Insurers face consequences whether or not reform fails

Posted by on Friday, Jan 22, 2010

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

If Bills Fail, a Quandary for Insurers

By Reed Abelson
The New York Times
January 21, 2010

With the possible collapse of the Congressional health care effort, health insurers might seem to have reason to celebrate. The legislation threatened to remake much of their business, with the prospect of burdensome government regulation and less profit from selling coverage to individuals and small businesses.

But now, in the possible absence of forced change to their business, the insurers still face the daunting challenge of selling a product that is increasingly out of reach for more Americans as the cost of medical care — and thus premiums — continues to climb.

Moreover, the industry’s main business of selling coverage through employers has largely stalled, while the weak economy has speeded the loss of customers as people lose their jobs and their health insurance.

“People are still being crowded out of the market because they can’t afford it,” said Sheryl R. Skolnick, a health care analyst for Pali Capital in New York.

But without the aid of the government through some provisions of the legislation, some policy analysts say the insurers might be hard pressed to rein in the fees charged by hospitals and doctors.

“They’ve lost all the leverage reform would have given them,” said Len Nichols, a health care economist for the New America Foundation, a policy research organization that supports an overhaul.

And the insurers say they know they cannot fix many of the problems in the health care system without the support of the government.

For insurers, the largest risk may be that without a government-led overhaul, their industry faces an even bleaker future should medical costs and premiums continue to soar, perhaps eventually prompting draconian changes from the government.

By the time Congress dares to try again to overhaul health care, some analysts predict, the problems with the system might be so acute that Washington might regulate the insurers more heavily than has been considered for the current legislation — or flirt even more with the idea of the federal government becoming directly involved in providing insurance.

“It’s going to come back to the forefront again,” predicted Matthew Borsch, an analyst at Goldman Sachs who follows the industry and says the insurers face an increasingly daunting environment.

We have stated repeatedly that health care costs are now so high that private insurers are no longer capable of providing health plans with affordable premiums if those plans are to be effective in preventing financial hardship in the face of medical need. Private health plans are an obsolete method of financing health care.

The health care reform process began with the goals of covering everyone and controlling health care costs. That would have been a straightforward task had they agreed to establish a single payer national health program. Instead it was decided to build reform on the foundation of our existing private insurance industry that is approaching obsolescence.

Keep in mind what health care now costs for our healthiest sector – the healthy workforce and their young healthy families. The average costs for a family of four is now $16,771 (Milliman Medical Index). This does not include insurer administrative costs. Considering that median household income is $50,303 (2008), the premium that must be charged for a private plan with adequate benefits, plus the out-of-pocket expenses, are totally out of reach for the average family.

The private insurance industry has survived to this point primarily for two reasons. Most important is that they have been able to sell their products to the healthiest of us – group plans for the healthy workforce, and individual plans for those who pass underwriting requirements. Also the tradition of employer sponsorship of plans has provided a revenue source that has been tolerated by workers who forgo their wage increases.

But the cost of these plans have reached a threshold such that employees are no longer tolerating stagnation of their wages, and employers are no longer tolerating the costs of their combined employee wage and benefit packages. Insurance plan innovations designed to slow the premium increases to keep them competitive have shifted costs to employees who actually need health care. The backlash against these unanticipated costs is sure to accelerate.

The insurance industry had no choice but to turn to the government for solutions that would ensure its survival. As Congress patched the reform proposal together, it became immediately obvious that the private insurance model was not capable of covering everyone, so they gave up on the goal of universal coverage. As they continued to work on the problem of high costs, the limitations of the private insurance model left them with wish-they-would-work policy options that would have very little impact on cost containment.

With abandonment of the two primary goals for reform, Congress was left with the job of patching together policies that would keep the insurance industry in play, as if protecting the private insurers was the primary goal in the first place. To greatly expand their market, the insurers would have to accept patients who actually needed health care, ending disqualification for preexisting disorders. To prevent adverse selection, everyone would be mandated to purchase health plans.

That would provide the plans with the market that they need, but it left one more problem. To make premiums affordable, even with subsidies, health care costs would have to be controlled. The insurers insist that the government must control the costs, but that does not work in a model designed to leave the private insurers in charge of health care financing.

