CMS pushing Sec 1332 waivers for high risk pools/reinsurance

Posted by on Monday, May 15, 2017

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.

CMS Checklist For State 1332 Waivers Focuses On High-Risk Pools, Reinsurance

By Timothy Jost
Health Affairs Blog, May 12, 2017

On May 11, 2017, the Centers for Medicare and Medicaid Services and the Department of the Treasury released a checklist for state 1332 innovation waiver applications. Following up on Health and Human Services Secretary Price’s letter to state governors of March 13, 2017, the checklist specifically focuses on state 1332 proposals to support high-risk pools or reinsurance programs.

The checklist restates the procedural requirements that states must meet under the current 1332 rules, such as posting a notice of the waiver proposal and accepting comments for at least 30 days, holding two public hearings, and consulting with Indian tribes where relevant.

Most elements in the checklist, however, describe specifically what information states must submit with applications for a 1332 waiver involving a reinsurance or high-risk pool program. While states must generally document state legislative authority to operate a 1332 waiver program, a state seeking a waiver to operate a high-risk pool or reinsurance program must establish that the legislation makes the program contingent on 1332 waiver approval or that the program will only become operational if the waiver is approved.

In sum, the checklist provides a roadmap for states that want to pursue high-risk pool or reinsurance 1332 waiver proposals, indicating again the priority that the Trump administration places on this approach for increasing the affordability of health insurance coverage.…

CMS Checklist for Section 1332 State Innovation Waiver Applications, including specific items applicable to High-Risk Pool/State-Operated Reinsurance Program Applications:…

One of the prime drivers of the Affordable Care Act was the inherent flaws in the individual insurance market. As more people with expensive health care problems enrolled in the individual plans, premiums went up and the healthy dropped out, resulting in the “death spiral” of skyrocketing premiums. Insurers countered by limiting benefits, by excluding individuals with preexisting disorders, or by pulling out of markets with higher-cost beneficiaries.

To cover those who had a greater need for care, many states established high-risk insurance pools, but these pools were very expensive. The benefits were quite limited, and the premiums were very high, but they also required large contributions from the states. Think about the fact that the 20 percent of people who had major health problems consumed 80 percent of the health care (the 80/20 rule). Moving 80 percent of the costs for these patient populations into separate pools proved to be far too much for the states, so the pools were severely underfunded. Benefits were spartan, many could not afford the premiums, and intolerable waiting lists were established due to enrollment caps. They were a policy failure.

Yet what does the current Congress and administration want to do about this problem? They have emphasized repeatedly that the leading priority is to make premiums affordable. To do this they would go back to the dysfunctional individual market in which only the healthy were insured, with one technical modification. They would reestablish separate high-risk pools to insure the costly patients, or they would leave everyone in the same risk pool but provide reinsurance to cover the excessive losses resulting from caring for the more expensive patients. In either case, the costs of the pools and/or reinsurance would be very high. Since they want to keep the premiums low these extra costs would have to be paid by the state or by “federal pass-through payments.”

The CMS checklist states, “State-operated reinsurance programs have a demonstrated ability to help lower premiums, and if the state shows a reduction in federal spending on premium tax credits a state could receive Federal pass-through funding to help fund the state’s reinsurance program.” In other words, the federal contribution would be only the amount that they would otherwise be contributing in the form of premium tax credits – a budget neutral solution. This could not possibly fund either a high-risk pool or a reinsurance program for the the most expensive patients. The prior experience with the state high-risk pools has already confirmed that the states, for both political and fiscal reasons, are not capable of funding these pools either.

So all of this talk about federal authorization of high-risk pools and reinsurance programs through Section 1332 waivers is garbage. The current federal government has no intention of funding these programs, but they will authorize them and then sit back and blame the states for failing to implement them properly. Who is harmed by all of this? The patients, of course.

We would not have to worry about the 80/20 rule if everyone were in the same universal risk pool as they would be in a single payer, improved Medicare for all program. Unless our current political leaders suddenly have a miraculous communal epiphany, we need to replace them.

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Medicare’s high out-of-pocket costs

Posted by on Friday, May 12, 2017

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.

Cost Burdens by Income and Health Status

By Cathy Schoen, Karen Davis, Amber Willink
The Commonwealth Fund, May 12, 2017


Issue: Fifty-six million people — 17 percent of the U.S. population — rely on Medicare. Yet, its benefits exclude dental, vision, hearing, and long-term services, and it contains no ceiling on out-of-pocket costs for covered services, exposing beneficiaries to high costs.

