Who will remain uninsured?

Posted by on Tuesday, Oct 9, 2012

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.

After Millions of Californians Gain Health Coverage Under the Affordable Care Act, Who Will Remain Uninsured?

By Laurel Lucia, Ken Jacobs, Miranda Dietz, Dave Graham-Squire, Nadereh Pourat, and Dylan H. Roby
UC Berkeley Labor Center, September 2012

The implementation of the Affordable Care Act (ACA) is predicted to expand coverage to millions of Californians by 2019. This increase in coverage will primarily result from the expansion of Medi-Cal and the availability of subsidized coverage in the California Health Benefit Exchange (Exchange). However, three to four million Californians could remain uninsured even after the law is fully implemented.

Many Californians will remain uninsured

* 3.1 to 4 million Californians are predicted to remain uninsured in 2019.

* Almost three-quarters of the remaining uninsured in California will be U.S. citizens or lawfully present immigrants.

* Half of all remaining uninsured, or two million Californians, will be eligible for Medi-Cal or Exchange subsidies but remain unenrolled under the base scenario. Barriers to enrollment could include lack of awareness about the programs, challenges in the enrollment process, or inability to afford subsidized coverage.

* 72 percent of remaining uninsured Californians will be exempt from paying tax penalties under the minimum coverage requirements of the ACA due to income, lack of an affordable offer of coverage or immigration status. Approximately three percent of all Californians will owe a tax penalty due to not obtaining minimum coverage.

* Nearly 40 percent of the remaining uninsured will lack an offer of affordable coverage with premiums costing eight percent of household income or less. Some uninsured Californians will be ineligible for subsidized coverage due to income or immigration status, while others will be eligible for subsidized plans in the Exchange with premiums that exceed the affordability standard.

* Some of the remaining uninsured will lack coverage for short time periods due to life transitions.

Some demographic groups will be more likely to remain uninsured

* Two-thirds (66%) of Californians remaining uninsured will be Latino, compared to a projected 45 percent of the non-elderly population in 2020.

* Nearly three out of five California adults who remain uninsured will be Limited English Proficient.

* 57 percent of Californians who remain uninsured will have household incomes at or below 200 percent of the Federal Poverty Level.


The projected numbers and demographics of the uninsured after full implementation of the Affordable Care Act in California are shameful. Although there would be regional differences in demographics, the national numbers would be roughly tenfold. We can do far better by enacting an improved Medicare for all.

Universal health care and the Iron Triangle myth of U.S. policy makers

Posted by on Monday, Oct 8, 2012

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.

Donald Light on the Iron Triangle Myth

By Donald Light

Response to the October 4, 2012 Quote of the Day on the meme of access, cost and quality (http://www.pnhp.org/news/2012/october/aaron-carroll-repeats-meme-of-acce…):

In my comparative studies of universal health care systems, I find their cost/quality profiles vary quite a bit between each other, and over time for the following reasons. The more such systems pay by fee, the more providers drive up costs in the name of “quality” from which they profit, such as Germany from after World War II up to the 1980s. The Canadian system has been suffering from this seeming trade-off for decades. Access stays universal but there seems to be “an iron trade-off” between cost and quality, until systems start moving towards bundled payments and then population-based capitation or salary within a national health service and an ethos of shared responsibility to improve quality within a fixed budget. (Notice the so-called “iron triangle” has faded from view.)

Thus it’s holding costs constant while maintaining universal access that is key to improving quality, not only by eliminating care that is detrimental but also unnecessary or avoidable care, by rethinking clinical strategies. Ironically, some of the models of shared access and budgets increasing quality are in the United States. Few, if any national systems, can match the steady improvements in quality and value of Kaiser Permanente, Intermountain, Marshfield, or the reformed VHA (Veterans Health Administration). For example, the English NHS has been learning from them for years.

The transformation of the VHA from a single-payer, fee-based, poor-quality set of hospital-centered services, to a single-payer system based on area population budgets centered on primary care, with coordinated, community-based specialty back-up and hospitals as a last resort offers inspiring lessons. Quality improved and costs sharply dropped, so that 30 percent more veterans could be treated within the same, fixed budget.

