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.
ACA critic Stephen Parente nominated as HHS deputy secretary
By Dave Barkholz
Modern Healthcare, April 10, 2017
Stephen Parente, a healthcare economist, has been nominated to be HHS’ assistant secretary of planning and evaluation.
The University of Minnesota professor would fill a post vacated in June by Harvard economist Richard Frank. In that role, Parente would be a principal advisor to HHS Secretary Dr. Tom Price, consulting on policy, legislative efforts, strategic planning and research.
Parente is familiar with the work of Price. In 2013-2014, he analyzed Price’s ACA replacement proposal in conjunction with the conservative think-tank American Action Forum.
The White House announcement:
Stephen Parente discusses a key option for the Affordable Care Act
By Christopher Snowbeck
StarTribune, December 3, 2016
With Republicans in Washington, D.C., promising to repeal the federal Affordable Care Act, or ACA, the focus is shifting to how the GOP might try to replace it. Stephen Parente of the University of Minnesota is well-positioned to describe what could be coming. In 2013-14, Parente worked with the American Action Forum, a conservative think tank, to evaluate the budget and coverage impact from the Empowering Patients First Act, an ACA replacement plan from U.S. Rep. Tom Price, R-Ga. Last week, President-elect Trump selected Price as his health secretary. More recently, Parente worked with staffers to model the economic impact of “Better Way,” the replacement plan put forward by House Speaker Paul Ryan.
Q: I gather that the dollar value of tax credits under Better Way would be smaller than with the Affordable Care Act, but this reduction fits with lower premiums for coverage, too. Is that right?
A: Correct. One of the biggest changes is the risk-rating piece. The ACA has a 3-to-1 ratio for modified community rating, which means insurers can’t sell coverage to an adult age 64 or older for more than three times what they’d charge a 21-year-old for the same health plan. Better Way proposes a 5-to-1 ratio.
There are fewer caps on deductibles and out-of-pocket spending with Better Way, so that’s another way deregulation brings lower premiums. Finally, fewer health benefits are required to be covered by health plans under Better Way, compared with the ACA.
Q: Minnesota is one of those blue states that has offered generous benefits via Medicaid, plus the MinnesotaCare health insurance program. Will federal funding for the state’s programs decrease?
A: I think many states are probably going to see less Medicaid funding, because it’s going to have to be spread around and there will be some budget constraints. There will definitely be, in that sense, some winners and losers.
Stephen Parente is the policy genius behind Tom Price’s “Empowering Patients First Act” and Paul Ryan’s “Better Way” – two of the cruelest policy proposals of the past decade that shift health care costs from the government to patients in need – all under the guise of “it’s about access” (but not about being able to afford health care).
Parente says that there definitely will be winners and losers, but he didn’t specify that the winners will be wealthy taxpayers and the losers will be patients.
Now Stephen Parente is going to guide policy, legislative efforts, strategic planning and research for the Department of Health and Human Services, under the leadership of HHS Sec. Tom Price. When we desperately need new public policies to help make essential health care more affordable for all of us, the man in charge of policy will begin to tear down and destroy what we do have. He may become the most dangerous individual in government as far as our health care is concerned.
Remember that name – Stephen Parente – and be prepared to use all civil means available to ward off his pending nefarious ventures. Then go out into the streets and march for 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.
CBO Provides A Roadmap For Improving AHCA
By Joseph Antos and James Capretta, American Enterprise Institute (AEI)
Health Affairs Blog, April 4, 2017
The future of the American Health Care Act (AHCA), the GOP-drafted plan to repeal and replace the Affordable Care Act (ACA), is unclear after the bill was pulled before the House of Representatives could vote on it. But the debate over the ACA and proposals to replace several of its key provisions is unlikely to remain off the national agenda permanently.
The best place to start is with the cost estimate of (AHCA) produced by the Congressional Budget Office (CBO).
Trump administration officials, some members of Congress, and assorted commentators have criticized CBO for this estimate, arguing that it is a fundamentally inaccurate assessment of what would occur if AHCA passed. This criticism is misplaced. While some of CBO’s assumptions are indeed questionable, there is little doubt that the agency’s bottom line assessment is basically correct: The bill, as currently structured, would trigger a rise in premiums in the short-run, a sharp increase in the number of people without insurance over the next two years, and then also a steady increase in the number of uninsured Americans over the following eight years.
Instead of trying to discredit this finding, the authors of the legislation would be better off fixing the bill. CBO’s estimate provides a roadmap for what needs to be done to improve the chances the bill will produce the results its authors intend.
Changing the ACA’s insurance rules in a coherent and systematic manner in AHCA was difficult because the proposal’s sponsors were trying to pass the measure using the budget reconciliation process.