Goal: To inform discussion of possible changes to Medicare, this issue brief looks at beneficiaries’ out-of-pocket costs by income and health status.

Methods: Spending estimates based on the Medicare Current Beneficiary Survey.

Findings and Conclusion: More than one-fourth of all Medicare beneficiaries — 15 million people — spend 20 percent or more of their incomes on premiums plus medical care, including cost-sharing and uncovered services. Beneficiaries with incomes below 200 percent of the poverty level (just under $24,000 for a single person) and those with multiple chronic conditions or functional limitations are at significant financial risk. Overall, beneficiaries spent an average of $3,024 per year on out-of-pocket costs. Financial burdens and access gaps highlight the need to approach reform with caution. Already-high burdens suggest restructuring cost-sharing to ensure affordability and to provide relief for low-income beneficiaries.

From the Summary and Implications

The high financial burdens documented in this brief illustrate the need for caution. Half of Medicare beneficiaries have low incomes; one-third have modest incomes (200% to 399% of poverty). Any potential policy should first consider the impact on beneficiaries.

Access and affordability remain key concerns. In any discussions of potential Medicare reform, it will be important to pay particular attention to consequences for those vulnerable because of poor health or low income. Indeed, the findings point to the need to limit out-of-pocket costs and enhance protection for low-income or sicker beneficiaries.…

Although President Trump has said that he is going to leave Medicare alone, we have learned that he is not a reliable source for information about pending policy changes. The Republicans controlling Congress have indicated that they want to reduce projected spending on Medicare by privatizing it and switching to vouchers (premium support) in order to ratchet down the government’s contribution to the program. So what does this report tell us about the wisdom of their intentions?

Medicare is already an inadequate program. Instead of cutting the Medicare budget further we should be expanding it to fill in the deficiencies that are leaving Medicare beneficiaries exposed to excessive debt.

The full article available at the link above discusses programs that are used to patch some of the holes, but just as patches are inadequate for the Affordable Care Act, patches have also been inadequate for Medicare, just as this report demonstrates.

We need a Medicare that meets the much higher standards of the “Physicians’ Proposal for Single-Payer Health Care Reform,” and then we need to enroll everyone in it automatically. That’s why we talk about an Improved Medicare for All.

Physicians’ Proposal for Single-Payer Health Care Reform:

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Political divide on AHCA

Posted by on Thursday, May 11, 2017

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.

YouGov, May 6, 2017

As you may know, Republican leaders in the House of Representatives recently passed a new health bill (AHCA). Do you generally favor or oppose this bill?

Favor strongly or somewhat:
Total – 31%
Democrats – 13%
Independents – 24%
Republicans – 69%

Oppose strongly or somewhat:
Total – 44%
Democrats – 70%
Independents – 40%
Republicans – 11%

Not sure:
Total – 25%
Democrats – 17%
Independents – 36%
Republicans – 20%…

This poll is being reported as showing that Americans oppose the Republican repeal and replace health care legislation (American Health Care Act) passed by the House of Representatives. It would be more accurate to state that Republicans and Democrats are divided in their support, but many remain undecided, especially amongst Independents. Neither support nor opposition reached a majority, except within the two major parties.

Unfortunately, the results indicate that political polarization remains strong between the two parties, but that a careful consideration of the implications and consequences of the policy features of the legislation seems to be lacking. That makes the assumption that we should be able to agree on what is better for America – affordable and accessible health care for all, or that individuals need to be empowered to take ownership of their health care or do without.

It is tragic that we reduce public health policies to a battle of political slogans. The health of the nation depends on getting the policies right. Too many of us seem to tune in to what our political leaders have to say, and then parrot their words. What a terrible way to try to craft rational, humane policy.

Many contend that moving forward from a political divide requires bipartisanship – compromise. No, not when both sides are wrong. Merging ACA and AHCA would only perpetuate our high costs, inequities, and wasteful administrative inefficiencies. We need to eject the politicians and move on with crafting reform based on sound policies. Perhaps it’s time to bring the sociologists into the arena.