If no reform is enacted, the entire insurance industry goes into the death spiral of ever higher premiums. If the Senate version is enacted, the insurers would get a temporary reprieve through the government subsidies, but it would not be long before rising costs would again be unbearable for the payers. The golden age of America’s private health insurance industry is about to end, whether or not a bill passes.

The Massachusetts election has given us a brief window in which we can step back and ponder, “What on earth are we doing!?” We can do it right. We can dismiss the obsolete model of private insurance plans and enact an equitably-financed, improved Medicare that really would include all of us, and provide an effective mechanism for slowing health care spending.

Will President Obama salvage his centerpiece?

Posted by on Thursday, Jan 21, 2010

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

George Stephanopoulos’ Exclusive Interview with President Obama

ABC News
January 20, 2010

President Obama:  I would advise that we try to move quickly to coalesce around those elements of the package that people agree on. We know that we need insurance reform, that the health insurance companies are taking advantage of people. We know that we have to have some form of cost containment because if we don’t, then our budgets are going to blow up and we know that small businesses are going to need help so that they can provide health insurance to their families. Those are the core, some of the core elements of, to this bill.


President Obama:  If you ask the American people about health care, one of the things that drives them crazy is insurance companies denying people coverage because of preexisting conditions. Well, it turns out that if you don’t — if you don’t make sure that everybody has health insurance, then you can’t eliminate insurance companies — you can’t stop insurance companies from discriminating against people because of preexisting conditions. Well, if you’re going to give everybody health insurance, you’ve got to make sure it’s affordable. So it turns out that a lot of these things are interconnected.

It looks like there are four choices: 1) walk away and accept the status quo, 2) use alternative political maneuvers to move the bill through Congress,  3) attempt to salvage at least a portion of the less controversial components of the current proposal, or 4) start over. Let’s look at these.

1) Walk away

Far too many individuals and businesses are no longer capable of paying the very high costs of our health care system. The existing spending controls in government and in the marketplace show no evidence of ameliorating the excessive growth of our total national health expenditures. The status quo is unacceptable. On this everyone agrees, so we cannot walk away.

2) Move the bill through Congress anyway

The strategy that has been advanced to pass the bill relatively intact would be to have the House approve the Senate version, and then make corrections in a budget reconciliation process. We can forget this approach since the bill managers’ head count in the House has come up far short of the votes needed. Also, cramming the bill through before Sen. Kirk is replaced by Scott Brown has been rejected by President Obama and other Democratic leaders. But the overriding reason why this bill will not clear Congress intact is that a majority of Americans are very displeased with it – that includes all conservatives, most liberals, and a majority of moderates. Sometimes we question the collective wisdom of Congress, but they’re not that dense.

3) Salvage a portion of the legislation

Crafting a health care financing system and integrating it with the health care delivery system creates a dysfunctional system if it is done piecemeal. That’s what we’ve been doing over the past century, and it’s obvious where that has led. As President Obama said, “it turns out that a lot of these things are interconnected.”

President Obama and some members of Congress would still like to salvage the centerpiece of this legislation – making health insurance markets work for us. They would like to do that without including the policies that offended so many in Massachusetts and throughout the nation – new taxes, and an individual mandate to purchase private insurance. If there is no mandate then there is less need for the taxes that would be required to pay for the private insurance subsidies. Of course, without a mandate, many more will be left uninsured, but that seems to be the price that many members of Congress are willing to pay simply to pass something that looks like reform.

President Obama shows that he understands the greatest difficulty with reforming the private insurance market as a stand-alone process. The insurer abuses that he wants to eliminate were there for a reason. They are designed to reduce the amount of health care that the insurers fund. Once the insurers are required to cover all risks, insurance premiums increase. With no mandate, many of the healthy will decide they cannot afford the higher premiums and will remain uninsured. The adverse selection that would result could send our entire private insurance industry into a death spiral of skyrocketing premiums.

Obviously, as we’ve been saying all along, the centerpiece based on private insurance plans is inherently a dysfunctional model that can never achieve efficiency, equity, universality, and affordability for all of us.