AHCA is thus an awkward proposal. It effectively eliminates the individual mandate while leaving in place the ACA’s rules prohibiting the use of health status in setting premiums or determining what is covered by insurance. The authors of the measure propose “continuous coverage protection” as a substitute for the individual mandate. Under that provision, insurers would charge a one-year, 30 percent surcharge on premiums to anyone who has experienced more than a two-month break in their insurance coverage.
This penalty is far too weak to work. A young, healthy consumer experiencing a break in coverage has a strong incentive to stay uninsured as long as possible. Once he decides to purchase health insurance, the consumer will be required to pay a 30 percent surcharge on his premium for one year. After that, the consumer will once again pay without penalty the same community rate as everyone else of the same age and gender.
AHCA also substitutes less generous age-based credits for the income-adjusted subsidies of the ACA for lower-income households, and repeals enhanced funding to the states for the Medicaid expansion population. As a result, younger and healthier consumers would have less of an incentive to buy coverage.
That is a recipe for even more adverse selection, driving up premiums for those who remain insured through the individual market.
* Higher Financial Penalties For Failure To Maintain Coverage
The AHCA approach is an attempt to replace governmental force with personal responsibility. Under AHCA, no one is required to have insurance, but there are financial consequences for choosing to remain uninsured. However, rather than an arbitrary fixed surcharge, the penalty should be commensurate with the added costs imposed on the health system when such people decide not to buy insurance. For example, the penalty could include a premium surcharge that increases with time out of the market, and a waiting period could be imposed before benefits are paid. Such an approach would eliminate the perverse incentive of a fixed penalty that encourages individuals to remain uninsured, avoiding premium payments, for as long as possible.
* The ‘No-Premium’ Health Insurance Option And Automatic Enrollment
Another factor reducing CBO’s estimate of the AHCA’s take-up of insurance is some people’s unwillingness to pay a premium that is larger than the value of their credit. A comprehensive revision of AHCA could broaden the types of plans offered by insurers to include at least one plan available with a premium exactly equal to the credit. Such a plan would provide protection against catastrophic losses without requiring first-dollar coverage for routine expenses. To further improve insurance take-up, AHCA should allow states to automatically enroll uninsured individuals into “no-premium” plans, with an option to change plans or opt out entirely.
* A Compromise On Medicaid Eligibility Within A Reformed Program
A new uniform national income standard could be set at a level that would free up resources to provide stronger federal support for all state Medicaid programs. Non-expansion states would not be required to expand their Medicaid eligibility to the new standard, but they would receive additional funding through a block grant. Expansion states would likely phase down their programs to the new income standard. In addition, states would be given more control over the program, allowing them to operate Medicaid in ways that promote individual responsibility and ease the transition to private health coverage.
* Additional Support For Low-Income Households Above Medicaid Eligibility
Subsidies ranging from $2,000 to $4,000 per person are not sufficient to make non-group insurance affordable for many with low incomes. AHCA should be revised to provide additional support for these families.
Instead of condemning or ignoring CBO, congressional leaders would be well-advised to take full advantage of the agency’s analytic expertise to make the needed adjustments to the AHCA plan. That will ensure all sides are better prepared for serious debate when health policy again moves back onto center stage.
By Don McCanne, M.D.
Trying to tweak the lousy AHCA model to make it work better is not a rational approach when more fundamental policy defects are ignored.
Worrying about keeping down spending through the federal budget doesn’t make much sense when it is total spending on health care, public and private, that is important. Federal health care spending is more efficient than spending through private insurers. In fact, eliminating private insurers reduces the profound administrative waste of both the private insurers and the burden they place on health care providers. Thus increasing the federal health care budget in this manner would produce an even greater offset in private spending. That savings could then be used to pay for the uninsured and for the excess cost sharing of the underinsured.
Inducing “personal responsibility” in health care spending is code language of conservatives for erecting financial barriers to health care – a terrible policy choice. The financing system should encourage, not discourage, access to beneficial health care services. The administrators can make better decisions than an uninformed public on what care is detrimental and should not be covered.
We already know what happens when Medicaid decisions are turned over to the states, and often it is not good for patients in need. Besides, Medicaid has a welfare stigma and would continue to be underfunded. It would be far better to cover everyone under the same comprehensive program that ensures access for everyone to all essential health care services.
Even continuing with ACA is a mistake because no matter how many tweaks are applied, we will continue to perpetuate the uninsured, underinsured, narrow networks, and excessive cost sharing (to slow premium increases to protect the private insurers instead of patients). These policies are detrimental to patients.
The policies we need are an efficient, publicly-administered universal risk pool, equitable funding based on ability to pay, removal of financial barriers to care, and free selection of health care providers. These policies benefit patients, and the models that have been constructed and are in use in some other nations would provide much better value for our health care spending.