Reforms in Germany in the 1990s through today have also improved quality while lowering relative costs and expanding access from about 94 percent to 99 percent. Germany’s multi-insurer base has been made single payer-like by the government creating a single channel where all insurers’ premiums are risk-adjusted so all insurers operate on the same risk-adjusted budgetary basis. The Dutch reforms since 2006 operate in a similar way, with some distinct differences.

In sum, I would say the key is not single-payer per se but population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames that give the lie to the so-called iron triangle.

The Iron Triangle is an American myth for lazy and unobservant policy leaders.

Donald W. Light, Ph.D.
Professor, UMDNJ-SOM
Visiting Researcher, Center for Migration & Development, Princeton University
Resident Fellow, Edmond J. Safra Center for Ethics, Harvard University
Senior Fellow, Center for Bioethics, University of Pennsylvania


As Professor Light shows us, with controlled budgets you can still improve quality in a system that ensures appropriate access for everyone. Although he states that the key is not single payer per se, it is clear that the Iron Triangle (interdependency of cost, quality and access) still applies to our fragmented, dysfunctional financing system in the United States – a system that has only been perpetuated with the Affordable Care Act. However, social insurance programs, including single payer and health service models, have shown that the inevitability of the Iron Triangle is a myth. An improved Medicare for all would provide us with “population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames.”

Physicians’ Presidential Poll

Posted by on Friday, Oct 5, 2012

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.

Results of the 2012 Physicians’ Presidential Poll

By Jackson & Coker Research Associates
Jackson & Coker Industry Report, October 1, 2012

A new survey of physicians shows that if the Presidential election were held today, 55 percent would vote for Mitt Romney and 36 percent would support President Obama, according to a survey conducted by Jackson & Coker, a division of Jackson Healthcare, the third largest healthcare staffing company in the US.

When asked how they felt about the Affordable Care Act, 55 percent said “repeal and replace” the new law while 40 percent said “implement and improve” the ACA.


Rather than demonstrating where physicians are on their beliefs and understanding of health policy, this poll merely shows that the debate has been reduced to the politics of the Affordable Care Act (ACA). Of the 55 percent who would replace ACA, there is no breakdown on those who would replace it with Medicare for All (neither candidate)  and those who would replace it with policies that likely would shift more of the financial burden to patients (Romney). Also, of the 40 percent who would improve ACA there is no breakdown of those who would support the dubious strategy of modifying it incrementally as a means of eventually achieving single payer reform (neither candidate). We need surveys of physicians’ views on policy, not politics.

Aaron Carroll repeats meme of access, cost and quality

Posted by on Thursday, Oct 4, 2012

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.

JAMA Forum — The “Iron Triangle” of Health Care: Access, Cost, and Quality

By Aaron Carroll, MD, MS
news@JAMA, October 3, 2012

When I talk about health policy, I often refer to the iron triangle of health care. The 3 components of the triangle are access, cost, and quality. One of my professors in medical school used this concept to illustrate the inherent trade-offs in health care systems. His point was that at any time, you can improve 1 or perhaps even 2 of these things, but it had to come at the expense of the third.

I can make the health care system cheaper (improve cost), but that can happen only if I reduce access in some way or reduce quality. I can improve quality, but that will either result in increased costs or reduced access. And of course, I can increase access—as the Affordable Care Act (ACA) does—but that will either cost a lot of money (it does) or result in reduced quality.

Anyone who tells you that he or she can make the health care system more universal, improve quality, and also reduce costs is in denial or misleading you.

We can make the system cheaper. We can make it more expansive. We can make it higher in quality. But we can’t do all 3.


We have heard for decades the meme that health care access, cost and quality are interdependent. Any change in one or two of them must produce a reciprocal change in either one or both of the others. Any improvement must always be offset with one or two impairments. Yet the single payer model shows that this is merely a replication of a seriously deficient concept that omits consideration of many other important health policies.