That said, there are some measures in this legislation that could be salvaged and enacted on an emergency basis until we finish the task of delivering a just health care system for all. As prime examples, we should move immediately to expand Community Health Centers and to reinforce our primary care infrastructure. We should also recover the overpayments to the Medicare Advantage plans that are wasted on excess administration and investor profits. There are many other beneficial measures that could be enacted without requiring that they be part of an omnibus bill.

4) Start over

The policy work has already been done. We know what we need – an improved Medicare for all national health program. President Obama and most of the Democrats in Congress know that as well.

Even the conservatives certainly understand that it would work for all of us and that, once enacted, it would be in place forever because of its popularity. Since they can’t oppose it based on its sound policies, they simply oppose it based on their ideological opposition to social solidarity. That is perhaps the saddest reality in this whole debate.

What Would FDR Do?

Posted by on Wednesday, Jan 20, 2010

I had some face time with Rahm Emmanuel two weeks ago at my friend Owen’s. (Owen’s brother-in-law is the former Chair of the Democratic National Committee.) Rahm said nothing surprising, but made his points. He had just finished David Kennedy’s 1999 book Freedom from Fear about WW II, the Depression, and, germane to this conversation, the tremendous compromises involved in forging the New Deal. Politically, he asserted, if you want to make big changes, you have to choose your battles and win the big ones. If health reform goes down, then energy, global warming, financial reform, and labor’s legislative agenda are all at risk. He stayed right on message.

I posed this to him: “Many Democratic politicians, including our Blue Dog Rep. Baron Hill, tell us in private conversations that they believe we have to get to single payer eventually. What advice would you give on how to get there?” Without a blink, he replied it’s “going to be a long haul”, and if we don’t pass this bill it’s going to be even longer. He asserted that this bill begins building the required infrastructure for any future progress.

Since then, with the loss of the Democrats’ super-majority in the Senate everything is up in the air. Which brings us back to the recurring question – Should we Kill the Bill? There has been an incredible amount written in the Progressive community about this. At one end is Helen Redmond (CounterPunch 12/23) Beware the Progressive Democrat arguing that we can’t trust Sanders, Weiner, or Conyers and that we’ve got to build our movement without any of that unreliable crew (kind of a rough “logical”conclusion”, if you ask me).

At the other end is Nate Silver of FIveThirtyEight (12/16) Health Care: The Elevator Pitch (and a number of other posts) where this bright political analyst makes the case for incrementalism. Silver also notes “I’ve gotten as many nasty comments and e-mails from Democrats on this issue [over the last two weeks] as I have in the past six months from conservatives on all issues. That emotion is a factor in this debate seems self-evident to me.”

All that emotion is evident as the blame is ladled out for Scott Brown’s Senate victory. Is the message that the country is turning against the Progressives’ urge to legislate change, or that Obama has compromised the hope for change he promised by reverting to Washington business-as-usual and disappointing his base?

The healthcare bill will be at the center of this cyclone, and it’s too soon to say what gyrations the Dems will attempt to push it through. Our response as single payer advocates should remain unchanged – we have strong, informed positions on the poor policy provisions in the bill. I think we are best to remain silent on the political strategy (tragedy?) to be pursued. I see an important distinction between being a pointed, persistent, insistent, carping, kvetching, nagging critic of this bill for policy reasons on the one hand, and joining in the political discussion about the merits of killing the bill on the other.

Let’s not be drawn into the classic Progressive Circular Firing Squad. Our message is clear. If the Democrats still manage to pass some form of health reform, they can celebrate, but WE’RE STILL FOR HEALTH REFORM, AND THIS AIN’T IT!

If no bill passes, then we have a different set of problems/opportunities. If those who predict Republican ascendancy in the ’10 elections are right, then our work is really cut out for us. Meanwhile, all those who forsook single payer for the allure of the public option are ripe to be brought back into our fold. Movement building will continue. Opportunities to form coalitions will appear. As the business community becomes even more frustrated they will open to our message.

Here are the real lessons learned as we look back to the Iowa caucuses last January, from our vantage point looking out on the chaos this January:

1. As much as we had hoped that this was a historic opportunity to make drastic, needed changes in our healthcare system, there really wasn’t the support to go all the way to single payer. We can second guess Obama and Rahm forever, but I don’t believe there ever was a chance in hell that Evan Bayh, much less Lieberman or Ben Nelson would have ever voted for single payer.

