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.
Dems’ ‘Mediscare’ a dubious winner
By Angie Drobnic Holan and Bill Adair
Politico, December 20, 2011
Republicans muscled a budget through the House of Representatives in April that they said would take an important step toward reducing the federal deficit. Introduced by Rep. Paul Ryan of Wisconsin, the plan kept Medicare intact for people 55 or older, but dramatically changed the program for everyone else by privatizing it and providing government subsidies. Democrats pounced.
• Just four days after the party-line vote, the Democratic Congressional Campaign Committee released a Web ad, saying seniors will have to pay $12,500 more for health care “because Republicans voted to end Medicare.”
• Rep. Steve Israel of New York, chairman of the DCCC, appeared on cable news shows and declared that Republicans voted to “terminate Medicare.”
• A Web video from the Agenda Project, a liberal group, said the Ryan plan would leave the country “without Medicare” and showed a Ryan look-alike pushing an old woman in a wheelchair off a cliff.
• And just last month, House Minority Leader Nancy Pelosi sent a fundraising appeal that read, “House Republicans’ vote to end Medicare is a shameful act of betrayal.”
PolitiFact debunked the Medicare charge in nine separate fact-checks rated False or Pants on Fire, most often in attacks leveled against Republican House members.
Now, PolitiFact has chosen the Democrats’ claim as the 2011 Lie of the Year.
At times, Democrats and liberal groups were careful to characterize the Republican plan more accurately. Another claim in the ad from the Agenda Project said the plan would “privatize” Medicare, which received a Mostly True rating from PolitiFact. President Barack Obama also was more precise with his words, saying the Medicare proposal “would voucherize the program, and you potentially have senior citizens paying $6,000 more.”
With a few small tweaks to their attack lines, Democrats could have been factually correct, said Norman Ornstein, a resident scholar at the American Enterprise Institute, a conservative think tank. “I actually think there is no need to cut out the qualifiers and exaggerate,” he said.
Long-Term Analysis of a Budget Proposal by Chairman Ryan
Congressional Budget Office
April 5, 2011
Among other changes, the proposal would convert the current Medicare program to a system under which beneficiaries received premium support payments – payments that would be used to help pay the premiums for a private health insurance policy and would grow over time with overall consumer prices. The change would apply to people turning 65 beginning in 2022; beneficiaries who turn 65 before then would remain in the traditional Medicare program, with the option of converting to the new system.
Under the proposal, most elderly people would pay more for their health care than they would pay under the current Medicare system. For a typical 65-year-old with average health spending enrolled in a plan with benefits similar to those currently provided by Medicare, CBO estimated the beneficiary’s spending on premiums and out-of-pocket expenditures as a share of a benchmark: what total health care spending would be if a private insurer covered the beneficiary. By 2030, the beneficiary’s spending would be 68 percent of that benchmark under the proposal.
PolitiFact has chosen the Democrats’ claim that “Republicans voted to end Medicare” as 2011 Lie of the Year. The facts that led the Democrats to attack the Ryan Medicare plan that the House Republicans passed are not in dispute. PolitiFact’s lie accusation stemmed simply from the imprecision of the Democrats’ political rhetoric, and not from a dispute about the actual facts that Democrats were attempting to publicize through simple sound bites.
Under the Republican-approved proposal, the traditional Medicare program would be phased out totally and replaced with private insurance plans. Much of the financing responsibility would gradually shift to the Medicare beneficiaries. According to the Congressional Budget Office, by 2030 two-thirds of the costs would be paid by the beneficiary, and only one-third paid by the government. In almost no way does this resemble the Medicare program that we know.
Nevertheless this almost entirely new program would still carry the Medicare label. Thus PolitiFact can argue that, technically, Republicans did not vote to end Medicare. But substantively, the infrastructure of the traditional Medicare program would be ended with not much more than the label surviving.
Norman Ornstein makes the important point that the Democrats would have been factually correct had they made a few small tweaks to their attack lines (e.g., “end Medicare as we know it,” which was used effectively). That is a lesson that we all should learn.
Unfortunately, PolitiFact did knock its credibility down a notch on this one. Poorly crafted sounds bites are worthy of a demerit, but the shocking truth behind the crucial message that the Democrats were trying to convey certainly did not warrant the “Pants on Fire” 2011 Lie of the Year award. That award should have been bestowed instead upon the Republicans who claimed that they voted to save Medicare.
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.
This article on unaffordable under-insurance was covered in a previous Quote of the Day (Dec. 8), but a new response posted on the In These Times website follows:
Health Reform Devolves Into ‘Unaffordable Under-Insurance’
By Roger Bybee
In These Times, December 7, 2011
Response by “Art As Social Inquiry”
19 Dec 2011
Thank you for this piece. I draw similar conclusions from my informal research. I am looking at how we access healthcare in the US by painting portraits and telling the stories of those who are using the system. More recently, the portraits are of people who actually HAVE insurance but because they are under-insured, they are suffering great financial and physical hardships. The great secret in the US is that millions of us are under-insured and don’t know it unless we suffer a medical catastrophe. This secret will be exposed if the essential benefits package of the ACA is too skimpy. People will get sick, think they are insured and find that even with insurance medical bills will eat up their savings. And they will be very angry. I don’t know…this next difficult phase may be the crucial first step toward a single-payer system? The ACA will help many millions, but is it enough? The question will always be “Can a for-profit system for delivering medical care really see to the needs of a country’s greatest asset – it’s people?”