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Medical debt and personal bankruptcy

Posted by on Wednesday, May 10, 2017

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

How the Affordable Care Act Drove Down Personal Bankruptcy

By Allen St. John
Consumer Reports, May 2, 2017

As legislators and the executive branch renew their efforts to repeal and replace the Affordable Care Act this week, they might want to keep in mind a little-known financial consequence of the ACA: Since its adoption, far fewer Americans have taken the extreme step of filing for personal bankruptcy.

Filings have dropped about 50 percent, from 1,536,799 in 2010 to 770,846 in 2016. Those years also represent the time frame when the ACA took effect.

So did the rise of the ACA—which helped some 20 million more Americans get health insurance—cause the decline in bankruptcies?

The many experts we interviewed also pointed to two other contributing factors: an improving economy and changes to bankruptcy laws in 2005 that made it more difficult and costly to file. However, they almost all agreed that expanded health coverage played a major role in the marked, recent decline.

The American Bankruptcy Institute suggested that veteran Chicago bankruptcy attorney and trustee David Leibowitz could also help parse the reasons for the decade long decline.

First, he says, the Bankruptcy Abuse Prevention and Consumer Protection Act of 2005 made it more difficult for consumers to file for bankruptcy. The law required credit counseling and income verification and forced many consumers to seek protection under Chapter 13, which restructures, but does not eliminate, most debt. The piles of paperwork also meant most filers needed a lawyer, which made bankruptcy more costly and therefore not an option for many poor consumers.

Then there was the economy. After a slow and steady recovery following the housing crisis of 2008, Leibowitz explains that American consumers generally had fewer problems with their mortgages, better employment prospects, and greater access to credit, which made them less likely to file.

The final factor, according to Leibowitz, has been the ACA, which afforded health coverage to many more consumers and expanded protections for all.

Over the past decade, determining the cause-and-effect relationship between medical debt and bankruptcy has become a political football, particularly during the years the Obama administration was trying to pass the ACA through Congress.

The truth is that it’s not that easy to determine how many bankruptcies are caused by medical debt. Examining the paperwork doesn’t always offer insight because debtors often juggle their indebtedness, for example, using a credit card to pay an outstanding medical bill while leaving other debts unpaid.

At its most basic level, health insurance allows consumers to pay for the medical care they need. Each year, the Centers for Disease Control and Prevention determines how well the system is working by surveying Americans and asking a simple but powerful question: Did you have problems paying medical bills in the last 12 months?

The percentage of those reporting problems has dropped from 21.3 percent of households when they first asked the question in 2011 (56.5 million) to 16.2 percent in 2016 (43.8 million). That’s almost 13 million fewer Americans no longer facing collection notices from a doctor or hospital.

In CR’s Consumer Voices survey in January 2017, 55 percent of consumers said they lacked confidence that they or their loved ones would be able to afford insurance to secure that care.…

It is reassuring to learn that personal bankruptcies are declining, but we should not extrapolate the conclusion that the Affordable Care Act is responsible for largely eliminating the problem of medical debt. It is still very much with us.

In 2016, about 43.8 million Americans had problems paying medical bills in the past 12 months. A Consumer Reports survey in January of this year revealed that “55 percent of consumers said they lacked confidence that they or their loved ones would be able to afford insurance to secure that care.” Affordability of health insurance and health care remains a major problem in the United States.

It is likely that the expansion of Medicaid and the introduction of generous subsidies for low-income individuals reduced the rate of medical debt amongst the 20 million people who gained coverage under ACA, but the reduction in the rate of personal bankruptcy for the other 300 million Americans was more likely due to a combination of an improved economy and the Bankruptcy Abuse Prevention and Consumer Protection Act of 2005 which made it much more difficult to file for personal bankruptcy. (The albatross of life-long debt is another story.)

When over half of Americans lack confidence that they can afford health insurance and almost 44 million are already having difficulties paying their medical bills, we have a problem. It could be virtually eliminated by enacting a well designed single payer national health program – an improved Medicare for all – that automatically includes everyone while removing financial barriers to care. Celebrating ACA is not enough.

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Healthy Indiana patients are being dumped into lower-tier plan

Posted by on Tuesday, May 9, 2017

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.

More than half of Indiana’s alternative Medicaid recipients didn’t make payment required for top service

By Maureen Groppe
IndyStar, May 8, 2017

More than half the low-income people who qualified for Indiana’s alternative Medicaid program failed to make a monthly payment required for the top tier of service — a key feature of the program Vice President Mike Pence insisted on as a condition to expanding the health care program when he was Indiana’s governor.