Under a properly designed single payer model, access is improved by removing financial barriers to care for absolutely everyone. The comprehensive design features of single payer also significantly improve quality, simply stated, by ensuring that patients receive the care that they need while reducing or eliminating care that is detrimental. And costs are the forte of the single payer system. Single payer reduces waste, redirecting those funds to patient care, and puts into place economic mechanisms that slow the rate of increase in future health care costs. Spending can be contained while both quality and access are improved.

It is time to retire the meme that improving access, costs or quality can be done only by introducing impairments. Don’t let the policy community get away with that claim anymore. Aaron Carroll’s integrity is of such a high caliber that he certainly is not misleading us, but he clearly needs to end his denial.

Many Insurance Plans Heap Healthcare Costs on Consumers

Plans with lower premiums burden members with potentially crushing costs

By Steve Sternberg and Chris I. Young
U.S. News & World Report, October 3, 2012

A first-ever U.S News analysis of nearly 6,000 health insurance plans marketed to individuals and families reveals that many of the consumers who enroll in these plans may confront budget-wrecking out-of-pocket costs that deplete their savings.

Each of the plans in the U.S. News database was scored and assigned a rating of one to five stars; plans available to both individuals and families were rated separately for each. A plan’s score depended on completeness of coverage in as many as two dozen benefit categories and subcategories—hospitalization, outpatient surgery, name-brand prescription drugs, and emergency room visits are just a few examples—and how much of the cost consumers have to pay.

The plans U.S. News rated, which are those sold to individuals and families who have no access to employer or public coverage, currently cover some 14 million people. That number could very well double once the major provisions of health reform’s Affordable Care Act take effect in 2014, according to the bipartisan Congressional Budget Office, because the ACA mandates that everyone must have health insurance or pay a penalty.

U.S. News spent several months working with data obtained from the Centers for Medicare and Medicaid Services (CMS), a federal agency that summarizes plan coverage and pricing on a consumer page but does not rate or rank plans against each other. The analysis posed many challenges, including constant flux in the number of plans available in the federal database. That is because of incomplete reporting and because health insurers periodically create new plans and stop enrolling applicants in established ones.

Research into purchasing behavior shows that health insurance shoppers are strongly influenced by the size of the monthly premium. It is a regular outlay, like a mortgage or rent payment, so weighing its impact on one’s monthly budget makes sense—to a point. An individual or family that opts for an easily affordable premium can be blindsided in the event of traumatic injury or major illness. A plan that may seem like a good choice because it has a lower monthly premium may require consumers to pay much more out-of-pocket every time they need medical care.

Plans are often far from transparent about how much consumers must pay for medical services. The term “out-of-pocket maximum,” supposedly meaning the most a consumer will have to pay for medical services, is misleading; 90 percent of plans exclude some combination of deductible, copays (upfront fees paid for service), and coinsurance (the consumer’s share of the charges). Nearly 100 plans exclude all three. A plan member with average coverage who needs surgery could end up paying thousands more than their out-of-pocket cap.

If a hospital’s physicians aren’t members of a health plan’s network, the cost may climb even higher, an expense that often comes as a shock to plan members who assume their care is covered. The same is often true for hospital services, such as occupational therapy, that are not provided by physicians.

The higher you have to climb the deductible ladder before benefits are paid out, the more vulnerable your income and savings. Medical bills tend to come in waves. A routine doctor’s visit that starts with an annual physical and progresses to a tentative diagnosis can trigger a cascade of expenses, from lab tests to prescription drugs to inpatient or outpatient hospital procedures. Plans rarely cover more than a portion of those costs, which may add up to tens of thousands of dollars when severe illness strikes.


No surprise. The title of this article says what we already knew: “Many Insurance Plans Heap Healthcare Costs on Consumers.” Further, individuals and families most often select plans based on how easily affordable the premium is, and those plans can easily exceed the supposed out-of-pocket maximum.

The Affordable Care Act includes some measures that will reduce some of the abuses of these plans, but it still leaves in place the fundamental infrastructure of private health plans. Shoppers in the state health insurance exchanges should understand that the plans they purchase will ensure neither financial security nor health security. We can do far better, beginning with establishing a single payer infrastructure.

