unaffordable. It is true that the 10 percent threshold may be revised, but the change is to be “based on the same analysis used to develop the initial 10 percent threshold.”

Thus, in assuaging the insurance industry’s fears that “any threshold would be over-inclusive,” HHS has made a decision to allow the private insurance industry to keep jacking up its premium rates at unreasonable and intolerable levels. That is no surprise considering the inadequacy of the measures theoretically designed to control the health care spending that the insurers would have to cover.

We can go back and do it right. We can create a beneficent public monopsony that covers everyone with a financing system that slows health care inflation to a tolerable level: an improved Medicare for all. That has to be better than a 9.9 percent compounded increase in premiums that we would be mandated to pay to the perverse, intrusive private insurance industry.

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