Besides, a majority of the population now understands the superiority of single payer, including many Trump supporters. The nation is now ready for a single payer, improved Medicare for all.
Although the ACA was an improvement, it still has fundamental structural defects that prevent us from achieving the goals of true universality, affordability, equity, efficiency and access, no matter how much it is tweaked. The Republican AHCA proposal was merely another set of tweaks that went in the wrong direction, and we would have fallen further behind in the goals of reform.
Joseph Antos and James Capretta understand policy well, but they have saddled themselves with the conservative ideology professing that much of the responsibility for containing health care costs should be placed in the hands of the patient-consumer. Models to do that do reduce government spending on health care, but at today’s very high costs they impair access to beneficial health care services because of the lack of affordability of the patient’s out-of-pocket component of the spending.
Some conservatives recognize that low-income individuals need greater government support, as do Antos and Capretta, but their consumer-directed models also place too much of a financial burden on America’s workforce and their families. Also their insistence on using private insurance plans in the marketplace perpetuates the profound administrative waste that uniquely characterizes the American health care financing system, and perpetuates the deleterious tools of the private insurance industry such as sky-high deductibles and ultra-narrow provider networks.
Look specifically at the policies that Antos and Capretta consider to be beneficial. They would assess a large, progressive premium penalty after an interval of being uninsured once that individual decides to purchase insurance – a clear disincentive to bringing the uninsured into the market when policies should be designed instead to be certain everyone is always covered, not to mention that the additional penalty would make the premium unaffordable for most individuals. They would create optional plans with premiums equivalent to the government credit – an approach only made possible by further increasing deductibles and other cost sharing to truly unaffordable levels, not only perpetuating but expanding the flawed policy of offering almost worthless coverage in order to make premiums affordable. They would reduce the federal support of and privatize the Medicaid program while increasing “individual responsibility” through out-of-pocket payments that Medicaid beneficiaries simply do not have (except for the insulting token payments promoted by Pence and Verma simply to satisfy their own conservative ideological preferences).
Antos and Capretta do not reject the principle of government spending since they recommend it for low- and middle-income individuals and families. But they are quite willing to sacrifice the efficiencies and equity of a single payer system simply to include conservative ideology that places individual responsibility over social solidarity. Other nations have shown that publicly administered single payer tools are capable of slowing the increase in health care spending in a patient-friendly manner. Requiring excess cost sharing and taking away provider choice certainly are not patient-friendly.
Forget trying to tweak AHCA by placing conservative principles above patient service. Also forget trying to tweak ACA by placing the concepts of incrementalism and supposed political feasibility above patient service. Let’s go for the model that places patient service first – a well designed, single payer national health program – 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.
Editorial: America, all things not being equal
The Lancet, April 8, 2017
In an effort to better understand the conditions and mechanisms driving health disparities in the USA, this week, The Lancet breaks ground once again by publishing, America: Equity and Equality in Health — a stark and dire update to the first Series — focused on appraising where the greatest discrepancies lie. Comprising five papers, the Series looks in depth at the current inequalities in the health-care system and chronicles the beneficial influence of the ACA on health-care equity as well as the continued barriers and shortcomings in providing coverage.
Inequality and the health-care system in the USA
By Samuel L Dickman, David U Himmelstein, Steffie Woolhandler
Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.
The Affordable Care Act: implications for health-care equity
By Adam Gaffney, Danny McCormick
Although the ACA improved coverage and access—particularly for poorer Americans, women, and minorities — its overall impact was modest in comparison with the gaps present before the law’s implementation. We discuss proposals for change from opposite sides of the political spectrum, together with their potential impact on health equity.
Structural racism and health inequities in the USA: evidence and interventions
By Zinzi D Bailey, Nancy Krieger, Madina Agénor, Jasmine Graves, Natalia Linos, Mary T Bassett
In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.
Mass incarceration, public health, and widening inequality in the USA
By Christopher Wildeman, Emily A Wang
The USA is the world leader in incarceration, which disproportionately affects black populations. Nearly one in three black men will ever be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison. The emerging literature on the family and community effects of mass incarceration points to negative health impacts on the female partners and children of incarcerated men, and raises concerns that excessive incarceration could harm entire communities and thus might partly underlie health disparities both in the USA and between the USA and other developed countries.
Population health in an era of rising income inequality: USA, 1980–2015
By Jacob Bor, Gregory H Cohen, Sandro Galea
Although the increase in income inequality since 1980 has been driven largely by soaring top incomes, the widening of survival inequalities has occurred lower in the distribution — ie, between the poor and upper-middle class. Growing survival gaps across income percentiles since 2001 reflect falling real incomes among poor Americans as well as an increasingly strong association between low income and poor health. Changes in individual risk factors such as smoking, obesity, and substance abuse play a part but do not fully explain the steeper gradient. Distal factors correlated with rising inequality including unequal access to technological innovations, increased geographical segregation by income, reduced economic mobility, mass incarceration, and increased exposure to the costs of medical care might have reduced access to salutary determinants of health among low-income Americans.
