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.
Income, Poverty, and Health Insurance Coverage in the United States: 2009
U.S. Census Bureau
Health Insurance Coverage in the United States
* The percentage of people without health insurance increased to 16.7 percent in 2009 from 15.4 percent in 2008. The number of uninsured people increased to 50.7 million in 2009 from 46.3 million in 2008.
* The number of people with health insurance decreased to 253.6 million in 2009 from 255.1 million in 2008. This is the first year that the number of people with health insurance has decreased since 1987, the first year that comparable health insurance data were collected. The number of people covered by private health insurance decreased to 194.5 million in 2009 from 201.0 million in 2008. The number of people covered by government health insurance increased to 93.2 million in 2009 from 87.4 million in 2008.
* Between 2008 and 2009, the percentage of people covered by private health insurance decreased from 66.7 percent to 63.9 percent. The percentage of people covered by employment-based health insurance decreased to 55.8 percent in 2009, from 58.5 percent in 2008. The percentage of people covered by employment-based health insurance is the lowest since 1987, the first year that comparable health insurance data were collected. The number of people covered by employment-based health insurance decreased to 169.7 million in 2009, from 176.3 million in 2008.
* The percentage of people covered by government health insurance programs increased to 30.6 percent in 2009, from 29.0 percent in 2008. This is the highest percentage of people covered by government health insurance programs since 1987. The percentage and number of people covered by Medicaid increased to 15.7 percent or 47.8 million in 2009, from 14.1 percent or 42.6 million in 2008. The percentage and number of people covered by Medicaid is the highest since 1987. The percentage and number of people covered by Medicare in 2009 (14.3 percent and 43.4 million) were not statistically different from 2008.
* In 2009, 10.0 percent of children under 18, or 7.5 million, were without health insurance. These estimates were not statistically different from the 2008 estimates. The uninsured rate for children in poverty (15.1 percent) was greater than the rate for all children.
* Between 2008 and 2009, the uninsured rate and the number of uninsured for non-Hispanic Whites increased from 10.8 percent and 21.3 million to 12.0 percent and 23.7 million. The uninsured rate and the number of uninsured for Blacks increased from 19.1 percent and 7.3 million to 21.0 percent and 8.1 million.
* The percentage and number of uninsured Hispanics increased to 32.4 percent and 15.8 million in 2009, from 30.7 percent and 14.6 million in 2008.
Census Bureau press release:
Highlights of the 2009 health insurance highlights:
* Uninsured increased to 50.7 million – 16.7 percent of the population
* Private insurance decreased to 194.5 million – 63.9 percent
* Employment-based insurance decreased to 169.7 million – 55.8 percent
* Medicaid increased to 47.8 million – 15.7 percent
* Uninsured children remain at 7.5 million
* Racial and ethnic disparities in coverage have compounded
Those who oppose government solutions to the health care crisis will likely pass these worsening numbers off as an expected consequence of the sputtering economy and the new age of unemployment. They will pay little heed to the fact that the numbers are still intolerable when the economy is thriving; that isn’t their concern.
Supporters of the Patient Protection and Affordable Care Act (PPACA) will no doubt be disturbed by these numbers, but it is very likely that they will make the most of them in selling PPACA by showing how it will dramatically reduce the numbers of uninsured. That is true. Many will be covered by Medicaid and by private health plans, even if far too many will still remain uninsured.
This Census Bureau report remains silent on one of the most important issues in health insurance – the numbers who are underinsured – those who will face financial hardship should medical needs arise.
PPACA is an underinsurance program. Employers will see little relief and will expand their present trend of shifting more insurance and health care costs onto their employees. Individuals buying plans in the new insurance exchanges will select underinsurance products with low actuarial values (30 to 40 percent of costs to be paid by the patient) with subsidies that are inadequate to avoid financial hardship. Many will move into the Medicaid program which has more expansive coverage, but which reimburses providers at such a low rate that far too many will not be willing to accept patients under this program. With Medicaid chasing away providers, it too has become another form of underinsurance.
Thus the touted increase in insurance enrollment under PPACA will be more than offset by the explosion in underinsurance – affecting the majority of Americans. At this point looking forward, this nefarious outcome is not obvious to most. But as underinsurance sneaks up on us, and more and more individuals are feeling the pain, they’ll be ready. Ready for what? Ready for an improved Medicare that will always be there for us – in both good and bad economic times.