2. We should look again at a strategy of incremental reforms, a strategy that has been fruitful for many movements. That is a longer story to explore later.

3. No matter how hard we try to predict the future, we will always be surprised. Remember that even if single payer had passed in the full glory of HR 676 without amendment, we would have to defend it, improve it, and deal with its unintended consequences. This work will never end.

How can we ever hope to win? As Bill Moyers asked David Corn on his PBS show January 8, “Have people been so politically abused that the will to fight for democracy, the political will has been dissipated? “

Will it first take campaign finance reform, to break the grip of the big money? Where will that movement come from? What other options do we have?

There is no better issue to organize around than universal health care. In the environmental movement we learned the word NIMBY – Not In My Back Yard. Sometimes people distain NIMBY’s, but many a NIMBY activist has started locally before coming around to a global perspective. Healthcare is everyone’s back yard, front yard, and right inside the house. Our issue’s not going away, even if some politicians do.

We will stay in this fight for the long haul. There is no real alternative except to quit. When I get discouraged, I turn to one of the original crusading journalists and a real hero, IF Stone (no relation):

“The only kinds of fights worth fighting are those you are going to lose, because somebody has to fight them and lose and lose and lose until someday, somebody who believes as you do wins. In order for somebody to win an important, major fight 100 years hence, a lot of other people have go to be willing – for the sheer fun and joy of it – to go right ahead and fight, knowing you’re going to lose. You mustn’t feel like a martyr. You’ve got to enjoy it.”

One of the great joys of being in PNHP has been the joy of meeting and working with so many wonderful people. I’m in this for the long haul and look forward to seeing you all many more times in the years to come.

Was the Massachusetts election about health reform?

Posted by on Wednesday, Jan 20, 2010

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

Exit poll: Health care mattered

By David Catanese
January 20, 2010

Scott Brown’s opposition to congressional health care legislation was the most important issue that fueled his U.S. Senate victory in Massachusetts, according to exit poll data collected following the Tuesday special election.

Fifty-two percent of Bay State voters who were surveyed as the polls closed said they opposed the federal health care reform measure and 42 percent said they cast their ballot to help stop President Obama from passing his chief domestic initiative.

“I’m not surprised it was the top issue, but I was surprised by how overwhelming an issue it was. It became a focal point for the frustration that has been brewing with voters, and it’s a very personal issue that affects everyone,” said Tony Fabrizio of Fabrizio, McLaughlin & Associates, a Republican firm that conducted the exit poll of 800 voters.

According to Fabrizio’s findings, 48 percent of Massachusetts voters said that health care was the single issue driving their vote and 39 percent said they voted for Brown specifically because of his vocal opposition to the measure.

Massachusetts has had a law in place for the past four years that requires every resident to purchase health insurance, and reaction among residents to the mandate has been mixed.

But Fabrizio said that program remains controversial with voters who have not seen their medical costs drop significantly. “It is grossly over budget and causing the state severe fiscal problems. In short, Massachusetts voters know the shortcomings of government health care,” he said.


NBC News/Wall Street Journal Survey

January 10-14, 2010

12. I’m going to read you two statements about the role of government, and I’d like to know which one comes closer to your point of view.

43% – Statement A: Government should do more to solve problems and help meet the needs of people.
48% – Statement B: Government is doing too many things better left to businesses and individuals.
6% – Some of both
3% – Not sure

30. From what you have heard about Barack Obama’s health care plan, do you think his plan is a good idea or a bad idea? If you do not have an opinion either way, please just say so.

33% – Good idea
46% – Bad idea
18% – Do not have an opinion
3% – Not sure

32. Thinking about efforts to reform the health care system, which would concern you more?

40% – Not doing enough to make the health care system better than it is now by lowering costs and covering the uninsured.
53% – Going too far and making the health care system worse than it is now in terms of quality of care and choice of doctor.
7% – Not sure

Oh no! Not another commentary on the significance of the Massachusetts special election for U.S. Senator.