U-Shaped Curve of Health Status and Coverage

Posted by on Tuesday, Oct 2, 2012

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 Status, Health Insurance, and Medical Services Utilization: 2010

By Brett O’Hara and Kyle Caswell
United States Census Bureau: Current Population Reports, October 2012

There is a U-shaped relationship between health status and having any type of health insurance coverage. Among all people who reported excellent health, 85.0 percent were insured. For those who reported good health, 80.2 percent had health insurance coverage. Finally, 85.1 percent of people who reported poor health also had health insurance coverage.

This U-shaped relationship for the overall insurance rate is partially attributable to trends in the type of health insurance coverage. For example, 15.7 percent of people with excellent health reported having only public insurance, compared with 44.7 percent of people with poor health. On the other hand, the percentage of people with excellent health who had private health insurance was 69.3 percent, compared with 40.4 percent of people in poor health.


This seemingly mundane observation from this Census Bureau report provides great insight into the problems with health care financing in the United States.

It is astonishing that a country that spends so much on health care would have a U-shaped curve, or any curve for that matter, on the relationship between health status and whether or not one is insured.

Considering our financing system, the curve is easy to understand. People in excellent health also tend to have favorable socioeconomic circumstances that would result in higher enrollment in private insurance plans. Likewise, people in poor health tend to have less favorable socioeconomic circumstances that would result in higher enrollment in public insurance programs. People in good health would fall in between and thus would lie in the trough of the U-shaped curve, with lower rates of insurance than those well off and those benefiting from government programs.

If we had a decent health care financing system, wouldn’t those in good health be as well covered as those in excellent health and those with public programs? More importantly, shouldn’t either end of the U-shaped curve reach 100 percent coverage? And wouldn’t the trough be wiped out so everyone with good health were covered as well?

The Affordable Care Act might shift the entire curve up as more are covered, but the 30 million who will remain uninsured will perpetuate the bizarre U-shape of the curve. We need a flat line, at the top, with 100 percent coverage. That’s everyone, like we would have in an improved Medicare for all.

Small business owners under the Affordable Care Act

Posted by on Monday, Oct 1, 2012

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.

How Small Business Owners Get Health Insurance

By Larry Levitt, Anthony Damico, and Gary Claxton
Kaiser Family Foundation, Health Insurance and Reform, September 28, 2012

As with any economic policy issue, there has been much discussion of how the Affordable Care Act (ACA) will affect small businesses. But, there’s been very little focus on how the health reform law will affect the owners of those businesses as people.

As our recently released Employer Health Benefits Survey shows, small businesses are much less likely than larger businesses to offer health benefits to their workers. Half of businesses with 3-9 workers and 73% of firms with 10-24 workers provide health insurance. That contrasts with 98% of firms with 200 or more workers that offer health coverage.

The workers in these firms that do not offer coverage must rely on employer-based insurance through a family member, buying insurance in the individual market (assuming they can afford the coverage and do not have a pre-existing health condition), or in many cases going uninsured.

But what about the owners of these small businesses? They’re pretty much in the same boat.

A few striking things emerge from this analysis:

• About one in four small business owners is uninsured, roughly the same as for non-elderly adults generally.

• Just 40% of small business owners get job-based insurance, either from their own job or through a family member. In contrast, almost six in ten non-elderly adults get their insurance through an employer.

• Small business owners rely heavily on the individual insurance market, with 30% of them buying “other private insurance” (the vast majority of which is coverage purchased in the individual market).

This suggests that the biggest effects the ACA will have on small business owners may not be changes in the rules for the small business insurance market, but rather the changes in the individual insurance market: guaranteed access to coverage and no premium surcharges for people with pre-existing health conditions, limits on how much premiums can vary by age, a requirement that all insurers cover a set of “essential” benefits, the creation of health insurance exchanges, the requirement to be insured, and tax credits to make premiums more affordable. In fact, an estimated 60% of small business owners now buying insurance in the individual market have incomes up to 400% of the poverty level and would be eligible for tax credits in exchanges or Medicaid, and 83% of owners who are now uninsured would be eligible for subsidized coverage (split about equally between tax credits and Medicaid).

It may be that we can gain more insight into the implications of policy issues like health reform for small business by focusing less on the businesses themselves and more on the people who own them.