The PNHP press release (link above) provides a reality-based perspective of just what these numbers mean.
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.
Teachers sue over health plan
By Susan Essoyan
September 15, 2010
Hawaii public school teachers filed suit yesterday in Circuit Court to block changes in their health coverage, saying that the state’s plan to do away with their health benefit trust fund is unconstitutional.
The suit, Kono et al. v. Lingle et al., seeks to represent more than 15,000 active and retired school teachers with health benefits in the Hawaii State Teachers Association Voluntary Employees’ Beneficiary Association Trust.
The teachers are objecting to the state’s plan to transfer their health benefit plans from “the financially sound” VEBA to the “insolvent or nearly insolvent” Employer-Union Health Benefits Trust Fund, according to the lawsuit.
“The forced transfer of the teachers into EUTF is designed to prop up that failing system on the backs of the teachers,” said Paul Alston, attorney for the plaintiffs. “What they will get if they are forced to transfer is higher costs and inferior benefits. It is clearly unconstitutional to take away the valuable benefits the teachers have.”
The suit contends that the change amounts to a breach of contract and violates the Hawaii Constitution by “diminishing or impairing” accrued benefits in the employees’ retirement system. After the switch, teachers will face higher co-payments and curtailed drug coverage and services, it said.
The lawsuit also alleges that the state improperly took $3.96 million from the VEBA trust surplus, which otherwise would have been used as reserves, and put it into the general fund.
The Legislature passed a law to phase out the VEBA trust on Dec. 31, and assign teachers to Employer-Union Health Benefits Trust, which covers more than 94,000 state and county employees and retirees.
The court filing included an April 12 letter from Gov. Linda Lingle to legislators in which the governor called the Employer-Union Health Benefits Trust “insolvent,” adding that “its governance is untenable.” She noted that Aon Consulting, the trust’s consultant, warned on March 31 that the trust fund would likely run out of money to cover expenses later this year.
Aon Consulting recommended a 26 percent increase in premiums as of July 1, but the Employer-Union Health Benefits Trust’s board of trustees has voted to keep rates and benefits the same through December of this year.
During Q&A at some of my speaking engagements, a common question from the audience: “Under a single payer, Medicare for all program, would I have to give up my excellent retired teachers’ health benefit program that we fought so hard for all of these years?”
That’s a very good question. These programs are often more comprehensive than Medicare. In fact, that is why we specify an improved Medicare as the framework for a single payer national health program. All essential health benefits would be included; deductibles, co-payments and coinsurance would be eliminated, and the administration of the program would be streamlined. There would be no need to maintain the teachers’ health benefit program as a separate entity.
What is alarming about this report from Hawaii is that these sacrosanct programs are now vulnerable. The teachers’ well-funded voluntary employees’ beneficiary association trust (VEBA) is about to be dumped into the near-bankrupt health benefit trust established for other government employees. The double tragedy is that the teachers lose, and other government employees who should have the most secure of health benefit plans are also losing as more of their health care costs inevitably will be dumped on them.
If our best and most stable health insurance programs are facing this uncertain future, what does that say about the security of other private insurance programs within our fragmented system of financing health care?
The Patient Protection and Affordable Care Act (PPACA) rewards employers who dump their health benefit programs by requiring health care assessments that are only a fraction of what they pay in premiums for their existing insurance programs. Their employees then are forced, by mandate, to purchase plans within the exchanges. Though purchased through exchanges, these plans are merely a slightly more regulated reincarnation of the individual market – the least stable and least reliable of private insurance plans. The subsidies for these plans are the equivalent of vouchers, providing a mechanism for shifting ever more of health care costs to those individuals with the greatest health care needs.
The teachers of Hawaii are right to be concerned. They need to fight hard to protect their VEBA, at least long enough for us to enact an even better program for them and everyone else – an improved Medicare for all.
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.
Blacks with muscular dystrophy die 10-12 years younger than whites: new study
September 13, 2010
African Americans with muscular dystrophy die 10 to 12 years younger than their white counterparts, according to research published in today’s (Tuesday, Sept. 14) issue of Neurology, the medical journal of the American Academy of Neurology.