“Art As Social Inquiry” is actually portrait painter Theresa BrownGold.
From her website:
Health Care in the United States
Art As Social Inquiry
This is a series of what will be 100-plus paintings depicting a cross-section of Americans. The titles of the paintings designate the kind of health insurance coverage or lack of coverage the sitters have. The goal is to paint a picture of the American health care system in the faces of our country’s citizens from the very best health coverage to the most horrific of circumstances resulting from a person’s lack of coverage. Who are we when it comes to health care? Let’s not be afraid to look at real people and be touched by their experiences – from the best to the worst – as we navigate this very big issue. There is no agenda but to ask, “What’s your experience? What are your thoughts on the subject?”
We have long heard tragic stories of the uninsured, but now the under-insured are joining them with their sad tales. Theresa BrownGold’s series of portraits on Health Care in the United States tells us stories of a cross section of Americans, while relating them to their insurance status.
You might take a moment to look at two extremes in her series. First click on the third portrait in the eighth row – painted in a style that indicates that the person is no longer with us. Those of us who have been in the trenches certainly recognize the description as being all too typical of when the U.S. health care system fails us miserably.
The other portrait to click on is the politician in the seventh row on the left, with blue eyes and wearing a blue sweater pulled over an open-collar white shirt. Again, many of us will recognize his description as being one of those power players who seem to be oblivious to the plight of those not well served by our health care system.
Everyone has a story, whether good or bad. We can thank Theresa BrownGold for giving us so many pictures, each worth a thousand words and more, motivating us to continue to do our best to see that all stories become good ones.
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.
Health and social services expenditures: associations with health outcomes
By Elizabeth H Bradley, Benjamin R Elkins, Jeph Herrin, Brian Elbel
BMJ Quality & Safety, March 29, 2011
To examine variations in health service expenditures and social services expenditures across Organisation for Economic Co-operation and Development (OECD) countries and assess their association with five population-level health outcomes.
A pooled, cross-sectional analysis using data from the 2009 release of the OECD Health Data 2009 Statistics and Indicators and OECD Social Expenditure Database.
OECD countries (n=30) from 1995 to 2005.
Life expectancy at birth, infant mortality, low birth weight, maternal mortality and potential years of life lost.
Health services expenditures adjusted for gross domestic product (GDP) per capita were significantly associated with better health outcomes in only two of five health indicators; social services expenditures adjusted for GDP were significantly associated with better health outcomes in three of five indicators. The ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost, after adjusting for the level of health expenditures and GDP.
Attention to broader domains of social policy may be helpful in accomplishing improvements in health envisioned by advocates of healthcare reform.
To Fix Health, Help the Poor
By Elizabeth H. Bradley and Lauren Taylor
The New York Times, December 8, 2011
IT’S common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality. Why are these other countries beating us if we spend so much more? The truth is that we may not be spending more – it all depends on what you count.
In our comparative study of 30 industrialized countries, published earlier this year in the journal BMJ Quality and Safety, we broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.
We studied 10 years’ worth of data and found that if you counted the combined investment in health care and social services, the United States no longer spent the most money – far from it. In 2005, for example, the United States devoted only 29 percent of gross domestic product to health and social services combined, while countries like Sweden, France, the Netherlands, Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the combination. We came in 10th.
What’s more, America is one of only three industrialized countries to spend the majority of its health and social services budget on health care itself. For every dollar we spend on health care, we spend an additional 90 cents on social services. In our peer countries, for every dollar spent on health care, an additional $2 is spent on social services. So not only are we spending less, we’re allocating our resources disproportionately on health care.
Unfortunately, instead of learning from countries like Sweden and France, we prefer the frantic scramble to recover money from one part of the health care system only to reallocate it toward retreads of previously failed reforms. We pretend that the fresh schemes are innovative, but they are usually long on promises, short on details and often marked with an annoying acronym: H.M.O., F.S.A., A.C.O. and so forth.
It’s time to think more broadly about where to find leverage for achieving a healthier society. One way would be to invest more heavily in social services. This may be difficult for many Americans to swallow as it suggests a potentially expanded role for government.
(Elizabeth H. Bradley is professor of public health at Yale and faculty director of its Global Health Leadership Institute, where Lauren Taylor is a program manager.)
Letters, The New York Times, December 18, 2011
To the Editor:
Re “To Fix Health, Help the Poor” (Op-Ed, Dec. 9):
Although Elizabeth H. Bradley and Lauren Taylor never use the words “social determinants of health,” they are illustrating the profound truth that it is the circumstances in which people live and work that determine the health status of any population, in any nation.
Along with that come some counterintuitive truths. First, that health care, while crucial to individual survival, makes at best a modest contribution to population health.
Second, that most social and economic policies are in effect health policies because of their impact on those social determinants. Even a perfect American health care system (let alone what we have now) cannot by itself fix our abysmal maldistribution of health.
When my colleagues and I worked at the nation’s first community health center in the Mississippi Delta in the 1960s, our doctors saved many lives and eased much suffering.
We repaired collapsing plantation shacks. We built sanitary privies. In the face of devastating poverty, unemployment and malnutrition, we organized a cooperative farm where residents grew tons of vegetables, and we found pathways to jobs and education.