Census tables on firm sizes, receipts and payrolls:

In both policy and political debates, small business owners have been separated out for special attention as “job creators” who should not have to pay higher marginal income tax rates on the portion of their incomes over $1 million. This deceptive framing that falsely suggests that they are the primary drivers of our economy masks the fact that most small business owners have very modest incomes and are heavily dependent on the dysfunctional individual insurance market, and one-fourth of them aren’t even insured.

Over three-fourths of firms have no payroll, so these represent self-employed business owners, presumably with very modest incomes on average (see Census link above). Of firms with payrolls, over half have total receipts of less than $100,000 which is used for payrolls, all other business expenses, and the net income of the business owner. Most small business owners do not fall into the prototype “job creators” that the politicians keep talking about.

They have a problem with health insurance. This Kaiser reports shows that many of them will benefit from the improvements in the individual insurance market that are required by the Affordable Care Act. But, as we have shown many times in the past, these plans will still have unaffordable premiums and unaffordable out-of-pocket costs, even with the subsidies to be provided by the Act. Many of them will remain in the ranks of the uninsured, estimated by the CBO to be 30 million people. The Affordable Care Act will not meet the health care needs of far too many small business owners.

Our small business owners deserve what all of us deserve: an affordable health care system that takes care of everyone – an improved Medicare for all.

Wealth redistribution for health care

Posted by on Friday, Sep 28, 2012

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.

Redistribution of Wealth in America

By Uwe E. Reinhardt
The New York Times, September 28, 2012

A recent article in The Washington Post and an audio clip accompanying it on the Web featured an excerpt from a speech in 1998 by Barack Obama, then an Illinois state senator, at Loyola University Chicago.

In that speech he remarked, “I actually believe in redistribution, at least at a certain level, to make sure that everybody’s got a shot.”

The article then quotes Mitt Romney: “I know there are some who believe that if you simply take from some and give to others then we’ll all be better off. It’s known as redistribution. It’s never been a characteristic of America.”


Aside from hard-core libertarians, who view the sanctity of justly begotten private property as the overarching social value and any form of coerced redistribution as unjust, how many Americans on the left and right of the political spectrum would disagree with Mr. Obama’s very general and cautiously phrased statement?

In fact, I wonder whether even Governor Romney actually disagrees with that general statement, aside from some dispute over “the certain level” at which redistribution takes place. After all, he has promised elderly voters to protect the highly redistributive Medicare program, which would remain highly redistributive, or become more so, under proposals by his running mate, Representative Paul D. Ryan, for restructuring Medicare.

The fact is that redistributive government policy — mainly through benefits-in-kind programs, agricultural policy and the like — has been very much a characteristic of American life, just as it has been in every economically developed nation, albeit at different levels.

At issue between the two political camps in this election season, then, is not redistribution per se, which is as American as apple pie. Rather, at issue is the “certain level” to which that redistribution is to be pushed. An honest and thoughtful debate on that would certainly be useful at this time. It would be useful at any time.

To be respectful to voters, such a debate should proceed at a level concrete enough to allow voters — or at least researchers and news organizations — to estimate fairly precisely how different families would fare under the different visions of that “certain level.”

It is the minimum voters ought to expect from political candidates.


Comment originally published on the New York Times Economix blog.

Even though Mitt Romney derides redistribution, he too actually supports it. “Romneycare” was prompted by an opportunity to use a larger share of federal Medicaid funds if they could design a program that would comply with federal requirements. Although Medicaid is a program with redistribution to the poor, in this instance it was also a redistribution to Massachusetts from the taxpayers of all other states, since Massachusetts would have had to forgo the funds had they not acted.

Romney is now taking pride in that transfer, but at the same time he rejects “Obamacare,” even though it is a program which ensures a similar redistribution as he supported in Massachusetts, but with a greater degree of fairness in the redistribution between states.

We could dismiss this as the silliness typical of electoral politics, except that the politicians carry through with policy once they are in control. That has consequences. We have the most expensive health care system of all nations, yet also one of the most inequitable, partly because of our failure to adopt policies that would ensure the fairest redistribution through an efficient health care financing system.