That’s according to a new evaluation of the Healthy Indiana Plan, a program designed by Indiana health care consultant Seema Verma, who — as the new administrator for the Centers for Medicare and Medicaid Services — can now grant other states permission to impose similar monthly fees.

Opponents say the department of Health and Human Services should not allow other states to do this, because this study and other research has shown requiring poor people to pay is a barrier to care.

Verma, along with HHS Secretary Tom Price, already have told states they want to be as permissive as possible.

Of the 590,315 Hoosiers determined eligible for Medicaid during the 22 months after Indiana expanded eligibility, 55 percent either never made the first payment or missed one while on the program.

Nearly nine in 10 ended up in the lower-tier plan as a result, according to an evaluation done for the state and submitted to the federal government.

“The evaluation makes clear that Healthy Indiana’s complicated use of premium payments is not working,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families. “More than half of the enrollees have missed a payment at some point, and as a result are bouncing around in and out of coverage sources or no coverage at all. These are very poor people for whom premiums are a hardship.”

Pence insisted on including monthly payments as a condition for expanding Medicaid through the Affordable Care Act. He argued the payments promote personal responsibility and better decision making by patients who have “skin in the game.”

It’s a sentiment shared by Verma. “The Healthy Indiana Plan is about empowering individuals to take ownership for their health,” Verma said during her confirmation hearing.

The insurance companies which offer the Medicaid plans say Indiana’s payment requirements and two-tiered system is more costly to administer.…

Although we’ve covered this topic before, this report provides new evidence that the Healthy Indiana Plan is providing a disservice to eligible Medicaid beneficiaries by shifting most of them into the lower-tier plan where they lose dental and vision benefits, have more limited drug coverage, and are exposed to copayments. Since most of these individuals have no discretionary income, many do without these important services. This is the opposite of what a program designed to provide low-income individuals with affordable access to health care should be doing.

One of the major problems with our health care financing system is that we pay hundreds of billions of dollars for outrageous administrative waste. Now the insurers report that the Healthy Indiana Plan is even more costly to administer than traditional Medicaid. Just exactly what we need – more administrative waste!

Recently-appointed CMS Administrator Seema Verma worked with then Governor Mike Pence to establish this ideologically-driven but cruel policy, and now she wants to work with HHS Secretary Tom Price to expand this concept to other states. Enough! We do not need more inefficiency and impaired access to care. We need a single payer national health program – an improved Medicare for all so that all of us can have the care that we need, when we need it.

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Charlie Munger supports single payer reform

Posted by on Monday, May 8, 2017

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.

Charlie Munger says single-payer healthcare is the solution

By Andy Serwer
Yahoo Finance, May 7, 2017

Charlie Munger says that single-payer healthcare is the answer to fix the nation’s healthcare system woes. A longstanding Republican, the Berkshire Hathaway vice-chairman acknowledges it is an unusual position for someone from his party to espouse.

“I’m not a normal Republican,” he said, noting that there’s “a lot wrong” with the system.

“Having a basic level of care for everybody with no insurance aspect as a right I think is a good idea” Munger said.

Munger, who Berkshire CEO Warren Buffett calls his partner, made the remarks in Omaha the day after Berkshire’s annual meeting. Munger said there’s good and bad parts of our healthcare system.

“At the top, it’s the best medical care in the world,” Munger said. He explained that if you have a difficult type of cancer or you’re in need acute care, you’re better off in the U.S. than anywhere else.

“That’s the good part,” he said. “The bad part is the Rube Goldberg system that arose by accident. There’s massive amounts of excess cost.”

“And of course the politicians on each side don’t want to figure this out, they just hate each other and scream at each other, so it’s a disgusting outcome. And of course the cost goes up three, four, five six percent a year!”

I asked Munger how to fix it.

“A benign despot would create a single payer system with people being able to opt out into private care that was a little faster or a little fancier like all of Europe and Canada,” he said.

I asked Munger if he was saying that a single-payer system is really the answer.

“Yes,” he said.

With an opt-out on the high end?

“Yes,” he said.

“I think you young people will live to see a healthcare system that looks a lot like Canada’s with a better private opt out system,” Munger said. “I won’t.” (Munger is 93.)