Those interventions did far more to save lives, ease suffering and improve our target population’s health than our medical care did.
H. JACK GEIGER
Brooklyn, Dec. 9, 2011
(The writer is professor emeritus of community medicine at the City University of New York Medical School.)
Opponents of health care reform frequently object to the use of statistics such as our lower life expectancy and greater infant mortality, arguing that these represent socioeconomic factors and therefore are not due to deficiencies in our health care system.
There are two problems with their position. One is that this allows them to gloss over the severe deficiencies in our overly expensive but inadequate health care system. The other is that they offer no remedies that might improve the social determinants of health, implying that misery and poverty are a simply matter of personal choice.
As this report shows, “The ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost, after adjusting for the level of health expenditures and GDP.”
The United States has distorted this ratio by spending so much on health care (much misdirected) while spending so little on social services.
We need to spend more money, but not on health care. We are already paying the health care delivery system enough, but we need to have a far more efficient financing system that improves the allocation of those payments.
Where we need to spend more money is on public social services, in the broadest sense of the term. The comment by Jack Geiger shows that it is not so much a matter of money as it is a matter of personal and societal dedication, supported by strong public policy.
We can make America a far better place for the least of us and for the rest of us as well. To accomplish that, we’re going to have to do better in promulgating the virtues of egalitarianism. We certainly could use more help from the One Percenters.
Essential Health Benefits: HHS Informational Bulletin
U.S. Department of Health & Human Services
December 16, 2011
On December 16, 2011, the Department of Health and Human Services issued a bulletin outlining proposed policies that will give States more flexibility and freedom to implement the Affordable Care Act.
Intended Approach: Comprehensive and Flexible
HHS intends to propose that essential health benefits are defined using a benchmark approach. Under the Department’s intended approach announced today, states would have the flexibility to select a benchmark plan that reflects the scope of services offered by a “typical employer plan.” This approach would give states the flexibility to select a plan that would best meet the needs of their citizens.
States would choose one of the following benchmark health insurance plans:
* One of the three largest small group plans in the state by enrollment;
* One of the three largest state employee health plans by enrollment;
* One of the three largest federal employee health plan options by enrollment;
* The largest HMO plan offered in the state’s commercial market by enrollment.
If states choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state.
The benefits and services included in the benchmark health insurance plan selected by the state would be the essential health benefits package. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.
To prevent federal dollars going to state benefit mandates, the health reform law requires states to defray the cost of benefits required by state law in excess of essential health benefits for individuals enrolled in any plan offered through an Exchange.
These benchmarks are generally regulated by the state and would be subject to state mandates applicable to the small group market. Thus, those mandates would be included in the state essential health benefits package if the state elected one of the three largest small group plans in that state as its benchmark.
This approach would provide maximum flexibility to states, employers and issuers while providing quality, comprehensive, coverage for consumers.
Essential health benefits must include coverage of services and items in all 10 statutory categories. Based on our research, we believe that these benchmarks will cover most of the essential health benefits outlined by the Affordable Care Act. These categories include preventive care, emergency services, maternity care, hospital and physician services, and prescription drugs.
Allowing Plans Flexibility to Innovate and Consumers Greater Choice
To meet the EHB coverage standard, HHS intends to require that a health plan offer benefits that are “substantially equal” to the benchmark plan selected by the state and modified as necessary to reflect the 10 coverage categories. Health plans also would have flexibility to adjust benefits, including both the specific services covered and any quantitative limits, provided they continue to offer coverage for all 10 statutory EHB categories and the coverage has the same value. Permitting flexibility will provide greater choice to consumers, promoting plan innovation through coverage and design options, while ensuring that plans providing EHBs offer a certain level of benefits.
Essential Health Benefits Bulletin (15 pages):
It looks like Health and Human Services has decided that the new standard for health insurance to be offered under the Affordable Care Act will be the cheapest of the three largest small group plans offered in any given state. There will be no national standard. Although they would allow states more generous options other than the skimpy small group plans, with today’s concerns over high health care costs, the cheapest option certainly will be selected by the state stewards.
There is a requirement that 10 categories of health benefits must be included, but the specific services covered within each category will be determined by the insurers. The insurers will retain the flexibility to adjust both the specific services and the amount of those services (quantitative limits). HHS claims that this benefits us by providing greater choice for consumers and by providing insurers with the opportunity to innovate. Why they should deem that to be beneficial is astonishing when considering that insurer innovation means having to choose between various plans that take away, to varying degrees, choices of providers, benefits, and amount of financial security.
The essential health benefits do not define the cost sharing features of the plans such as deductibles, copayments and coinsurance. Guidance on that will be forthcoming, but we already know that the least expensive plan will be the bronze plan with an actuarial value of 60 percent (the plan pays 60 percent of only the covered health care services). Again, because of our high insurance premiums, most people will select the cheapest actuarial-value plan.
Can you think of anything worse than having cash-starved states selecting the cheapest private plans with the most spartan selection of benefits allowable – benefits selected by the private insurance industry – and offering those plans to struggling middle-income Americans who will be mandated to purchase these plans when many of them will not be able to afford even the bottom bronze plans in spite of the subsidies? And don’t even think about how they’re going to pay the high out-of-pocket expenses when they actually need health care.