Comment: An agenda to fight inequality
By Bernie Sanders
The USA is one of the richest countries in the world, but that reality means very little for most people because so much of that wealth is controlled by a tiny sliver of Americans. During the past 35 years, there has been a massive transfer of wealth away from the middle class and the poor to the top 0·1% of the US population.
Such inequality continues to be one of the greatest moral and economic issues of our time. It is also a huge health issue.
The USA’s dysfunctional health-care system is a major contributor to the nation’s health inequalities. Today, the US health-care system too often serves to enrich wealthy investors and executives, while impoverishing, and even bankrupting, many working families.
Health care is not a commodity. It is a human right. The goal of a health-care system should be to keep people well, not to make stockholders rich. The USA has the most expensive, bureaucratic, wasteful, and ineffective health-care system in the world.16 Medicare- for-all would change that by eliminating private health insurers’ profits and overhead costs, and much of the paperwork they inflict on hospitals and doctors, saving hundreds of billions of dollars in medical costs.
Making sure that every citizen has the right to child care, health care, a college education, and a secure retirement is not a radical idea. It is as American as apple pie. It will allow us to realise the ideals of the USA: that all of us are created equal — that we all have the right to life, liberty, and the pursuit of happiness.
Profile: David Himmelstein and Steffe Woolhandler: advocates for an equitable US health system
By Richard Lane
With President Donald Trump’s failure to get the American Health Care Act (AHCA) as far as a vote in Congress, are they optimistic for the future? “The AHCA’s defeat has certainly buoyed our spirits. Obamacare expanded coverage, but its adherence to a market-based approach hobbled the reform, leaving it open to Trump’s attacks”, says Woolhandler. “The surging opposition that triggered the collapse of the Republican plan signals the broad support for a non-market alternative that can create a new opening for single payer, so yes, we have some grounds for optimism,” Himmelstein says.
For those looking for something to read this weekend, you couldn’t do better than this Lancet series on the lack of equity and equality in America and its impact on health care. If you don’t have time, at least you can get the gist of the theme by reading these relatively short excerpts. Also, the articles are well worth saving as a reference source to use in our advocacy for expanding health care justice throughout America.
The Economist/YouGov Poll, April 2-4, 2017
81. Opinion on health reforms – Expanding Medicare to provide health insurance to every American
Percent who favor strongly or favor somewhat:
63% Family income under $50K
58% Family income $50-100K
63% Family income over $100K
80% Clinton voters
40% Trump voters
This poll shows once again that about 60 percent of Americans favor expanding Medicare to cover everyone. To no surprise, about 80 percent of liberals, Democrats and Clinton voters are in support. But what we should be especially aware of is that over 40 percent of conservatives, Republicans and Trump voters also support Medicare for all.
It is wrong to narrowly target the single payer message to liberals and Democrats. The message resonates with a significant percentage of conservatives and Republicans as well. They should certainly be included in the grassroots coalition efforts to support Medicare for all. The majority of the nation working together will get us there.
By John Conyers Jr.
Detroit Free Press, April 3, 2017
I’m as happy as anyone with the way the Republicans’ plan to wreck our healthcare system crashed and burned last week. And President Donald Trump is right: Republicans lost because Democrats beat them. We beat them because we were organized, we were unified and we were backed by unprecedented grassroots energy. Members of the U.S. Congress hosted dozens of rallies, advocacy organizations hosted hundreds more and constituents showed up in overwhelming numbers at town halls across this country to make their voices heard.
And what exactly was their message? One of the most poignant moments came at a town hall hosted by U.S. Rep. Diane Black, Republican of Tennessee, where a constituent explained her opposition to the GOP bill using faith. As a Christian, she said, her faith was rooted in helping the unfortunate, not cutting taxes on the rich, so why not expand Medicaid and allow everyone to have insurance? And she’s not alone. Last week, a Quinnipiac survey found that voters overwhelmingly oppose cuts to Medicaid — 74% of them — including 54% among Republicans.
Given the record high support for publicly funded healthcare, economists, policy experts and commentators everywhere have called on the Democratic party to build on our momentum by supporting a single payer system. But perhaps the most convincing case I heard came from Jessi Bohan, the teacher from Cookeville, Tennessee who spoke at Rep. Black’s town hall.