The most efficient system that eventually would receive the support of the majority of U.S. citizens would be an improved Medicare program that served everyone. That would be the right way to redistribute our wealth to the benefit of our health, if only we citizens had the political wisdom to demand it.

Important! Large self-insured employers are bailing out

Posted by on Thursday, Sep 27, 2012

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.

Big Firms Overhaul Health Coverage

By Anna Wilde Mathews
The Wall Street Journal, September 26, 2012

Two big employers are planning a radical change in the way they provide health benefits to their workers, giving employees a fixed sum of money and allowing them to choose their medical coverage and insurer from an online marketplace.

Sears Holdings Corp. and Darden Restaurants Inc. say the change isn’t designed to make workers pay a higher share of health-coverage costs. Instead they say it is supposed to put more control over health benefits in the hands of employees.

The approach will be closely watched by firms around the U.S. If it eventually takes hold widely, it might parallel the transition from company-provided pensions to 401(k) retirement-savings plans controlled by workers and funded partly by employer contributions. For employees, the concern will be that they could end up more directly exposed to the upward march of health costs.

“It’s a fundamental change…the employer is saying, ‘Here’s a pot of money, go shop,’ ” said Paul Fronstin, director of health research at the Employee Benefit Research Institute, a nonprofit. The worry for employees is that “the money may not be sufficient and it may not keep up with premium inflation.”

Darden did say that employees will pay the same contribution out of their own pockets that they currently do for approximately the same level of coverage. Employees who pick more expensive coverage will pay more from their paychecks to make up the gap. Those who opt for cheaper insurance, which may involve bigger deductibles or more limited networks of doctors and hospitals, will pay less.

“It puts the choice in the employee’s hands to buy up or buy down,” said Danielle Kirgan, a senior vice president at Darden. The owner of chains including Olive Garden and Red Lobster will let its approximately 45,000 full-time employees choose the new coverage in November, to kick in Jan. 1. Darden says that employees with families to cover will be given more money to buy insurance than employees covering just themselves.

The hope is that insurers will compete more vigorously to get workers to sign up, which will lower overall health-care costs. Darden and Sears are both currently self-insured, meaning that the cost of claims each year comes out of company coffers.

Several big benefits consultants and health insurers are betting on the employee-choice model. Major consulting firm Aon Hewitt, a unit of Aon PLC, is behind the insurance exchange that Sears and Darden will use, while rival Towers Watson TW & Co. in May bought Extend Health Inc., an online marketplace used by employers to hook retirees up with Medicare coverage. It plans to expand the marketplace to include active workers buying individual plans, starting in 2014.

“Within the next two or three years, it’s going to be mainstream,” said Ken Goulet, executive vice president at WellPoint Inc. The insurer will roll out a product next year called Anthem Health Marketplace that lets employers offer a variety of its plans to workers, paired with a fixed contribution. Mr. Goulet said it is close to signing up more than 30 midsize and large employers for early next year, including one with more than 50,000 workers.

Exchange operators today say they offer employers more predictable costs, as well as potential savings gleaned from workers’ voluntary choice of skinnier coverage and competition among insurers offering plans on the exchanges.


Many larger employers have said that they do not want to be the first to initiate major structural reforms in their employee health benefit programs – reforms that would bring the employers relief but at a cost to their employees – but that they would quickly follow others out the door. It looks like the door has opened.

This is a very fundamental change in employee health benefit coverage. The Affordable Care Act relies heavily on self-insured large employers maintaining their coverage of a large percentage on America’s workforce, so that the Act can concentrate on lower-income and uninsured individuals. Under the radical change described in this WSJ article, employers will discontinue their self-insured programs and switch to a defined contribution – a specific dollar amount that employees will use to shop for health plans in these employer insurance exchanges.

There has been considerable discussion recently over converting Medicare to a defined contribution – premium support or voucher program – in which the costs to the government would be fixed to some index of inflation, whereas the greater increases in health care costs would be borne by the Medicare beneficiary. Thus health care would become less and less affordable, especially for those with greater health care needs.