Dissecting out each individual policy perhaps can make them easier to understand, but when you patch them together, just try to explain the resulting health care financing infrastructure to the average individual who just wants health care when needed. Most individuals may not be able to understand the complexities of health policy, but once they’ve been exposed to the new standard, they certainly will understand what is meant by UNAFFORDABLE UNDER-INSURANCE.
Try this thought experiment. Since the common defect in these Quote of the Day policy messages seems to be the dominance of the private insurers, try constructing a health care financing system without the private insurers being included. Wow! That was easy!
All we need now is to elect leaders who are willing to dismiss the insurers so that we can get on with building a system that works for all of us.
Originally published in the Berkshire Eagle.
The Institute of Medicine (IOM) has just released recommendations for the “essential benefits” of the health insurance coverage mandated under the Affordable Care Act (the 2010 federal health reform law). The IOM is the health arm of the National Academy of Sciences, described on their website as “an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public.”
“Skimpy coverage” is the best description for the “essential benefits” package the IOM panel has recommended. These bare-bones policies come with unaffordable deductibles and co-payments, as well as uncovered services. Rather than endorsing the more comprehensive coverage plans of large employers, the panel chose coverage similar to that offered by small employers, making these skimpy plans the new standard.
This inadequate coverage will shift costs from corporate and government payers onto families, which will lead to delaying care. Millions of Americans are already underinsured with skimpy insurance policies, and as a result, forego necessary medical care or fail to fill prescriptions they need. Of course, delaying care eventually leads to higher medical costs when patients finally receive treatment, because they are sicker.
Rising deductibles and co-payments over the past two decades have not stopped medical inflation. Costs keep going up, and more and more people suffer financial ruin when they have serious illnesses.
A new study has just been released, by Masscare and Massachusetts Physicians for a National Health Program, about the outcome of our state health reform law four years after its full implementation. This is an important study because the Affordable Care Act is based on the Massachusetts Health Reform Law, which was enacted in 2006. The study finds that the number of uninsured people in Massachusetts decreased by one-half to two thirds. However, most of the gains have come from expansions in publicly subsidized insurance, shifting patients from the previous Free Care Pool, which compensated hospitals directly, to private insurance plans, which are a more expensive way to provide coverage.
In addition, cost-shifting to patients has accelerated due to skimpy coverage in employer-sponsored insurance, especially for policies for small business employees. Since the reform, the use of high-deductible plans more than tripled for Massachusetts residents with private insurance.
Reform has not reduced the burden of medical bills and medical bankruptcy in Massachusetts. The federal Affordable Care Act, like health reform in Massachusetts, will probably have similar mixed outcomes, expanding coverage to the uninsured, but doing this through inadequate insurance policies purchased through private insurance companies, who will reap big profits even as the cost of policies become unaffordable.
As you might suspect, the panel from the IOM who made these recommendations for the federal health reform law is “riddled with conflicts of interest,” according to a protest letter signed by 2,400 doctors, nurses, and health advocates. The IOM panel members include Sam Ho, executive vice president of United Healthcare, and Leonard Schaeffer, a former CEO of Wellpoint, two of the largest health insurance companies.
Last year, a journalist at the Los Angeles Times wrote, “Leaders of Cigna, Humana, UnitedHealth, WellPoint and Aetna received nearly $200 million in compensation in 2009, according to a report, while the companies sought rate increases as high as 39 percent” for insurance premiums. Other members of the IOM panel with conflicts of interest include executives from 3M Health Information Systems, a medical supplier; Milliman, Inc., an actuarial consulting firm with close ties to the insurance industry; and The Blackstone Group, a private equity firm with major health care interests. These health industry ties violate a 2009 recommendation from the IOM itself that those with industry conflicts should be excluded from such panels.
Of course, the IOM panel recommendations were lauded by insurance industry leaders. Health insurance companies, who stand to gain by issuing skimpy insurance policies that patients will avoid using until they are very sick, have attempted to undermine real health reform all along the way. The Lancet, one of the oldest and most respected medical journals has stated: “Corporate influence renders the U.S. government incapable of making policy on the basis of evidence and the public interest.”
No wonder the Occupy Wall Street movement has the support of increasing numbers of American people who are awakening to the effects of corporate influence on our lives. Health insurance policies are just one example.
Single-payer health insurance, an improved and expanded Medicare plan for everyone, would remove corporate influence and greed from our health care insurance system, be cost-effective, and provide comprehensive health care coverage for everyone. Unlike the skimpy coverage suggested by the IOM, a single-payer health care system would actually pay for care when we are sick.
Dr. Susanne King is a Lenox-based practitioner.
A Bipartisan Way Forward on Medicare
By Ron Wyden and Paul Ryan
The Wall Street Journal, December 15, 2011
Our plan would strengthen traditional Medicare by permanently maintaining it as a guaranteed and viable option for all of our nation’s retirees. At the same time, our plan would expand choice for seniors by allowing the private sector to compete with Medicare in an effort to offer seniors better-quality and more affordable health-care choices.
Under our plan, Americans currently over the age of 55 would see no changes to the Medicare system. For future retirees, starting in 2022, our plan would introduce a “premium support” system that would empower Medicare beneficiaries to choose either a traditional Medicare plan or a Medicare-approved private plan. Unlike Medicare Advantage, these private plans would compete head-to-head with traditional, fee-for-service Medicare on a federally regulated Medicare exchange.