The week after her question went viral she wrote to the Washington Post that she was troubled to see her comments used as a “defense of Obamacare” instead of what they were: an indictment of any healthcare policy that leaves anyone out. As Bohan so eloquently put it, “it is immoral for health care to be a for-profit enterprise” that allows insurance companies to make “enormous sums of money off the sick while people are struggling to pay their medical bills.” If she had it to do over again, she wrote, she would have explained to Black “the Christian case for universal, single-payer health insurance, which would protect all Americans.”
While her message was targeted at Republicans, it is one that many of my colleagues in the Democratic Party need to hear as well. For two weeks, I’ve watched Democrats point to the Congressional Budget Office’s analysis of the Paul Ryan bill and express righteous outrage that it would lead to 24 million Americans losing their insurance. But that same CBO score says that 28 million Americans will still be without insurance even under the Affordable Care Act. I’m impressed that the ACA has expanded Medicaid eligibility in states that have adopted it and more than 20 million previously uninsured now have insurance, but universal healthcare it is not.
Time and time again I’ve heard Democrats dodge questions about their support for universal healthcare by saying they’re focused right now on defending the ACA. Now that we have repelled Paul Ryan’s attack and Donald Trump has signaled that Republicans will move on, the time for those excuses has passed.
For years, I’ve also watched as Democrats, including our presidential nominee last year, have avoided putting their name behind single payer by saying they’re focused on politically achievable short-term goals.
Single payer is politically achievable.
Gallup, the Kaiser Family Foundation, and other polling organizations have found that there is majority support for Medicare for All in America today. But more important, elected officials are not supposed to move to the political center, we are supposed to stake out the moral center and convince others to join us there.
November’s election results showed that we can’t just say “the other side is awful,” however true that may be, and expect Americans to flock to us. To win again, we must be a party of principles and present bold ideas and a vision for the future.
It is true that single-payer healthcare has been implemented in virtually every other advanced democracy on Earth. It is also true that in those countries, people live longer and healthcare is dramatically less expensive than it is here. And finally, it is true that Medicare for All is the direction Americans overwhelmingly want us to go. Nevertheless, I want my colleagues to join me in supporting single-payer not to save money or to win elections, but because it is the moral and just thing to do. If, like me, you believe healthcare is a right to everyone and not a privilege to those who can afford it, let’s be organized and let’s be unified in our support for Medicare for All.
John Conyers represents Michigan’s 13th District in the U.S. Congress. He has introduced H.R. 676 Medicare for All bill in every Congress since 2003.
Congressman John Conyers is right on target. The time has come for an improved Medicare for all. HR 676 now has 84 cosponsors. Single payer, here we come.
Editorial: Take the lead on health care as a right
National Catholic Reporter, April 1, 2017
The survival of the Affordable Care Act means that millions of people who have never had health coverage before can continue to buy plans from HealthCare.gov or find relief from an expanded Medicaid.
So, yes, let’s breathe a short sigh of relief. But then let’s roll up our sleeves and prepare for the next battle in the war that has been declared on the American middle class and people living in poverty.
Independent Sen. Bernie Sanders of Vermont promises to introduce a bill that would move health care coverage to a single-payer, Medicare-like system. Now is the time for Democrats to come back into the spotlight and use this opportunity to work with Sanders to create a system that works — that works for those who can afford health care insurance and, more vital, for those who cannot.
Other industrialized nations, such as Canada, France and Japan, treat basic health care as a human right for all people. They built their health care systems on that tenet. It’s time for the U.S. to recognize that right in this nation. The right to receive care can no longer be predicated on one’s financial situation. Everyone in this country deserves the same treatment in the emergency rooms, hospitals, and medical and dental offices in all 50 states.
Once we’ve taken our deep breath, that should be the next fight.
Another welcome editorial making it clear that preventing the repeal of the Affordable Care Act was important but not enough. We must begin treating health care as a human right for all people by moving health care coverage to a single-payer, Medicare-like system.
Don’t expect Medicaid work requirements to make a big difference
By Drew Altman, president and CEO of Kaiser Family Foundation
Axios, April 3, 2017
Medicaid “work requirements.” But their impact depends on how they are implemented and is likely to be very small — because most people on Medicaid who can work already are.
With Trumpcare dead for now, expect Republican governors to begin submitting waiver proposals to the Department of Health and Human Services to move their Medicaid programs in a more conservative direction. Medicaid “work requirements” are likely to be an element of many of those waiver requests, possibly from Republican-led states now looking to expand Medicaid under the Affordable Care Act.
During the Obama administration, HHS rejected mandatory work requirements as inconsistent with the purposes of the Medicaid statute, spurning requests from Arizona, Indiana, and Pennsylvania under a previous governor. Under the Trump presidency, HHS is expected to approve them.