The black-white mortality gap, which was calculated on the basis of 20 years of data, is among the largest ever observed in the annals of research into racial disparities in health care, say Dr. Nicte Mejia and Dr. Rachel Nardin, co-authors of the editorial. “Furthermore,” they write, “white patients with MD [muscular dystrophy] enjoy increasing survival, while survival of black patients with MD barely budges,” leading to an ongoing widening of that gap.
“Inequities in the health delivery system – and the multiple ways in which race constrains access to care – seem the most likely explanation for the observed MD black-white mortality gap,” Mejia and Nardin write in their editorial. But they add that inadequate access to care due to lack of good quality health insurance may also be part of the picture.
“Nonelderly African Americans are 1.5 times more likely than whites to lack any type of insurance and about twice as likely to rely on Medicaid,” they write, noting that lack of health insurance is linked to lack of access to care.
And while Medicaid, the public health program for the poor, compares favorably with private insurance in providing access to primary care, it falls short when it comes to providing access to the standard-of-care treatments needed to manage conditions like muscular dystrophy, they say.
These shortcomings of Medicaid coverage are “particularly worrisome because more than half of the new health coverage under the 2010 National Health Reform will be Medicaid.”
In a separate comment made today, Nardin said, “Replacing the current U.S. health care financing system with a single-payer system that would ensure comprehensive insurance coverage for every American, regardless of race, would go a long way toward reducing this type of disparity.”
Neurology: Widening gap in age at muscular dystrophy–associated death between blacks and whites, 1986–2005
It is shameful that we have tolerated for so long a health care system that has failed to address the inequities and injustices exemplified by a widening black-white mortality gap in patients with muscular dystrophy – an inherited disorder inflicted on blameless victims.
Opponents of true reform (based on principles of health care justice) often blame the victim, implying that it is not the deficiencies in our health care system that are to blame, but it is the patients’ own personal failures that result in their predicaments, and we have no responsibility to intervene.
Even the most callous opponents of reform may acknowledge that there are exceptions in which the victims cannot be blamed, but even in those instances, the unfavorable outcome is often attributed to other socioeconomic factors over which we have no control. The “leave me out of this” mentality certainly contributes to our national inertia.
Maybe we can’t fix everything that’s wrong with our health care system and with society in general, but what we can do is reject the message of the passive obstructionists who contend that we’re each on our own, and join together in solidarity to address our societal deficiencies that have permitted terrible injustices such as sentencing muscular dystrophy patients to die a decade early merely because of their personal circumstances associated with being black.
The Patient Protection and Affordable Care Act will provide many of these unfortunate individuals with access to an insurance program, Medicaid, but as a chronically underfunded welfare program, that in no way ensures access to the actual medical care that they need. Many of them are already on this program, yet it doesn’t prevent them from dying a decade earlier than they might otherwise.
Although we have much to repair in this nation, a very good place to start would be to enact a health care financing system that would ensure that all of us receive the health care that we need – an improved Medicare for all. Furthermore, since collectively we are multi-tasked, we can revitalize and expand simultaneously our work on all of the other social justice issues as well.
Low Costs Of Defensive Medicine, Small Savings From Tort Reform
By J. William Thomas, Erika C. Ziller and Deborah A. Thayer
In this paper we present the costs of defensive medicine in thirty-five clinical specialties to determine whether malpractice liability reforms would greatly reduce health care costs. Defensive medicine includes tests and procedures ordered by physicians principally to reduce perceived threats of medical malpractice liability. The practice is commonly assumed to increase health care costs.
Across all specialties, reductions in medical malpractice premiums would lead to statistically significant savings in 2.0 percent of the conditions analyzed, but these are high-volume situations, comprising 35.8 percent of all episodes. However, the magnitude of savings that could be realized is small, accounting for less than 1 percent of medical care costs in every specialty. Across all thirty-five specialties, savings associated with a 10 percent premium reduction in medical malpractice premiums would be just 0.132 percent. Even if medical malpractice premiums were to be reduced as much as 30 percent, defensive medicine costs would decline no more than 0.4 percent.
Will bringing an end to defensive medicine reduce our national health expenditures? According to this and other studies, yes, but not by much.