During the meeting, Warren Buffett called rising healthcare costs “a tapeworm,” eating away at American business. Munger agreed and added that U.S. manufacturers have a “huge competitive disadvantage caused by the health system” over say European counterparts since U.S. businesses have to pay for health care costs while European companies don’t.”…

When a prominent Republican Wall Street billionaire, Charlie Munger, endorses single payer, it is clear that the message is getting across.

Also, when his partner, Warren Buffet, says that U.S. manufacturers have a huge competitive disadvantage caused by the health system, then all of Wall Street and the business community at large should be listening as well and then taking action in support of single payer reform.

(One concern is that he calls for wealthier individuals being able to opt out into faster or fancier care, presumably creating a two-tiered system. Perhaps the wealthy should be allowed extras that should not be part of a publicly financed system, such as a hospital penthouse suite, but they should not automatically be granted a position at the front of a queue for essential services. In an equitable, egalitarian system we need them to advocate for policies that reduce excessive queues so that everyone, including themselves, has timely access to appropriate care. However this should not deter Munger from supporting single payer, since, as a billionaire, he will always have a place at the front of the queue, no matter the rules.)

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Physicians shouldering more of patients’ cost sharing

Posted by on Friday, May 5, 2017

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.

As Patients Take On More Costs, Will Providers Shoulder The Burden?

By Michael Chernew and Jonathan Bush
Health Affairs Blog, May 4, 2017

Despite the uncertainty about the future of the Affordable Care Act (ACA) and any replacement, in the coming years, more Americans will almost surely find themselves in health plans with considerable patient cost sharing at the point of service (for example, high deductibles, copayments, or co-insurance). The trend toward more limited plans has been a reality for more than a decade. For example, the average deductible has grown from $818 in 2006 to $2,069 in 2015.

Moreover, Congress may try to reduce cost-sharing subsidies and encourage people to select more limited plans in other ways, such as increasing the attractiveness of health savings accounts. Cost sharing lowers premiums (an important goal for payers and policy makers) by lowering use and, to some extent, encouraging consumers to shop for lower-price care. It also shifts costs away from payers toward patients.

Public debate about more limited insurance plans has mostly focused on their impact on beneficiaries. Missing from the discussion has been an analysis of how these plans could affect providers.

Calculating The Provider Burden From Cost Sharing

Using medical claims data from athenahealth’s national network of 88,000 providers, we computed out-of-pocket obligations for commercially insured patients across all provider specialties, from 2012 through 2016. Our sample includes 125 million visits for ambulatory services (for example, office visits and ambulatory surgical procedures) by 18 million patients across 1,348 practices.

For each visit, we computed the required patient cost-sharing amount. We looked at those patient obligations across four broad categories, based on size of the patients’ out-of-pocket charge for the visit: small ($0-$35), medium ($35-$75), large ($75-$200), and very large (more than $200). We found that the average patient obligation per visit increased 20 percent between 2012 and 2016, with the overall distribution shifting from small to larger obligations.

Using the 2015 data, we then computed collection rates after 12 months for the different patient obligation size categories. For visits with small patient obligations, 93.8 percent of the balance was paid within a year. The rate drops to just 66.7 percent for visits with obligations above $200. For visits with the highest obligation, roughly 16 percent were written off as bad debt or abandoned, and about another 17 percent were sent to collection agencies.

Compounding this issue with larger patient balances is the opacity of obligation amounts at the time of service. While practices have visibility at the point of service into patient copayment amounts through eligibility data, the amount they can collect for patients with high-deductible health plans is unknown. Under current rules, they must bill the insurance carrier and wait for an explanation of benefits (often a two-week lag time) before billing the patient for his or her portion. Aside from this being an extremely complex and costly process, we know that collecting any amount becomes markedly more difficult once the patient leaves the office.


The tax on providers from increased patient cost sharing occurs against a backdrop of very slowly rising fees. The new physician payment system outlined in the Medicare Access and CHIP Reauthorization Act of 2015 calls for physician fees to rise by 0.5 percent (before accounting for inflation) through 2019 and then to be flat through 2024 and beyond. If general inflation rises by 2 percent through 2024, roughly as projected by the Federal Reserve, this represents an inflation-adjusted reduction in fees on average of more than 10 percent. While some physicians may fare well under the performance bonus system, fee increases for the high performers, beyond the exceptional performance bonus, will be funded by a reduction in fees for low-scoring physicians. The result for physicians could be a perfect storm of fee cuts and losses from writing off uncollected patient payments.