This one will be brief, and include input from the current NBC News/Wall Street Journal Survey.

The election confirmed that there is significant opposition to the health care reform bill before Congress.

When expressed in generalities, people remain divided on the appropriate role of government in solving our problems. That conclusion cannot be extrapolated to specific programs and policies.

Question # 32 (NBC/WSJ) requires individuals to choose between “lowering costs and covering the uninsured” on the one hand and “quality of care and choice of doctor” on the other, when most individuals support all four concepts. The implication is that you can’t have it all, but an improved Medicare program covering everyone would achieve all of these goals.

We must be very careful to not misinterpret the rejection of the highly flawed reform proposal before Congress. It does not mean that comprehensive reform has been rejected.

There is overwhelming support for our Medicare program. If the public understood that all of us could benefit from an improved Medicare program for everyone, the political dynamics could shift. But we have much more work to do to deliver that message.

California’s lesson on promptness of corrective legislation

Posted by on Tuesday, Jan 19, 2010

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

California limits HMO wait times

By Duke Helfand
Los Angeles Times
January 19, 2010

Seeking to reduce the long waits many people endure to see a doctor, California regulators are implementing new rules that specify how quickly patients in health maintenance organizations must be seen.

The regulations by the California Department of Managed Health Care, in the works for much of the last decade, will require that patients be treated by HMO doctors within 10 business days of requesting an appointment, and by specialists within 15.

The managed healthcare department acted in response to a 2002 law that mandated more timely access to medical care. The law left it to state officials to work out the details, which became subject to protracted negotiations with HMOs, doctors, hospitals, consumer groups and other healthcare activists.

In all, it took seven years to finally reach agreement amid intensive talks, bureaucratic hurdles and a lengthy rule-writing process, participants said.

HMOs will be given until January 2011 to comply.,0,3456276,full.story

Remember the managed care revolution in the latter part of the last century? Remember how angry everyone became over the interventions designed to control spending by preventing patents from having timely access to care?

As a leader in managed care, California, very early on, began the process to enact corrective legislation to reduce some of the abuses. However it took them until 2002 to pass a law as simple as limiting the delays for appointments for medical care, and the law won’t even apply until 2011.

What have they done to correct other abuses such as the refusal to pay after bungled prior authorization requests, or the refusal to even authorize recommended care, or gouging made possible by tiering of benefits, or exposing patients to high out-of-pocket expenses through innovations in insurance product design, especially high deductibles, or, one of the worst, taking away patents’ choice of physicians and hospitals by limiting care within contracted networks of providers?

Our legislators initially jumped on the managed care bandwagon by enacting laws establishing the enabling regulatory framework that the managed care entities required. Those of us who raised alarms about the flawed policies were told that any problems could be fixed later. They never were fixed, and we’re still living with that mess.

And now we’re shouting as loud as we can that the policies contained the current legislation will leave too many uninsured, many more underinsured, and health care costs will keep increasing at intolerable rates. And what are we told now? Let’s pass this and we can fix the problems later.

We already know what the problems are, but they will not be officially acknowledged until many years after the program formally begins a few years from now. Then we will see many more years of fighting over tweaks to the system, but with no substantial reform.

Everyone understands the problems of managed care, and this reform theoretically should be replacing that flawed system with substantial reform. But what is this reform proposal? More managed care! And now with a mandate to purchase these plans or be assessed penalties.

Really. Think of what they would be doing many years from now to fix this system. Pass a federal law to specify the maximum number of days that can elapse before your provider must grant you an appointment? Come on!

This system can’t be fixed. It will have to be replaced with an improved Medicare for everyone. Why delay for maybe decades, prolonging the physical and financial suffering of those who need care now? We need to replace the system now – in 2010!

Martin Luther King, Jr. – A Proper Sense of Priorities

Posted by on Tuesday, Jan 19, 2010

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

A Proper Sense of Priorities

A speech by Martin Luther King, Jr.
Washington, D.C.
February 6, 1968

Closing remarks:

As we were marching today, some 5,000 strong, I thought about Selma because I could look around and see so many who have marched with us in Selma, and from Selma to Montgomery. And we are still marching and we are still moving. And I give you my commitment today that I plan to continue.