Defensive medicine represents those tests and procedures that physicians order for the purpose of reducing the risk of medical malpractice liability. These are not random tests, but they are tests selected to prevent the patient from suffering harm – an essential component of malpractice.
If there were no liability exposure, why would a physician decide against ordering a test that might prevent a harmful outcome for the patient? Do physicians really believe that it is acceptable to gamble with the health of the patient by omitting potentially beneficial tests, yet is is not acceptable to place that same bet if a malpractice suit might ensue? Are these tests really for the benefit of the doctor and not for the benefit of the patient?
How often have you heard a physician confess to ordering a test that the patient didn’t need, but the test was still necessary to prevent a lawsuit? That is a non sequitur. If the physician could be sued for not ordering the test, then the test was absolutely essential.
The point of today’s message is that we keep looking in the wrong places for ways to try to control health care spending. Though we need malpractice reform for other reasons, we can’t look at it as a source of significant health care savings.
The most important first step to begin to control runaway health care costs would be to replace our wasteful, dysfunctional health care financing system with a single payer national health program – an improved Medicare for everyone – a Medicare that provides us with the financial tools with which we could slow the rate of health care spending increases.
About the National Commission on Fiscal Responsibility and Reform
President Obama created the bipartisan National Commission on Fiscal Responsibility and Reform to address our nation’s fiscal challenges. The Commission is charged with identifying policies to improve the fiscal situation in the medium term and to achieve fiscal sustainability over the long run. Specifically, the Commission shall propose recommendations designed to balance the budget, excluding interest payments on the debt, by 2015. In addition, the Commission shall propose recommendations that meaningfully improve the long-run fiscal outlook, including changes to address the growth of entitlement spending and the gap between the projected revenues and expenditures of the Federal Government.
The Commission will meet as a whole once a month while Congress is in session. The Commission will vote on a final report containing a set of recommendations to achieve its mission no later than December 1, 2010. The final report will require the approval of at least 14 of the Commission’s 18 members.
Republicans Dominate Medicare Discussions On White House Fiscal Commission
By Brian Beutler
September 9, 2010
The White House’s fiscal commission has become a target for progressive activists in large part because a number of reports and public statements indicate that the panel will recommend benefit cuts to Social Security.
But the commissioners are also grappling with another sensitive entitlement program: Medicare. For a number of reasons, the commission is farther from consensus on Medicare than it is on Social Security. But the ideological conservatism of the Republicans on the commission — and, indeed, of the commission as a whole — combined with Democratic fatigue over health care reform mean that the center of gravity of discussions is tilted to the right.
“[B]asically you’ve got some Dems saying they don’t want to jump back in the [health care reform] pool, so you’ve mainly got Republicans swimming in there on their own,” says one source familiar with the commission’s proceedings.
“There have been some discussions about cost-sharing. There have been some discussions about Medi-gap policies,” the source says.
At a staff level, this source says, the feeling is that “there needs to be more skin in the game and people need to pay more…the whole argument that people don’t understand how much health care costs and are wasteful.”
“A lot of discussion on the commission has been that people need to get better price signals and be smarter shoppers,” the second source said. “And that is very, very worrisome.”
Apparently President Obama’s National Commission on Fiscal Responsibility and Reform is considering changes to Medicare that would make beneficiaries “smarter shoppers” by adopting innovations that would require them to pay more out of pocket for health care.
Considerations include reducing or eliminating Medi-gap policies, increasing deductibles and coinsurance, and using vouchers that would establish financial incentives to choose more Spartan private plans.
Although the commission theoretically is politically balanced, all of the Republican members are right-wing conservatives, and the Democrats are split between progressives and deficit hawks who would rather reduce government spending than increase tax revenues. If you check the list of commission members (available at the fiscal commission link above) it is difficult to identify with certainty the five members necessary to block these deleterious “consumer-directed” policies.
Single payer supporters are already finding some resistance from colleagues to the “Medicare for all” label, especially with the continued failure to resolve the SGR (sustainable growth rate) issue. Although we speak of an “improved” Medicare, that distinction is not always clear and certainly would not mean much when holding up a further handicapped Medicare program as a model of reform.
Should the commission end up making these outrageous recommendations, hopefully the 310 million of us would respond by insisting that Medicare be protected and improved, as opposed to latching onto former Senator Alan Simpson’s infamous milk cow.