As in other markets, providers should have the price transparency and flexibility to offer discounts for time-of-service payments.

For physicians to weather the financial pressures coming, they will need to design and manage a “retail front end” for their practices, with the ability to offer “sales” to patients in return for speedy payment. They will also need to get sophisticated about accessing insurance companies online to assess what patients will owe before they leave the office. As important, physicians will need to find ways to manage their practice costs. Under existing fee-for-service payment models, however, any efficiency gains made by reducing wasteful care are captured by payers.…

The increasing prevalence and magnitude of cost sharing is not news. We have long recognized the burden this has placed on patients, not only the financial burden but also the decline in access to beneficial health care because of the lack of affordability due to higher out-of-pocket expenses. Today’s article adds the concern that the burden of cost sharing is being shifted onto physicians because of the difficulty that patients have in paying their cost-sharing obligations.

This is no small burden for physicians. Patient deductibles now average over $2000. It would not take very many delinquent accounts to significantly reduce the physicians’ take-home pay. Further, MACRA not only brought to physicians the burden of MIPS and APMs but it also scheduled flat fees in the future amounting to a ten percent inflation-adjusted reduction of fees. Further, the performance rewards will be financed by fee reduction penalties for those physicians who dedicate themselves to caring for the most needy since these patient populations result in empirically low “quality” scores.

Nobody expects the insurers or legislators to back off on the march toward more patient responsibility for paying medical bills. It will get worse, and, as these authors state, “a perfect storm of fee cuts and losses from writing off uncollected patient payments” will be brewing.

But what is the authors’ solution? Design and manage “a retail front end” – offer discounts, hold sales, reward speedy payments, develop more sophistication in accessing insurance companies to determine cost sharing requirements, and, of course, the inevitable recommendation that physicians are simply going to have to reduce their practice costs (where do you cut when you’re already down to the bone?).

Is this really the practice environment that patients want for their physicians (“… but today only, just for you, a deal you can’t refuse …”)? For that matter, do patients really want to exercise their consumer prowess by having the opportunity to pay upfront charges for their health care?

Sorry. This is not where we should be headed. We need to dump all this and move forward with first dollar coverage through a well-designed single payer national health program – an improved Medicare for all.

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Vote on the American Health Care Act

Posted by on Thursday, May 4, 2017

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.

House of Representatives, May 4, 2017

Yea: 217
Nay: 213

Fulfilling a rhetorical election promise was more important to conservative members of Congress than is the health care of the American people. After all, how could they face their voters? Yes, how can they?

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A fiscally conservative businessman says single payer would be better

Posted by on Wednesday, May 3, 2017

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.

Why I’m finally ready to agree a single-payer healthcare system would be better for business

By Gene Marks
The Washington Post, April 28, 2017

My wife is English and one of the biggest surprises she had when moving to this country was healthcare. “I don’t understand why my employer is involved in my healthcare,” she said back then – and still says today. After years of listening to that argument, I’m starting to understand what she means.

I can’t believe I’m saying this. I consider myself a smaller-government, fiscally right-of-center guy. I own a small business. I want lower taxes and less regulations. And yet, after watching and studying and writing about healthcare reform for going on 10 years I think I’m finally to the point of caving in and admitting that maybe, just maybe, a single-payer system would be what’s best for businesses, including businesses like mine.

Every year I speak and work with thousands of business owners and managers and each and every one of them are terrified come summertime when healthcare rates for the next year are announced. Every year – and I mean every year – my clients have suffered with double-digit increases in their healthcare costs. Sure, they are pushing more of these costs down to their employees. But most are still covering a large part of the health insurance offered to their people.

We spend too much time trying to figure out ways to reduce our healthcare insurance – which, to many represents a significant line item on our income statements. This time distracts us from ways to grow our businesses. But we have to do this because we have to offer a healthcare benefit. Our employees expect it. Our competitors are offering theirs. The labor pool is tight. My wife asks “why?” So do I.

We’re at the point where many of my clients – and many who are fiscally right-of-center like me – would seriously consider an individual tax increase and all the risks of a single-payer system just to take this headache away from our businesses so we can focus on…well…our businesses.…

Placing health financing decisions into the hands of employers for a majority of Americans is a historical fluke and continuing to do so defies logic. A single payer national health program would end this nonsense (not to mention providing affordable, comprehensive health care for everyone).