With this move by employers, they are putting in place the same perverse defined contribution approach which we have determined would be so destructive to our Medicare program. And, oh yes, the benefits consultants and health insurers are jumping in to draw off even more health care funds in administrative costs – already one of the greatest burdens in our health care system. The executive vice president of WellPoint says, “Within the next two or three years, it’s going to be mainstream.”

Further, as was reported in yesterday’s Quote of the Day, over 90 percent of individuals do not select the Medicare Part D drug plan that would be best in their individual circumstances. It shows that health insurance shoppers really do not know how to shop for health insurance. Obviously comprehensive health plans are much more complex, and it would be virtually impossible for individuals to select the best plan, even with the language of simplified plan descriptions called for in the Affordable Care Act.

In fact, several studies have shown that most individuals select plans based primarily on the lowest net premium, with very little attention paid to plan benefits and cost sharing. The most common strategy for insurers to keep premiums low is to use large deductibles and coinsurance, though they also manipulate benefits and provider networks to reduce costs. Besides the increasing deductibles, coinsurance is particularly a problem since it is a percentage of the charges rather than a dollar copayment which is usually much smaller. Low premium plans tend to set coinsurance rates at very high percentages. As this article states, the savings will be dependent upon “workers’ voluntary choice of skinnier coverage.” It’s all the workers’ fault!

It is likely that the initial defined contributions will be fairly close to the amounts that employers are currently paying for the health benefit programs, so the immediate impact will not be transparent. Only after many employees face bankrupting medical debt – a phenomenon that will increase as the employer contribution buys ever less insurance – will the implications be clear. It is tragic that so many will have to experience financial hardship before we are ready to get serious about fixing our system by enacting an improved Medicare for everyone.

Important! Over 90 percent fail choose the right Part D plan

Posted by on Wednesday, Sep 26, 2012

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.

Plan Selection in Medicare Part D: Evidence from Administrative Data

By Florian Heiss, Adam Leive, Daniel McFadden, Joachim Winter
The National Bureau of Economic Researchm June 2012

From the NBER Digest:

Fewer than 10 percent of individuals enroll in what for them would be the most cost-effective plans.

In Plan Selection in Medicare Part D: Evidence from Administrative Data (NBER Working Paper No. 18166), co-authors Florian Heiss, Adam Leive, Daniel McFadden, and Joachim Winter analyze data on medical claims in Medicare Part D drug insurance programs. They find that fewer than 10 percent of individuals enroll in what for them would be the most cost-effective plans. This is apparently because seniors pay more attention to their out-of-pocket premiums than to the overall benefits of the dozens of drug plans available to them. Equally significant, the researchers believe that how seniors decide whether to enroll in Medicare Part D, and what plans they select, is important not only for management of the Part D program, but also is indicative of how consumers behave in real-world decision situations with a complex, ambiguous structure and high stakes. The researchers add that their findings may yield predictions for how seniors will handle plan choices in the new general health insurance exchanges that will implement the Patient Protection and Affordable Care Act of 2010.


NBER Working Paper No. 18166 (47 pages):

If over 90 percent of purchasers of the Medicare Part D drug plans fail to choose the plans that are best for themselves, then how could we ever expect them to make wise decisions in selecting the best plans from the much more complex plans of the state health insurance exchanges, or, for that matter, from the choice of Medicare Advantage plans or the plan choices to be offered in the proposed premium support (voucher) markets?

The last sentence from “Conclusions” in their paper: “Our results then do not support the proposition that consumers can make and benefit from good choices in private health insurance markets, and direct health care resources to their best use.”

This is really important. Inserting very expensive, profoundly wasteful insurer administrative intermediaries into the system under the guise of choice – choices that cannot be made on a rational basis, choices that are all worse than a single, comprehensive publicly-administered plan would be – is the ultimate of reckless decisions made by the policy community and the politicians that they work for.

Let’s improve Medicare by eliminating the Part D and Medicare Advantage intermediaries and folding an improved version of those benefits into the traditional Medicare program, and then provide it to everyone. It would be cheaper overall and would open up our choices to the choices we really want – that of our health care professionals and institutions. That would be far better than this nonsense of choosing from all the wrong choices.

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