National Health Spending Projections: The Estimated Impact Of Reform Through 2019
By Andrea M. Sisko, Christopher J. Truffer, Sean P. Keehan, John A. Poisal, M. Kent Clemens and Andrew J. Madison (from the CMS Office of the Actuary)
September 9, 2010
Projected National Health Expenditures (NHE)
2010 – $2,600 billion (17.5% of GDP)
2019 – $4,571 billion (19.6% of GDP)
In this analysis, we have shown that the net impacts of key Affordable Care Act and other legislative provisions on total national health expenditures are moderate, but the underlying effects on payer spending levels and growth rates are much more pronounced and reflect the Affordable Care Act’s many substantive changes to health care coverage and financing. As the provisions are implemented over time, their actual impacts may well differ considerably from these estimates.
Many important details of the legislation will evolve through regulatory activity and become more concrete. Moreover, behavioral responses to reform provisions on the part of health care providers and consumers, employers, and insurers are difficult to anticipate. These will become more apparent only after the bulk of reforms have been implemented in 2014.
Report – free download for the next two weeks only:
What does this mean? Here are some of today’s headlines of articles covering this report:
Health Plan Won’t Fuel Big Spending, Report Says (New York Times)
Gov’t: Spending to rise under health care overhaul (Washington Post/AP)
Government Economists Say Health Overhaul Won’t Significantly Increase Spending (Kaiser Health News)
Health Outlays Still Seen Rising (Wall Street Journal)
Consumers to Pay Nine Percent More Out of Pocket (Fiscal Times)
Is health care spending rising or isn’t it? The confusion stems from the fact that the additional increase in projected national health expenditures (NHE) resulting from the enactment of the Patient Protection and Affordable Care Act (PPACA) is relatively modest when compared to the projection of NHE without enactment of PPACA. Without PPACA, NHE for 2019 was projected to be $4.48 trillion (19.3% 0f GDP), whereas now the projection is $4.57 trillion (19.6% of GDP).
Thus the conflicting reporting reflects the “I told you so” arguments on both sides. The opponents of PPACA are saying that the promises of lower costs are not true, and this is yet one more report that shows that costs will increase. The proponents of reform are saying that this report proves that many more individuals will be covered without a significant increase in costs. This is the wrong debate.
The fact is that national health expenditures had been predicted to increase at a rate well in excess of inflation, and that PPACA will do nothing to slow that increase, though it will not make it much worse. What PPACA is doing instead is that it is rearranging the financing of health care in a manner that will result in more Americans – but not all – having some sort of health care coverage, but it does so in a way that can have a significant negative impact on patients and providers.
How can so many more people be covered without spending much more money? There are some hints in this report.
“For example, higher projected spending by a greater number of insured people is somewhat offset by the projected impact of the Medicare savings provisions and relatively lower prices paid to providers for services to newly insured Medicaid beneficiaries.”
Providers will be paid significantly less for the large influx of Medicaid patients, because of the reductions in Medicare payments, and especially because of the reductions that will be dictated by the Independent Payment Advisory Board. This could be disruptive to the care provided by the physicians and hospitals that are targeted by these reductions.
” By 2018, however, we project out-of-pocket spending growth of 9.6 percent — four percentage points faster than our February 2010 projection. This effect is mainly attributable to the excise tax on high-cost employer-sponsored plans, which is expected to result in greater cost sharing as many affected employers scale back coverage to minimize their tax exposure.”
There are other measures in PPACA that will result in additional cost shifting to patients, such as the low actuarial value of the exchange plans with subsidies that are inadequate to prevent higher out-of-pocket spending. Making health care less affordable for those who need it does reduce spending, but at a terrible cost in impaired health outcomes.
Covering tens of millions more people for about the same spending, using our inefficient fragmented health care financing system, is being accomplished by making patients and their health care providers absorb the much higher costs. Just wait until we all feel the pain.
California regulators seek up to $9.9 billion in fines from PacifiCare
By Duke Helfand
Los Angeles Times
September 7, 2010
California regulators are seeking fines of up to $9.9 billion from health insurer PacifiCare over allegations that it repeatedly mismanaged medical claims, lost thousands of patient documents, failed to pay doctors what they were owed and ignored calls to fix the problems.