Someone said to me not long ago, it was a member of the press, “Dr. King, since you face so many criticisms and since you are going to hurt the budget of your organization, don’t you feel that you should kind of change and fall in line with the Administration’s policy. Aren’t you hurting the civil rights movement and people who once respected you may lose respect for you because you’re involved in this controversial issue in taking the stand against the war.”

And I had to look with a deep understanding of why he raised the question and with no bitterness in my heart and say to that man, “I’m sorry sir, but you don’t know me. I’m not a consensus leader. [Laughter – Applause] I don’t determine what is right and wrong by looking at the budget of the Southern Christian Leadership Conference or by taking….[Applause] Nor do I determine what is right and wrong by taking a Gallup poll of the majority opinion.” [Applause] Ultimately a genuine leader is not a searcher of consensus but a molder of consensus. [Applause]

On some positions cowardice asks the question, is it safe? Expediency asks the question, is it politic? Vanity asks the question, is it popular? But conscience asks the question, is it right? And there comes a time when one must take a position that is neither safe, nor politic, nor popular but he must take it because conscience tells him it is right. [Applause]

Yes… truly a proper sense of priorities… and especially apropos now for us and our friends and colleagues at PNHP.

The speech of Martin Luther King, Jr., “A Proper Sense of Priorities,” was, as the title states, a speech on the proper sense of priorities. As a central theme he expressed his opposition to the war in Vietnam.

For those who believe that it was a stretch to use a quote from an anti-war speech of Martin Luther King, Jr. to advance the cause of health care justice, the following excerpt from the same speech should clarify the intent of my message:

“I’m still convinced that the struggle for peace and the struggle for justice or the struggle for civil rights, we call it in America, can be tied together. These two issues….[Applause] They are tied together in many many ways. And I feel the people who are working for civil rights should be working for peace and I feel that those who are working for peace should be working for civil rights and justice.”

Justice in health care is what Physicians for a National Health Program is all about (and many of us incidentally are pacifists as well).

I apologize to those who perceived my communication to be deficient, though the stand-alone words of Martin Luther King, Jr. certainly require no clarification.

Health professional students restore hope

Posted by on Friday, Jan 15, 2010

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

(Note: This event occurred earlier this week, before the tragic earthquake in Haiti.)

The future of healthcare reform came to Sacramento yesterday

by Shockwave
Daily Kos
January 12, 2010

I joined the California Health Professionals Students Alliance at the Embassy Suites about a mile from the Capitol building.

Students from every medical school in California came in buses the night before.  I was impressed by their enthusiastic support of SB 810 and their ability to explain the advantages of Single Payer and this pivotal legislation which will be re-introduced at the Senate floor next month.

We then marched about a mile toward the Capitol building.

Shockwave’s diary and a 3 minute video of the event:

California Health Professional Student Alliance

This week medical students and other health professional students and colleagues marched on Sacramento in support of Sen. Mark Leno’s SB 810, a reintroduction of Sen. Sheila Kuehl’s single payer bill that was passed and vetoed twice in prior legislative sessions.

Reading Shockwave’s diary and watching the brief video can give you renewal. California’s health professional students understand that Congress abandoned so many important policies that they are ending up with legislation that ostensibly achieves a political victory, but one that is reform in name only, while leaving most of our dysfunctional system in place.

These students know what real reform is. They hold our future in their hands. Thanks to them and to all of the rest of the single payer activists, the process will continue until every single one of us can have the health care that we need.

Cato on implicit taxes of the individual mandate

Posted by on Thursday, Jan 14, 2010

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

Obama’s Prescription for Low-Wage Workers: High Implicit Taxes, Higher Premiums

by Michael F. Cannon
Cato Institute
January 13, 2010

Executive Summary

House and Senate Democrats have produced health care legislation whose mandates, subsidies, tax penalties, and health insurance regulations would penalize work and reward Americans who refuse to purchase health insurance. As a result, the legislation could trap many Americans in low-wage jobs and cause even higher health-insurance premiums, government spending, and taxes than are envisioned in the legislation.