Low-income seniors who qualify for both Medicare and Medicaid would continue to have Medicaid pay for their out-of-pocket expenses. Other lower-income seniors would receive fully funded savings accounts to help offset any increased out-of-pocket costs, while wealthier seniors would receive less help.
In the event that these efforts did not stem the rising tide of Medicare spending, there would be a cap on the program’s rate of growth. But unlike other proposals, spending that exceeds the cap would neither be addressed through bureaucratic cuts nor passed on to seniors by default as higher premiums.
Instead, Congress would be required to do its job: Determine why the costs exceeded the cap and – when the evidence merits – reduce payments to providers, drug companies, or others who may be responsible for escalating costs.
Our plan would also expand health-care options for working Americans by giving smaller businesses the opportunity to empower their employees to make their own health-care choices. Under this “free choice option,” employees take the amount that their employer was contributing toward their employer-provided health coverage and use it to purchase their own health insurance instead. The cost to the employer – and the tax-free benefit to the worker – would remain the same.
Yes, these are ambitious reforms, and while we are hopeful for the future, we are under no illusions that they will pass tomorrow. Nevertheless, we offer this plan as proof that Democrats and Republicans don’t have to spend next year making Medicare reform more difficult. Instead, our parties can work together on bipartisan reforms to save and strengthen Medicare.
(Mr. Wyden, a Democrat, is a U.S. senator from Oregon. Mr. Ryan, a Republican, is a U.S. representative from Wisconsin.)
White paper (13 pages):
Although Sen. Ron Wyden (D-Oregon) and Rep. Paul Ryan (R-Wisconsin) have released their white paper on a proposal for reforming Medicare, there is no intent on their part to follow it up with legislation during this session of Congress. Their stated intent is to initiate a bipartisan discussion on Medicare reform, but it appears instead that other political considerations prompted this proposal.
Paul Ryan was stung by the response to his original proposal to end the traditional Medicare program and replace it with a premium support (voucher) program of private health plans. The Congressional Budget Office reported that his plan would cause a major shift of costs from the government to Medicare beneficiaries, and his own constituents beat up on him back home. Also, the Republicans in the House of Representatives are now on record as having voted for the Ryan premium support plan, and the Democrats have made it clear that they will make this a major issue in the coming elections.
This white paper gives the Republicans an out. They can now claim that this is better than the original Ryan proposal because it protects Medicare by leaving it as an option while providing more choices of competing private plans. Obviously this takes away the sting of the Democrats’ attack.
Why would Ron Wyden cooperate with Paul Ryan in this effort to defuse the Democrats’ strategy of using the premium support vote against the Republicans? It is because he is more supportive of his own previous proposal for health care reform than he is for the Democrats to prevail in the next election. His Healthy Americans Act that he pushed throughout the reform process called for an individual mandate to purchase private plans, shifting the tax benefit from employers to individuals (a concept included in this white paper). He has said that Democrats want universal coverage, Republicans want choice, and his plan, and now the Ryan-Wyden proposal, would enable both.
The problem for single payer supporters is that this is a digression that shoves the concept of an improved Medicare for all further into the background. The substance of the debate will be over converting the Medicare Advantage plan into a voucherized program competing on price. Single payer supporters will not be welcome participants in that debate, nor should we.
We shouldn’t waste our resources on countering premium support. That’s the wrong debate. We need to continue with a very strong message on countering private, corporate control of health care, while promoting a publicly-financed and publicly-administered Medicare for everyone. That’s the message that America needs to hear.
Waiting Your Turn: Wait Times for Health Care in Canada – 2011 Report
by Bacchus Barua, Mark Rovere and Brett J. Skinner
Fraser Institute, December 2011
This edition of Waiting Your Turn indicates that waiting times for elective medical treatment have increased since last year. Specialist physicians surveyed across 12 specialties and 10 Canadian provinces report a total waiting time of 19.0 weeks between referral from a general practitioner and receipt of elective treatment.
Wait Times in Canada—A Comparison by Province, 2011
Canadian Institute for Health Information (CIHI)
At least 8 out of 10 Canadian patients are receiving priority area procedures, such as hip replacements, cataract surgery and cancer radiation treatment, within medically recommended wait times, according to a new study from the Canadian Institute for Health Information (CIHI). The study provides the first comprehensive national picture of how long Canadians wait for care in priority areas as compared with evidence-based benchmarks of acceptable waits.
The Fraser Institute has released its 21st annual report on wait times for health care in Canada. This report is used widely to condemn Canada’s reliance on their single payer medicare program for the financing of health care. It helps to fulfill the Fraser Institute’s libertarian agenda of advocating for privatization of their health care system. Today’s comment takes a critical look at this report.
The findings in the report are based on the solicited opinions of Canadian physicians. Questionnaires were sent to 10,737 of the 68,000 active Canadian physicians. Of these, 1,696 physicians responded (15.8% response rate). Distributing these responses amongst the 12 specialties and ten provinces results in single digit tallies for 63 percent of the categories, and often only one physician falling into a given category. For instance, only one specialist in internal medicine represented the views of all internists in the province of Prince Edward.
Besides questioning whether these numbers are adequate to represent the views of all Canadian physicians, there are two other factors that may have skewed the results.
As an enticement to return the questionnaires the physicians were given the chance to win $2000. Physicians with an entrepreneurial mentality – those who more likely favor privatization of health care – might be more favorably inclined to try for this reward. More altruistic physicians who really care about the problem of queues might be insulted by this attempt to buy responses with a prize.