In court filings and other documents, the California Department of Insurance says PacifiCare violated state law nearly 1 million times from 2006 to 2008 after it was purchased by UnitedHealth Group Inc., the nation’s largest health insurance company by revenue.
“This is about intentional disregard for the interests of doctors, hospitals and patients in California, and the pursuit of cutting costs at any means possible,” said Adam Cole, the insurance department’s general counsel. “It’s a story of intense corporate greed.”
The largest health insurer in the nation (in terms of revenue), UnitedHealth Group, through UnitedHealthcare’s subsidiary – PacifiCare, violated California state insurance laws nearly a million times! This is the industry that the Patient Protection and Affordable Care Act was designed to protect instead of replacing, even though that meant that not everyone would be insured and many more would be underinsured. This was a trade-off that resulted in a loss on both ends.
This is more than the gross incompetence of an insurer that has failed to provide the excessive administrative services for which we are being gouged involuntarily. As the insurance department’s general counsel said, “It’s a story of intense corporate greed.”
It’s time to throw these incompetent thieves out, fix Medicare, and then provide it for everyone.
Where Americans Get Acute Care: Increasingly, It’s Not At Their Doctor’s Office
By Stephen R. Pitts, Emily R. Carrier, Eugene C. Rich and Arthur L. Kellermann
Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care — treatment for newly arising health problems — are made to patients’ personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. Health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. The challenge for reform will be to succeed in the current, complex acute care landscape.
When you say “my physician,” what do you mean? For most of us, that means the physician whom you call when you have a medical need. It’s the physician who will always be there for you, or who will at least ensure that a colleague is available when taking an off-call breather or when on vacation. Yet, as this study shows, personal physicians or their associates provide care for only 42 percent of acute problems. Increasingly, patients can no longer rely on their doctor’s office when they need acute care.
The policy community certainly recognizes the crisis in primary care. Much attention has been directed toward improving chronic care management within the primary care environment. Unfortunately, much of these efforts remain in the discussion phases, and only limited improvement has been made in the application of these relatively imprecisely defined concepts.
Yet what the primary care professional should be really good at – timely care of acute problems – has been almost completely ignored by the policy community. Physicians are too busy and don’t have time to take care of their patients. (Although that thought certainly can be expanded upon, the irony is inescapable.)
What are some of the solutions?
* Emergency departments (EDs) already are bearing the largest portion of the overload. Queues in EDs are enough of a problem without adding to the waiting room backlog of many individuals who would be more appropriately cared for in a less intensive environment, such as a primary care practice. Adding to the problems with our overcrowded EDs is the burden of having to care for over one-half of all uninsured individuals with acute care problems.
* Patients in the next largest sector directly access specialists for their acute problems. Sometimes this may be quite appropriate, yet many times it may result in more expensive care for problems that would be more appropriately managed in a less expensive primary care environment. Also some patients who should be cared for by specialists may not be able to access them for several reasons, and, once again, the primary care physician would be in a better position to enable that access for the patient.
* Outpatient departments of integrated health systems appropriately may fulfill the role as the acute care provider as long as arrangements are made for access outside of clinic hours. These departments are usually associated with larger institutions, and, as such, would never be much more than a niche provider of acute care services.
* Retail clinics are capable of providing only the most basic of acute care services, and further fragment the coordinated care that should be provided in the primary care environment. Further, retail clinics skim off the easy, cash paying “customers” (a more appropriate term than “patients” in this retail environment). The same is true of urgent care centers and their customers, though they are usually capable of caring for a greater variety of problems.
* Concierge physicians do provide greater personal attention, but for very high fees that most of us cannot afford. To provide this higher level of accessibility, they sharply reduce the number of patients in their practices, further compounding the problem of the critical shortage of primary care physicians.
* Community health centers (CHCs) fulfill an important role in primary care, especially because they usually provide access for underserved patients in underserved communities. They provide acute care services during clinic hours, though patients often must rely on EDs when the clinics are closed. Most CHCs continue to struggle with finances. Also, most have difficulties in obtaining the cooperation of an adequate variety of specialists in providing care for more complex problems.
Members of Congress are quite aware of the profound deficiencies in our primary care infrastructure, so they included some measures in the Patient Protection and Affordable Care Act (PPACA) designed to address this issue. Will they help?