Those mandates and subsidies would impose effective marginal tax rates on low-wage workers that would average between 53 and 74 percent — and even reach as high as 82 percent — over broad ranges of earned income. By comparison, the wealthiest Americans would face tax rates no higher than 47.9 percent.

Over smaller ranges of earned income, the legislation would impose effective marginal tax rates that exceed 100 percent. Families of four would see effective marginal tax rates as high as 174 percent under the Senate bill and 159 percent under the House bill. Under the Senate bill, adults starting at $14,560 who earn an additional $560 would see their total income fall by $200 due to higher taxes and reduced subsidies. Under the House bill, families of four starting at $43,670 who earn an additional $1,100 would see their total income fall by $870.

In addition, middle-income workers could save as much as $8,000 per year by dropping coverage and purchasing health insurance only when sick. Indeed, the legislation effectively removes any penalty on such behavior by forcing insurers to sell health insurance to the uninsured at standard premiums when they fall ill. The legislation would thus encourage “adverse selection” — an unstable situation that would drive insurance premiums, government spending, and taxes even higher.

Since the numbers and policy details in the final reform legislation have not yet been released, the results presented here by Michael Cannon of the Cato Institute may be modified, but unchanged will be the conclusion that the complex, jerry-rigged method of paying for health care premiums will not eliminate inequities.

It is almost impossible to get right the amount that each person or family should pay with so many variables moving in different directions: insurance premiums, actuarial values, premium subsidies, cost-sharing subsidies, income levels, family sizes, age rating, bracketed income cliffs of eligibility, and other factors. Financing health care by using a fixed premium for a given private insurance plan no longer works because premiums for adequate plans are no longer affordable for the majority. Trying to make health care affordable by applying corrections for the many variables increases the administrative complexity while falling short on equity.

Financing would be greatly simplified and much more equitable if we established a single risk pool that covered everyone and funded it through progressive taxes. (That likely would not be the conclusion of the libertarians at Cato, but they offered no alternative suggestions in this report, and we wouldn’t agree with them anyway.)

Urgent appeal for aid to Haiti

Posted by on Thursday, Jan 14, 2010

In the wake of Tuesday’s devastating earthquake in Haiti, the need for medicines, basic medical supplies, food and shelter is extremely urgent. Financial contributions to the relief effort are also badly needed, as are trained medical staff.

There are numerous ways to help groups already on the ground in Haiti. One of the best, Partners In Health, founded by Dr. Paul Farmer and several others, has been operating in the country since 1987. PIH operates clinics in Port au Prince and other major Haitian cities. With hospitals and a highly trained medical staff in place, Partners In Health is already bringing medical assistance and supplies to areas that have been hardest hit. Donations to PIH to help earthquake relief efforts will be quickly routed to the disaster.

You can donate online to the Partners in Health effort via this link:

or send your contribution to:
Partners In Health,
P.O. Box 845578
Boston, MA 02284-5578

Trained medical staff are also urgently needed.

Nurses who want to volunteer in Haiti are being coordinated by the Registered Nurse Response Network (RNRN), a project of the 150,000-member National Nurses United (NNU), formed last month through the unification of the California Nurses Association and other nurses unions.  RNRN is hoping to have nurse volunteers on the ground in Haiti within the next few days and is coordinating with Haitian nurses on the effort.

Details are still being worked out, but those able to support the efforts of these nurses can get involved via:

* to sign up to volunteer or donate
* @NationalNurses on twitter or by following: #haitiRN
* Call the RNRN hotline: 1-800-578-8225

The RNRN may also be able to help direct physicians who would like to volunteer in the recovery effort. Groups like Doctors without Borders are among those who are already treating victims.

Health insurers fund Chamber attack ads

Posted by on Wednesday, Jan 13, 2010

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

Health Insurers Funded Chamber Attack Ads

By Peter H. Stone
National Journal
January 12, 2010

Just as dealings with the Obama administration and congressional Democrats soured last summer, six of the nation’s biggest health insurers began quietly pumping big money into third-party television ads aimed at killing or significantly modifying the major health reform bills moving through Congress.