Liberals find Medicaid work requirements repugnant because they believe that Medicaid beneficiaries want to work if they can, and that providing health coverage to people who cannot afford it is an obligation of any moral nation. Conservatives who favor work requirements see Medicaid coverage as another form of government welfare benefit, like cash assistance, requiring reciprocal obligations from beneficiaries, and a disincentive to work.
The reality, though, is that most Medicaid beneficiaries are working already, and the vast majority of those who are not working are likely to be exempted from all but the most draconian Medicaid work requirements when front-line caseworkers apply state rules.
* 59% of all Medicaid beneficiaries who were not on Supplemental Security Income — the program for low-income people with disabilities — were working full time (41%) or part time (18%) in 2015.
* That leaves 41% who were not working. Of those, the vast majority (89%) had reasons for not working, including that they were sick or had a disability (35%), were taking care of a family member (28%), or were in school (18%).
* Another 8% said they could not find a job which, when documented, usually satisfies work requirements.
* All told, just a tiny subset of Medicaid beneficiaries are-able bodied adults who do not have a reason for not working that would fail to pass muster with a state case worker.
Why are some people opposed to other people having health care? In the case of Medicaid, some conservatives would deny people health care merely because they failed to meet certain work requirements. It is not as if this is a ubiquitous problem since, according to this report, only a tiny subset of Medicaid beneficiaries are able-bodied adults who do not have a reason for not working.
Is the denial of medical care a proper punishment for not being able to find a job? Only 3 percent of Medicaid beneficiaries fell into this category – lower than the national unemployment rate. And the conservatives would deny them care? This seems to be an unusually cruel punishment for what is largely a circumstance of fate.
The other issue is who really deserves to be denied health care? Nobody you say? Then why don’t we have a system that guarantees that everyone does have affordable health care when needed, like maybe an improved Medicare for all? Segregating people into arbitrary groups for health care coverage leaves many out, such as what would happen under these conservative work requirements for Medicaid.
HHS Secretary Tom Price and CMS administrator Seema Verma like these work requirements and are eager to grant states the right to exercise them. And we tolerate this in our government? What have we become?
In the state with the highest medical debt, it’s the middle class who carries the burden
By Max Blau
STAT, March 24, 2017
Americans are no strangers to medical debt, and the burden is most severe in Mississippi, where nearly 40 percent of adults under age 65 owe hospitals or doctors, according to the Urban Institute. But the men and women carrying that debt are not always poor — they’re increasingly middle class.
And their inability, or refusal, to pay their bills is straining hospital budgets and threatening the availability of care.
Mississippi, where the median household income hovers near $40,000, has one of nation’s highest rates of uninsured and underinsured adults. As a result, the state has one of the highest percentage of adults who avoid doctors due to potential costs, said Therese Hanna, executive director at the Center for Mississippi Health Policy.
At the same time, medical debt remains the leading cause of bankruptcies, according to Roy Mitchell, executive director of the Mississippi Health Advocacy Program.
Over the past five years, James Henley Jr., a bankruptcy trustee in Jackson, said he has seen a sharp increase in the number of middle-class residents with bankruptcy claims after “extending their lines of credit, maxing out credit cards, [robbing] Peter to pay Paul.”
Welfare Audit Bill Passes With No Statistics Given on Fraud
By Sarah Smith
U.S. News & World Report, March 29, 2016
Mississippi could hire a private company to audit Medicaid, welfare and food stamp recipients and make sure they aren’t cheating the program under legislation approved by the Senate on Wednesday after a debate in which supporters offered no statistics about welfare fraud.
The bill, which is on its way to Gov. Phil Bryant, had already passed the House on Tuesday.
House Bill 1090 would let the state hire a contractor to help check that recipients live in Mississippi and are who they claim to be. The contractor would also check recipients’ income levels. The measure also requires able-bodied recipients to be working, and it tracks where recipients use their money.
Republican proponents say the bill will bring the state one-time savings of about $4 million to $5 million. Sen. Brice Wiggins, a Republican from Pascagoula who presented the proposal Wednesday, said the state Department of Human Services gave him the estimate.
But that number started to fall apart under questioning from Democratic Sen. Hob Bryan of Amory. He had never seen a number, he said. Could he take a look?
“I am told that — I’m not going to lie, numbers get thrown around all the time,” Wiggins said. “We need this bill to get to that.”
Bryan asked again if the figures came from the Department of Human Services.
“As I said, numbers were all over the place,” Wiggins replied.
Several Democrats pointed out the sponsors have no numbers on fraud.
“How many people are riding the system who aren’t deserving?” asked Sen. David Jordan, a Democrat from Greenwood. “Don’t you think you should have some statistics?”
Wiggins had no statistics to offer. Finding out just how much fraud is going on, he said, is part of the bill’s purpose.