Funds are being allocated for primary care training programs. That is certainly a step in the right direction, but the funds are quite limited and will hardly make a dent in the problem.
More funds are being allocated for community health centers, again certainly a beneficial measure, but one which falls far short of meeting the need.
Some Medicare funds are being shifted from other services to primary care but not enough to even begin to narrow the compensation gap between primary care and the surgical specialists. Why would medical students, saddled with education debt, choose primary care with its long hours and modest pay, when specialties promise higher pay and more free time?
PPACA contains measures to promote the medical home model – theoretically the ideal primary care model. Although medical home demonstration projects are under way, it will be a long time before the specifics of the model will be precisely defined and ready for universal application. Further, the logistics of permeating the nation with medical homes may be beyond the capabilities of our public and private stewards working within the limitations of our dysfunctional financing system. Though the medical home model shows great promise, we need a financing system that will make it much more feasible.
The great hope of PPACA has been pinned on accountable care organizations (ACOs). This Health Affairs article defines ACOs as “integrated or virtually integrated delivery systems that will provide care for a defined population in a range of settings, linked by health information technology.” The supporters of ACOs have described everything from full service integrated health care delivery systems to “virtual” systems that are not connected by much more than an information technology system.
Although the providers of health care may seek to create innovative ACO systems that theoretically would improve patient care, it is likely that the emphasis will be on, not just controlling, but actually reducing spending. The ghost of managed care past will be embellished through the “integrated and accountable” efforts of the insurers partnering with health delivery entrepreneurs. Only the patients, patient-oriented health care professionals, and the patient-oriented hospitals will be losers.
Whatever you need – preventive services, continuing care for your chronic condition, or timely management of an acute problem – wouldn’t it be nice if you always had available your own personal physician’s team to meet your needs? With our fragmented, dysfunctional system of financing health care, it is unlikely that in the future this will be more than a dream for the majority of us.
If we had our own Medicare-for-all monopsony (single purchaser of health care) it could become a reality for all of us. We would simply insist that a primary care system coordinating a full complement of specialized services is all that we’re going to pay for. The insurers and health profession entrepreneurs can take a hike.
A special message from Senator Mark Leno on SB 810, the California Universal Health Care Act:
September 3, 2010
By now most of you have heard the disappointing news that our bill, SB 810, the California Universal Health Care Act, was held on the Assembly Floor on the last night of session, effectively killing the measure until next year. Over my strong objections, Assembly leadership decided to hold the bill. Although we are greatly disappointed, we are determined to come back even stronger next year.
I want to thank and recognize the work of the California School Employees Association and California Nurses Association who worked hard to lobby members all year. I also want to recognize Health Care for All, California Physicians for a National Health Plan, Single Payer Now, California Alliance for Retired Americans, California Health Professional Student Alliance, League of Women Voters and the other dozen organizational members of our statewide alliance. Most importantly, I thank the thousands of advocates who made phone calls, requested meetings, attended rallies, and sent letters, faxes and emails, making it clear to legislators that the single payer health care movement is vibrant, strong and growing larger every day.
Our movement has always acknowledged that it is founded on a long-term vision and strategy. This setback does not change our work, it only emboldens it. For decades we have found the courage to speak out for single payer, even when others around us told us that now is not the right time. We have learned that fear and hesitation can only be overcome by courage and commitment – something with which our movement is rich. That is how we have come so far, and that is why we will win.
Without question, I commit to reintroducing this bill again next year, and to work ever harder with you to achieve the only real solution to our health care crisis – Medicare for All.
I encourage you to begin our work today to ensure the passage of this bill next session. Now is the time to educate your current representatives, and those who are seeking office, about the need for single payer universal health care and to ask for their support. More importantly, now is the time for you to educate your co-workers, neighbors, friends, and family members about why their elected officials should take a strong stance in support of Medicare for All.
We’ve always said that the closer we come, the harder our work will become. So often, it’s “two steps forward, one step back.” Let this temporary detour enliven us to work even harder to see single payer become a reality in California. With term limits, it is clear that each new class of representatives needs to be educated and reminded of how important this issue is to our state. Next year will bring a new governor and a new legislature – and consequently, new opportunities and challenges. To win, we must come closer together as allies, fight smarter, and work even harder.