A great many Canadian physicians strongly support their medicare program and oppose the current efforts to privatize both the delivery system and the health insurance system. These physicians are acutely aware of the agenda of the Fraser Institute and would be much less likely to cooperate in their biased studies.
Thus it is unlikely that the sampling truly represents the views of mainstream Canadian physicians.
Another important consideration is that this study was heavily weighted toward elective surgeries. Emergency conditions were not included. Patients in Canada have excellent access when a true emergency exists. So this study is not looking at acute, urgent conditions.
Instead, this study was looking more at patients with chronic conditions which are usually managed over a long period of time, sometimes for a lifetime. Yet the authors imply that the disorders for which they are treated began at a single point in time in the generalist’s office.
In reality, when the physician and patient decide that it is time to consider more options for managing a chronic problem, often a decision is made to obtain a specialist’s consultation. These are not emergencies so a routine appointment is scheduled. Except for a few specialties, most of these appointments are within a reasonable time interval.
Once the patient sees the specialist, more time is consumed for appropriate comprehensive evaluation of the problem before a decision is made on definitive management. Again, these time intervals are mostly reasonable.
Once the decision is made to schedule the elective surgery or other procedure, then excessive waiting times can be more objectionable. But how long are these waiting times?
The specialists were asked what a reasonable waiting time was for their given procedures, and how long their patients had to wait. With the exception of plastic surgery and orthopedics, most waiting times were very close to those that the specialists considered to be reasonable. (Internal medicine was also an outlier for endoscopy and non-urgent angiography.)
The Fraser report is very deceptive because they add to the time between scheduling a procedure and completing a procedure the time for the routine request by a generalist for a consultation, and the time for the specialist to complete the full evaluation before deciding on the specific management. If you separate these out, most of the intervals are quite reasonable. The 19 week wait reported by Fraser has little meaning, since it does not represent the time between scheduling a procedure and completing it.
The much more credible study from the Canadian Institute for Health Information confirms that Canada is doing quite well in delivering care within medically recommended wait times.
This does not mean that there are no problems. There is a very major problem, and it is political. Conservative politicians who currently control much of the government would like to privatize the health care system. Their approach is to abandon their role as stewards of the health care system, deliberately allowing longer queues to develop. Then the public is told that the only way to fix these outrageous delays that are killing people is to turn to the private health care markets in order to bypass the queues. As this view gains traction there is greater support for what amounts to a two-tiered system – the best of care for the relatively wealthy, and an under-funded public program for the masses.
Sound familiar? Only we’re far ahead of them in fragmenting our system.
Allowing Insurers to Withhold Data on Enrollees’ Health Status Could Undermine Key Part of Health Reform
By Edwin Park
Center on Budget and Policy Priorities, December 12, 2011
Risk adjustment is one of the critical elements of health reform (i.e., the Affordable Care Act, or ACA) that’s designed to encourage insurers to compete based on price and quality – not on attracting the healthiest enrollees and deterring those in poorer health, as they typically do today in the individual and small-group insurance markets.
Under the ACA’s risk adjustment provision, insurers in the individual and small-group markets with sicker-than-average overall enrollment will receive payments to compensate them for their resulting higher costs. The payments will come from plans that enroll healthier-than-average people who do not cost as much to cover. By compensating insurers that enroll people in poorer health, risk adjustment reduces the incentive for insurers to “cherry pick” the healthy and avoid enrolling people with chronic illnesses and other serious health conditions.
To implement this “risk adjustment” provision, the federal government proposes that the entities administering risk adjustment – states or the U.S. Department of Health and Human Services (HHS) – determine the health status of plan enrollees based on data that insurers submit to them, which is similar to how risk adjustment in Medicare works today. But some insurance companies, as well as some House Republicans, are urging the federal government to allow insurers to measure the health status of their enrollees themselves without submitting any data.
Some insurance companies are mounting strong opposition to the HHS proposal on risk adjustment data submission. Instead, they are pushing HHS to adopt a “distributed” approach to the collection of risk adjustment data.
Under a distributed approach, insurers would standardize their data (according to federal and state specifications), themselves apply the risk adjustment methodology and calculate their own risk scores and then simply submit those scores to the entity administering risk adjustment. Insurance companies would not provide the risk adjustment entity with any of the underlying claims and encounter data needed to determine whether the data are reliable and valid and whether the risk scores have been accurately calculated. (Insurers would be expected to make a sample of that data available after the fact for retrospective audits.)
Risk adjustment is an essential element of the Affordable Care Act. Letting insurers calculate their own risk scores without having to submit the underlying data needed to make sure those calculations are accurate would place the health reform law’s risk adjustment system at substantial risk of error, upcoding, and fraud, threatening the long-term success of the exchanges and the major health insurance market reforms scheduled to take effect in 2014.
Letter to Centers for Medicare & Medicaid Services
Re: Proposed Rule for Standards Related to Reinsurance, Risk Corridors and Risk Adjustment (CMS-9975-P)
BlueCross BlueShield Association
October 31, 2011
We strongly recommend that HHS use a distributed model for accessing risk adjustment data. Our recommended model: 1) alleviates members’ privacy concerns since States will not be collecting confidential, individually identifiable health information; 2) retains issuers’ control of proprietary data that has strategic importance; and 3) allows States/HHS to maintain the same control over the process while alleviating the burden of creating, securing, maintaining and updating a large costly centralized multi-payer database.