“What is driving some of us up the wall is the notion that somehow the entire class of people receiving Medicaid or other benefits are a bunch of clever, crafty people out trying to steal money from hard working folks and if we could only crack down on this we could balance the state budget,” Bryan said.
The residents of Mississippi have a serious problem with medical bills and resulting debt impacting 40 percent of adults under 65. The fact that their state legislators are not particularly responsive to this problem is represented by the fact that they rejected an expansion of Medicaid under the Affordable Care Act which would have provided coverage to an additional 300,000 Mississippians.
Of course the medical debt problem persists, so the legislature finally acted. But talk about a non sequitur, in this case a double non sequitur.
First, defining the problem. These people needed medical care but did not have adequate means of paying for it and thus were saddled with medical debt. It seems that a logical response would be to set up a health insurance program to pay for the medical expenses. No, even a Medicaid program with 90 percent federal funding was rejected by the legislators.
So they had a second chance, and what did they do? They somehow decided that these people in need were a bunch of flakes who were just after free handouts, so, with no supporting evidence whatsoever, they voted to authorize a private contractor to ferret them out if they relied on public benefits. In spite of this double whammy of incompetence, it does look like the legislators have had one dubious success – they have managed to blame the victim.
Sometimes this states’ rights thing goes overboard. We cater to the legislators and governors of the states while we neglect the needs of the people. Mississippi desperately needs a universal insurance program. It is not as if the federal government has no rightful role because seniors and individuals with long term disabilities have the right to Medicare. Why shouldn’t we extend that right to everyone in Mississippi, or, for that matter, to everyone in the United States? Well, we should.
Several states have proven that it is unethical for us to continue to allow the states to make their own decisions about who should or should not be entitled to health care when so many are harmed by bad governing decisions. Limiting health care coverage to the gentry or whatever other qualifying social order is un-American. Mississippi shows us that it is an absolute imperative that we have a national health program that includes everyone and is effective in removing financial barriers to all needed care. That is just what an improved Medicare for all would do.
“…our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal. Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived and so dedicated…”
No, let’s not go there again. Let’s just get heath care out to everyone.
SB-562, The Healthy California Act
California Legislature, Amended in Senate March 29, 2017
This bill, the Healthy California Act, would create the Healthy California program to provide comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state. The bill, among other things, would provide that the program cover a wide range of medical benefits and other services and would incorporate the health care benefits and standards of other existing federal and state provisions, including, but not limited to, the state’s Children’s Health Insurance Program (CHIP), Medi-Cal, ancillary health care or social services covered by regional centers for persons with developmental disabilities, Knox-Keene, and the federal Medicare program. The bill would require the board to seek all necessary waivers, approval, and agreements to allow various existing federal health care payments to be paid to the Healthy California program, which would then assume responsibility for all benefits and services previously paid for with those funds.
The bill would state the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for the Healthy California program. The bill would create the Healthy California Trust Fund in the State Treasury, as a continuously appropriated fund, consisting of any federal and state moneys received for the purposes of the act.
Sec. 1 (b)
(2) It is the intent of the Legislature for the state to work to obtain waivers and other approvals relating to Medi-Cal, the state’s Children’s Health Insurance Program, Medicare, the PPACA, and any other federal programs so that any federal funds and other subsidies that would otherwise be paid to the State of California, Californians, and health care providers would be paid by the federal government to the State of California and deposited in the Healthy California Trust Fund.
(3) Under those waivers and approvals, those funds would be used for health coverage that provides health benefits equal to or exceeded by those programs as well as other program modifications, including elimination of cost sharing and insurance premiums.
Sec. 2 TITLE 22.2. The Healthy California Act
Chapter 7. Funding
Article 1. Federal Health Programs and Funding
(1) The board shall apply to the United States Secretary of Health and Human Services or other appropriate federal official for all waivers of requirements, and make other arrangements, under Medicare, any federally matched public health program, the Affordable Care Act, and any other federal programs that provide federal funds for payment for health care services that are necessary to enable all Healthy California members to receive all benefits under the program through the program, to enable the state to implement this title, and to allow the state to receive and deposit all federal payments under those programs, including funds that may be provided in lieu of premium tax credits, cost-sharing subsidies, and small business tax credits, in the State Treasury to the credit of the Healthy California Trust Fund, created pursuant to Section 100655, and to use those funds for the program and other provisions under this title.
(2) To the fullest extent possible, the board shall negotiate arrangements with the federal government to ensure that federal payments are paid to Healthy California in place of federal funding of, or tax benefits for, federally matched public health programs or federal health programs.
Article 2. The Healthy California Trust Fund
100655. (a) The Healthy California Trust Fund is hereby created in the State Treasury for the purposes of this title.
Article 3. Healthy California Financing
100657. (a) It is the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for the program. In developing the revenue plan, it is the intent of the Legislature to consult with appropriate officials and stakeholders.