As the author of SB 810, I believe deeply in you, this cause and this movement. Until every Californian has health care and no family faces medical bankruptcy, we will not be deterred. Until our state budget and entire economy are no longer being swallowed by health care costs, we will not cease. Until we have “Medicare for All,” we will not stop fighting. We’re the fastest growing grassroots movement in America, and we will win universal health care. Let’s dig deep, redouble our efforts and get back to work.
Senator Mark Leno
On Health Care, the Devil’s in the Details
By Uwe E. Reinhardt
The New York Times
September 3, 2010
The recently passed Affordable Care Act requires heath insurance issuers to use at least some minimum fraction of revenue from the premiums it receives on medical services. While the idea might sound straightforward, this fraction, known as the “medical-loss ratio,” is open to all sorts of creative arithmetic, and you can bet that interest groups from every corner are trying to get the math to add up in their favor.
Under the new law, health insurers are supposed to spend at least 85 percent of premiums collected from large groups of insured on something defined as “medical benefits and activities that improve health care quality.” For small groups and individually sold policies, the standard is lower, at 80 percent.
Put yourself in the shoes of the health care providers.
They would like to put as many of an insurer’s outlays – other than provider payments – as can be justified into the denominators as “selling or administrative expense.” That would put pressure on insurers to increase payments to providers or to spend less on administration to meet the ratio requirement. Therefore, providers typically plead for a very narrow definition of an insurer’s outlays for “health care quality improvement” that, by statute, are to go into the numerator.
Health insurers, on the other hand, would like to pack as many of their outlays as possible into the numerator of the ratio.
In a letter to the commissioners, the president of America’s Health Insurance Plans, which represents about 1,300 member companies that provide insurance for more than 200 million Americans, pleads for inclusion in “activities to improve health care quality” such items as fraud prevention and detection, utilization review, costs associated with administrative simplification and health-information technology expenses, and the cost of implementing the new International Classification of Diseases, or ICD-10, codes.
Finally, there are the commissions that insurers pay to brokers, who currently play an important role in the small-group and individual market for health insurers.
The commissions usually range between 4 and 8 percent of the premium, depending on the state, but sometimes are 20 percent of the premium in the first year of a policy before dropping to the normal range.
How these commissions are incorporated into the ratio can have a significant impact on the economics of insurance brokers, whose future role in health care is of great concern to the commissioners.
10. Don McCanne, San Juan Capistrano, CA
September 3rd, 2010
Focusing on narrow issues such as whether the administrative cost of brokers’ fees somehow represents patient care or quality improvement as opposed to being an administrative expense distracts us from the much more important overriding issue of the profound administrative waste throughout our health care system that is related to the dysfunctional, fragmented manner in which we allocate health care spending.
The first consideration is the administrative cost of the private insurers. Should we really be allocating 15 to 20 percent of the insurance premiums to the private insurers for them to use for their own intrinsic purposes – funds that never make it to paying for health care? When you consider the very high health care expenditures in our nation, 15 to 20 percent is a huge allocation for non-medical purposes.
Another very important diversion of health care dollars is the cost of the administrative burden placed on hospitals and physicians merely to deal with our fragmented system of a multitude of public and private plans – especially in claims processing, including not only the protracted process of managing disputed claims, but also other administrative diversions such as negotiating and managing insurance company contracts.
This administrative burden on the providers has been estimated to consume about 12 percent of premium dollars. Thus the combined administrative costs merely for the insurance function will be about 27 to 32 percent of the insurance premium – a very high percentage of our very high priced system. That does not include all of the other essential administrative functions that hospitals and physicians face. What a waste!
It is unfortunate that consideration of a single publicly-financed and publicly-administered financing system was excluded before the reform negotiations began. Such a financing system – a single payer or an improved Medicare for all – would have dramatically reduced this profound administrative waste.
Even more important, a single financing system would have created our own public monopsony (single buyer of health care) in which we could ensure that we would be receiving maximum value in our health care purchasing – avoiding excessively high prices while ensuring that enough funds are available to maintain adequate capacity in the system. That is the cost control that we really need. And, oh yes… everyone is included!
Wasn’t that the goal of reform? Cover everyone and control costs?
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