That money, between $10 million and $20 million, came from Aetna, Cigna, Humana, Kaiser Foundation Health Plans, UnitedHealth Group and Wellpoint, according to two health care lobbyists familiar with the transactions. The companies are all members of the powerful trade group America’s Health Insurance Plans.

The funds were solicited by AHIP and funneled to the U.S. Chamber of Commerce to help underwrite tens of millions of dollars of television ads by two business coalitions set up and subsidized by the chamber.

In late October, (AHIP President Karen) Ignagni wrote in a letter to the Washington Post defending a health insurer-funded study critical of congressional cost estimates, “Let me be clear and direct, health plans continue to strongly support reform.” However, by that time money was already flowing through AHIP to the chamber to fund its negative ads.

The fundraising started last September and continued through December using AHIP as a conduit to avoid a repeat of the political flak that hit the insurance industry after it famously ran its multimillion-dollar “Harry and Louise” ads to help kill health care reforms during the Clinton administration.

AHIP’s December 2008 proposal for reform (pages 7-11):

This is not a simple Gotcha! The largest private insurers in the nation have been caught red-handed, secretly passing funds through their lobby organization, AHIP, to the United States Chamber of Commerce to help fund the Chamber’s advertising campaign opposing the reform proposal currently before Congress.

AHIP’s Karen Ignagni repeatedly has professed publicly to “strongly support reform,” yet has now been caught in this dishonest scheme campaigning in opposition to the current proposal. When you read AHIP’s proposal for reform (link above), you will see that it almost could be used as a description of the legislation. That is no surprise since it essentially was written by the private insurance industry. The legislation contains virtually every major policy that they requested.

So why should the insurers be involved in this effort to sabotage the bill? The answer is in two parts: what they don’t like about the current legislation, and what they do like about the status quo.

As the bill moves along in the late stages towards enactment, Karen Ignagni has stated many times that this bill does not require the government to do enough to control health care spending. The industry has been struggling with innovations in health plans to slow the increase in premiums, which are already placing a strain on individuals and businesses. Health care costs are so high that they can no longer provide insurance products with affordable premiums if those products are designed to provide adequate protection from financial hardship for those who actually need health care.

Working with Congress, the Congressional Budget Office, and now academically-compromised Jonathan Gruber, the industry has seen that their proposal must leave perhaps tens of millions without insurance, and leave the majority of working families with plans set at actuarial values that are so low that anyone who needs health care will still face major bills. The answer to this problem was to be found in the subsidies, but for them to be adequate would require a massive increase in government spending. Neither Congress nor the Obama administration were willing to consider the massive tax increases that would be required to make this work.

Increasingly unaffordable premiums for plans with diminishing benefits increases the instability of the private insurance market. The insurers should rightfully fear that the time is not far away when our policy makers would decide that we finally would have to replace the insurance industry with an efficient single payer system that actually would provide everyone the essential care that they need. They know that they cannot possibly deliver of the promise of affordable health care for everyone.

So what do they like about the status quo? The largest, healthiest, least expensive sector – the employer-sponsored market – is still working very well for them. In fact, that market would change very little with the current legislation, though the insurance industry would be inconvenienced with some additional regulatory oversight. The private Medicare Advantage plans are working well for them as well, but they would not be as lucrative under the reform proposal. The individual market works well for them because they can skim off the healthy, but they would have to include the high-cost chronically ill under the reformed system, making plans even less affordable.

Why would they want to comply with all of the other measures in this bill when they already have most of what they want, and they are very effectively avoiding what they don’t want? If they can kill this bill, they would be much better off.

What we have now is not working – too many are uninsured, and too many of the insured still face excessive medical bills. What this legislation proposes will not work – too many would remain uninsured, and too many of the insured would still face excessive medical bills. What we could have, an improved Medicare for everyone, would work – everyone would be insured, and no one would have to face excessive medical bills. Furthermore, as a nation, it would provide us with a financing system that we could afford, unlike our current system or the system in the flawed proposal.

AHIP, Aetna, Cigna, Humana, Kaiser Foundation Health Plans, UnitedHealth Group and Wellpoint have lied to us, telling us that they support reform while secretly spending millions on a campaign to defeat it. Congress and President Obama now have every reason to show these crooks the door, and they should do so immediately.

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