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Expanding coverage under ACA did not reduce access for the continuously insured

Posted by on Tuesday, May 2, 2017

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.

By Salam Abdus and Steven C. Hill
Health Affairs, May 2017


Recent expansions in health insurance coverage have raised concerns about health care providers’ capacity to supply additional services and how that may have affected access to care for people who were already insured. When we examined data for the period 2008–14 from the Medical Expenditure Panel Survey, we found no consistent evidence that increases in the proportions of adults with insurance at the local-area level affected access to care for adults residing in the same areas who already had, and continued to have, insurance. This lack of an apparent relationship held true across eight measures of access, which included receipt of preventive care. It also held true among two adult subpopulations that may have been at greater risk for compromised access: people residing in health care professional shortage areas and Medicaid beneficiaries.

From the Introduction

The ways in which population-level increases in insurance coverage affected people who were already insured during the recent insurance expansions depend on three key factors. The first is providers’ capacity and willingness to offer more visits and supply additional services. If providers had excess capacity, then increased demand could easily be met, but many observers have expressed concern that providers could not supply enough additional services—especially primary care services. Concern about reduced access may be most relevant in medically underserved areas—that is, areas already facing shortages of primary care providers.

The second factor is the extent to which the provider market is segmented by the types of insurance patients carry, if any. Some providers, such as federally qualified health centers, primarily serve patients with public insurance and the uninsured. More generally, providers are less likely to accept Medicaid patients than Medicare and privately insured patients. Thus, people who had Medicaid before the ACA-related Medicaid expansions might have been at greater risk of reduced access, especially because Medicaid enrollment increased 25 percent from 2013 to 2014 in states that expanded eligibility for Medicaid.

The third factor is the effects of ACA provisions intended to increase health care capacity. In particular, the act provided funding for expanding the capacity of federally qualified health centers; training more physicians, mid-level practitioners, and nurses; and encouraging more providers to work in primary care and in underserved areas. It also temporarily increased Medicaid payments for some services supplied by primary care providers. The ACA set its capacity-building activities in motion before the biggest eligibility expansions occurred, whereas Massachusetts did not begin to address provider capacity problems until after its insurance expansion. Thus, the efforts to increase supply built into the ACA had the potential to mitigate negative spillovers such as those seen in Massachusetts. Moreover, many of the ACA provisions were designed to mitigate negative spillovers among the groups most likely to be negatively affected: people in medically underserved areas and Medicaid beneficiaries.

From the Discussion

We found no consistent evidence that increased local-area insurance coverage rates reduced access to care among the continuously insured. This remained true even when we restricted our sample to adults residing in geographic Health Professional Shortage Areas or to adults continuously insured by Medicaid.

Our results are consistent with the possibility that funding in the ACA to increase provider capacity mitigated potential negative spillovers, as intended. While we know of no rigorous evaluations of these provisions, data suggest that capacity did expand. ACA funding was used to add sites of care and other expansions of community health center capacity, which was associated with serving more patients. ACA funding for training might have contributed to growth in the number of midlevel practitioners, who can help meet increased demand for primary care. From 2009 to 2014 the number of employed physician assistants rose 19 percent, and from 2012 to 2014 the number of employed nurse practitioners rose 15 percent. ACA funding to expand capacity began to be disbursed shortly after the act passed, before the major insurance eligibility expansions in 2014.

From the Conclusion

Despite concerns, increasing rates of insurance coverage did not appear to reduce access to care among the continuously insured.…

One concern about the increases in the numbers of people insured as a result of implementation of the Affordable Care Act was that people already insured might find that their access to care became impaired because the increased demand for care might overload the delivery system. However, measures to increase capacity in the system, such as expansion of community health centers and increased training of health care professionals helped to alleviate that concern. Thus, “increasing rates of insurance coverage did not appear to reduce access to care among the continuously insured.”

Well designed health care reform includes giving attention to system capacity. Central planning along with separate budgeting of capital improvements is designed to ensure that capacity is adequate and equitably distributed. People who are satisfied with their current insurance need not be concerned that expanding coverage to include everyone – as in an improved Medicare for all – would result in impaired access. Not only would access be assured, they would have better coverage than the best of current plans in the private sector.

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