National Bureau of Economic Research report on risk adjustment in the Medicare Advantage Program:
Thus the authors conclude that the Medicare Advantage program both increased total Medicare spending and transferred Medicare resources from the relatively sick to the relatively healthy, and that risk-adjustment was not able to address either of these problems.
Insurers that corner the market of healthy individuals have an unfair advantage over insurers that cover a greater number of high cost, sicker patients. To protect those insurers with high costs from failing in the markets, risk adjustment corrects for the market distortions by taking funds from the insurers with low cost patients and transferring them to the insurers with high cost patients.
Risk adjustment may be a great theory, but in practice it doesn’t work very well. As an example, even though prohibited from selectively enrolling healthier patients, Medicare Advantage plans have been very successful at selectively marketing to the healthy. Insurers end up with significantly lower costs, even though they are paid higher amounts than are paid for patients in the traditional Medicare program.
In 2004, Medicare began to adjust for risk, but the Medicare Advantage insurers gamed the system, as was demonstrated in an NBER report (link above), further increasing the unfair differential to about $3000 per patient. The Medicare-supervised risk adjustment was ineffective, not due to the incompetence of Medicare, but rather due to the deviousness of the Medicare Advantage plans in coding patients with just a touch of illness, making them appear as being more seriously ill than they were.
Now the insurers want to do their own “distributed model” of risk adjustment, preventing federal or state bureaucrats from looking over their shoulders as they do their dirty deeds. This applies not only to Medicare Advantage plans but to all plans in and out of the exchanges, except for grandfathered plans. They claim that this secrecy is necessary to maintain patient privacy and to protect the insurers’ proprietary data, but risk adjustment of the Medicare Advantage program has demonstrated that these are not valid concerns.
Risk adjustment does not work, as the insurers will always game the system. The insurers’ solution is to allow them to do it in greater secrecy, with a “trust us” attitude that certainly has not been earned based on their previous behavior.
A solution that would benefit all of us would be to totally eliminate the need for risk adjustment. How do you do that? You simply eliminate multiple risk pools by eliminating the private insurer middlemen, and then establish a single, universal risk pool – an improved Medicare for all. There would never be a need for Medicare to risk adjust itself.
The Bomb Buried In Obamacare Explodes Today-Hallelujah!
By Rick Ungar
Forbes, December 2, 2011
I have long argued that the impact of the Affordable Care Act is not nearly as big of a deal as opponents would have you believe. At the end of the day, the law is – in the main – little more than a successful effort to put an end to some of the more egregious health insurer abuses while creating an environment that should bring more Americans into programs that will give them at least some of the health care coverage they need.
There is, however, one notable exception – and it’s one that should have a long lasting and powerful impact on the future of health care in our country.
That would be the provision of the law, called the medical loss ratio, that requires health insurance companies to spend 80% of the consumers’ premium dollars they collect – 85% for large group insurers – on actual medical care rather than overhead, marketing expenses and profit. Failure on the part of insurers to meet this requirement will result in the insurers having to send their customers a rebate check representing the amount in which they underspend on actual medical care.
This is the true ‘bomb’ contained in Obamacare and the one item that will have more impact on the future of how medical care is paid for in this country than anything we’ve seen in quite some time. Indeed, it is this aspect of the law that represents the true ‘death panel’ found in Obamacare – but not one that is going to lead to the death of American consumers. Rather, the medical loss ratio will, ultimately, lead to the death of large parts of the private, for-profit health insurance industry.
Why? Because there is absolutely no way for-profit health insurers are going to be able to learn how to get by and still make a profit while being forced to spend at least 80 percent of their receipts providing their customers with the coverage for which they paid. If they could, we likely would never have seen the extraordinary efforts made by these companies to avoid paying benefits to their customers at the very moment they need it the most.
Today, that bomb goes off.
Today, the Department of Health & Human Services issues the rules of what insurer expenditures will – and will not – qualify as a medical expense for purposes of meeting the requirement.
As it turns out, HHS isn’t screwing around. They actually mean to see to it that the insurance companies spend what they should taking care of their customers.
Here’s an example: For months, health insurance brokers and salespeople have been lobbying to have the commissions they earn for selling an insurer’s program to consumers be included as a ‘medical expense’ for purposes of the rules. HHS has, today, given them the official thumbs down, as well they should have. Selling me a health insurance policy is simply not the same as providing me with the medical care I am entitled to under the policy. Sales is clearly an overhead cost in any business and had HHS included this as a medical cost, it would have signaled that they are not at all serious about enforcing the concept of the medical loss ratio.
So, can private health insurance companies manage to make a profit when they actually have to spend premium receipts taking care of their customers’ health needs as promised?
Not a chance – and they know it. Indeed, we are already seeing the parent companies who own these insurance operations fleeing into other types of investments. They know what we should all know – we are now on an inescapable path to a single-payer system for most Americans and thank goodness for it.