Now we have the full text of California’s new single payer bill – SB 562. It calls for comprehensive health care coverage for all residents of California with no premium, copayment, coinsurance, deductible, nor any other form of cost sharing, for all covered benefits. “Resident” means an individual whose primary place of abode is in the state, without regard to the individual’s immigration status. It’s the real thing.
Last week, Gov. Jerry Brown seemed to dismiss the idea of a single payer system with this response to reporters, “Where do you get the extra money? This is the whole question.”
Of course, the money is already there and being spent on health care. Current government and private spending combined is enough to pay for a comprehensive system for all residents wherein the administrative savings and other efficiencies frees up enough funds to pay for those currently uninsured and underinsured.
There are two issues that may have prompted the governor’s response: transferring current federal health care funds to the state, and establishing a state tax system to replace current private spending.
The excerpts from SB 562 posted above indicate that it is the “intent” to obtain “waivers and other approvals” that would enable the federal government to transfer to the state funds from Medicare, Medicaid, Chip, ACA, and other federal programs. The problem is that current waiver programs are inadequate to fully accomplish that, and new federal legislation would be required. Considering the composition of the current Congress, that could be a difficult task (a comment that does not require a mastery of understatement).
Health care spending through the private sector is relatively inefficient compared to spending in government programs such as Medicare. Yet when the taxes that would replace private spending are spelled out specifically, they seem overwhelming to the average individual with an aversion to taxes in general. It is difficult for them to see what they are already paying for our health care system that is not particularly transparent such as the component of employer-sponsored health plans that are only nominally paid by the employer, the tremendous tax expenditures for employer-sponsored plans that go disproportionately to higher income individuals, the huge spending for government employee health plans on the federal, state, and local level, and the costs of health care built into the prices of services and products to pay for employee coverage, worker’s comp, liability coverage, and the like. When that spending goes away and is replaced by government spending, the taxes to pay for that can look formidable. Just ask former Gov. Peter Shumlin of Vermont. Then try to sell that to the residents of California. When you try to explain to them that the tax system would be more equitable and efficient, and most would actually pay less overall, they are already blinded by the proposed tax increases that they do see (but are not yet spelled out in SB 562).
What we need is a well designed, national single payer health program. We should continue to pull all stops toward that goal, though it is difficult to see when we will reach the political threshold that will make that possible. Until then we should also support state efforts to relieve the physical suffering and financial hardship that is being wrought on our people by our dysfunctional health care financing system.
Thus we should strongly support SB 562. We should make every effort to obtain “waivers and other approvals,” as difficult as that will be. We should increase our efforts to educate the public on what a really good deal this would be for them, otherwise our efforts could be sunk by a few soundbites from the industries that profit excessively from our sick system (as they were in prior ballot measures in California, Oregon and Colorado).
But while we do this, we cannot let up the least in our advocacy for a national health program. Our brothers and sisters in other states desperately need our help.
Justice Department Joins Lawsuit Alleging Massive Medicare Fraud By UnitedHealth
By Fred Schulte
Kaiser Health News, March 28, 2017
The Justice Department has joined a California whistleblower’s lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.
Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben’s case with that of another whistleblower.
Swoben has accused the insurer of “gaming” the Medicare Advantage payment system by “making patients look sicker than they are,” said his attorney, William K. Hanagami. Hanagami said the combined cases could prove to be among the “larger frauds” ever against Medicare, with damages that he speculates could top $1 billion.
“This is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena,” said Patrick Burns, associate director of Taxpayers Against Fraud in Washington, a nonprofit supported by whistleblowers and their lawyers.
“This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope,” Burns said.
When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.
But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars.
Regular readers know that the private Medicare Advantage plans have been cheating the taxpayers by upcoding the diagnoses of insured patients to make them appear sicker than they really are in order to qualify for extra risk adjustment payments. This update confirms the seriousness of the allegations in that the Justice Department has joined the lawsuit against the insurers. Damages could top a billion dollars.
This is particularly pertinent right now since there is intense political pressure to reduce entitlement spending (Medicare and Social Security) in the forthcoming federal budget negotiations. A plan favored by HHS Secretary Tom Price, House Speaker Paul Ryan, and others in the Republican leadership would convert traditional Medicare into a defined premium (voucher) program, turning all of Medicare over to these crooks.
Although our first priority must continue to be advocacy of a single payer national health program – an improved Medicare for all – it is imperative that we protect the Medicare that we do have if we are going to use an improved version of it to provide health care to all.
Special credit should go to the author of this KHN/NPR article, Fred Schulte, who has done extensive investigative reporting on this topic, having authored the articles on it previously published by the Center for Public Integrity. Thanks, Fred!
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