Ungar responds to criticism of this article:
PNHP co-founders David Himmelstein and Steffie Woolhandler respond to Rick Ungar’s “The Bomb Buried in Obamacare…”:
“Limiting overhead to 15%-20% is far from the stringent regulation that Ungar implies. Private insurers’ overhead currently averages about 14% nationwide, and they will probably be able to reclassify some items currently classified as overhead into the patient care expense category (despite regulations that attempt to stop this). Moreover, some current sales expenses will be offloaded to the insurance exchanges, which are likely to have overhead of 3-4%, and the exchanges’ expenses will not count as part of insurers’ overhead. Finally, ACOs will take over many of insurers’ administrative tasks and expenses, but these ACO overhead expenditures will not count toward the 15%-20% overhead limit. In sum, total insurance overhead (and profit) is likely to grow, not fall in the years ahead.”
Never have we received as many requests to comment on an article as we have on Rick Ungar’s “The Bomb Buried in Obamacare…” He is to be highly commended for his enthusiastic support of single payer, but his analysis that the insurers’ requirement to comply with the statutory medical loss ratios is an Obamacare bomb that will cause so much damage that we’ll be on an inescapable path to single payer might represent… well, perhaps a touch of hyperbole, intended or not.
In the response above, David Himmelstein and Steffie Woolhandler explain how the medical loss ratio will have very little impact on reducing total insurance overhead and profit, although some recategorization will likely take place. Thus it isn’t quite the bomb that will relieve us of their excesses and intrusions, nor relieve the health care providers of the administrative burdens that are placed upon them by the insurers and by the general complexity of our fragmented, dysfunctional health care financing system.
That said, it is political season. We can thank Rick Ungar for providing us with well-meaning hyperbole that that is appropriately provocative and makes people want to look once again at single payer as an answer to our health care mess. As Ungar says, “we are now on an inescapable path to a single-payer system for most Americans and thank goodness for it,” even if the medical loss ratio bomb won’t really budge us in that direction.
Although PNHP will remain meticulous with the facts, upholding our reputation as a highly credible resource on single payer reform, it would be great if Rick Ungar and many others would continue with passionate pro-single payer advocacy, though perhaps fine tuning the hyperbole in order to ensure credibility.
Social Insurance and Individual Freedom
By Uwe E. Reinhardt
The New York Times, December 9, 2011
The continuing debate over the Affordable Care Act and the commentary on this blog have convinced me that nothing can ever unite Americans on their vision of an ideal health system.
We need different health insurance systems for different Americans. I mean by this not Americans who differ by age or ability to pay but Americans with different notions of a just society.
Closing the Door to Statutory Insurance
By law, every German must have coverage for a prescribed benefit package. German employees and pensioners earning less than 49,500 euros ($66,350) per year (in 2011) are compulsorily insured under the statutory system.
Employees and pensioners above that threshold are free to opt out of the statutory system and purchase private, commercial coverage, but if they do, they cannot ever return to the statutory system unless they are paupers. The intent is to minimize gaming of the insurance system by individuals.
It is this feature that intrigues me, as it has my colleague Paul Starr, in his proposed alternative to an individual mandate to be insured.
What if Americans at, say, age 26 (beyond which they can no longer be included on their parents’ insurance policy) or even as late as age 30 were offered the choice of:
1. joining the community-rated health insurance offered through the insurance exchanges called for in the Affordable Care Act;
2. remaining in a private insurance system that is free to charge in any year “actuarially fair” premiums, that is, premiums that reflect the applicant’s projected health status and spending for that year and is free to refuse issuing a policy altogether;
3. simply self-insuring, by remaining uninsured?
For want of better terms, we might call the exchange system the “social insurance track” (because it leans heavily toward social insurance) and the second and third options the “rugged individualist tracks,” because they cater to Americans with individualist preferences.
For people choosing the rugged individualist tracks, Professor Starr proposes to shut the door to the social insurance track for only five years.
I believe his stricture is too weak and propose instead to follow the German example by shutting the door permanently to social insurance to any individual who chose one of the two rugged individualist tracks, unless such individuals were truly pauperized. A return then would have to be allowed, because, for better or for worse, our civic sentiments preclude letting anyone – even a myopic rugged individualist — die for want of critically needed health care.
Admittedly, this approach would confront young Americans with a serious life-cycle choice. But life-cycle choices are made all the time, and choices do have consequences that people in their mid-20s should be mature enough to think about. Adults must realize that individual freedom has its price.
The American health insurance system now is structured as a paradise for clever adolescents, inviting gaming of many sorts that makes sensible health policy almost impossible. It is time to move away from such a system.
Those of us who have great admiration for Paul Starr were disappointed by his recommendation to require anyone who opted out of coverage to be prohibited from having coverage for the next five years.
Under this policy, many of these very healthy young people will decide to take the chance that they will not need expensive care, and most will win that bet.
There are two problems with this. Some will have major trauma, some will develop serious disorders such as cancer, and some will develop severe chronic problems such as type I diabetes. These people should receive the care that they need regardless of the fact that they made the unwise decision to decline insurance. Who pays for that care?
The other problem is that we do need the many who are healthy to pay into the risk pools to cover the fewer with greater health care needs. Otherwise those pools end up with a death spiral of ever higher premiums.
Just as our nation does not allow me, a pacifist, to not pay through my taxes the costs of our ill-considered wars, our nation should also prohibit the rugged individualists from not paying their share of our collective national health expenditures.
The nation will continue to disagree on this, which is precisely Professor Reinhardt’s point. But that won’t stop some of us from continuing to advocate for what is right.
Comment originally published on the NYTimes Blog: http://economix.blogs.nytimes.com/2011/12/09/social-insurance-and-individual-freedom/?comments#permid=1
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