Los Angeles Times series on private insurers

Posted by on Thursday, Oct 23, 2008

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.

An eroding model for health insurance

By Lisa Girion and Michael A. Hiltzik
Los Angeles Times
First of three parts
October 21, 2008

The health insurance system has become increasingly expensive and inaccessible. It leaves patients responsible for bills they understood would be covered, squeezes doctors and hospitals, and tries to avoid even minuscule risks, such as providing coverage to a newborn with no serious illness.

At the heart of the problem is the clash between the cost of medical care and insurers’ need to turn a profit.

During her pregnancy, Jennifer Danylyshyn’s regular visits to her obstetrician were covered by her Blue Shield policy. So was the delivery of Ava on March 24. The couple expected that Ava would be covered as a matter of course.

When the company rejected the baby because of the hip misalignment, her parents appealed with the help of their pediatrician.

Blue Shield refused to budge.



Health insurers reinvent themselves as money managers

By Michael A. Hiltzik
Second of three parts
October 22, 2008

WellPoint Inc., the nation’s largest health insurance company, ran into a snag last year while pursuing an important new business initiative.

Federal banking regulators insisted on classifying WellPoint as a healthcare company. And that was interfering with its efforts to open a bank.

The Federal Reserve Board eventually agreed that the company’s core insurance business could be considered financial services.

That a medical insurer would agree to keep a lid on healthcare expenditures so it could get approval to open a bank illustrates a fundamental change in the industry: Insurers are moving away from their traditional role of pooling health risks and are reinventing themselves as money managers — providers of financial vehicles through which consumers pay for their own healthcare.

Because he has high blood pressure, (Alex Kipper, an engineer who lost his employer-provided health insurance during the dot-com bust) found himself virtually uninsurable. Fearing that he could be financially wiped out in a medical emergency, he signed up for a bare-bones policy that provides no coverage until his medical expenses exceed $8,000 in a year.

His health plan’s concession to preventive care was a $25 discount on a physical. Once diagnostic tests were included, the fee for the checkup came to more than $300, Kipper said — which the health plan declined to pay.

He hasn’t returned to a doctor’s office in three years.

Although the policy costs only $200 a month, “nothing is covered, absolutely nothing,” Kipper said.



The battle of the medical bills

By Daniel J. Costello, Lisa Girion and Michael A. Hiltzik
Third of three parts
October 23, 2008

“Insurers have found a very creative way of denying, delaying or slowing payments in a way that is having a real impact on patient care and some of our survival,” said Von Crockett, Centinela’s chief executive. “Every single doctor and hospital is writing off money they are legally owed but don’t collect. It’s an insane situation.”

In June, the American Medical Assn. released its first rating of insurers’ billing patterns. It found that United Healthcare paid physicians the contracted fee 62% of the time, Aetna paid 71% of the time and Medicare paid 98% of the time.

Dotti Smith, office manager for a group of surgeons affiliated with St. Mary’s Hospital in Long Beach, recently billed a major insurance company for a gallbladder operation. The insurer had preauthorized the surgery and the surgeon was a member of the insurer’s network of preferred physicians, Smith said. But the company refused to pay the $3,100 bill.

Why? The patient was enrolled in a subcategory of coverage with a smaller network of doctors that did not include the Long Beach surgeon.


This important series of three articles published this week in the Los Angeles Times explains why the private insurance industry has neither the efficiency nor the moral authority to continue to manage our health care dollars. Each of the excerpts above provides an example of the management perversities of the industry, along with an example of the impact on a real-life patient. Much more can be found in the articles.

The private insurance industry has shifted from an amoral business model selling us administrative services to help manage our health care spending, to an immoral racketeering industry that is threatening the health and financial security of all of us.

We desperately need to reform health care financing in the United States, but not with a model that keeps these crooks in play.

Fragmentation of family health care

Posted by on Wednesday, Oct 22, 2008

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.

Uninsured Children and Adolescents With Insured Parents

By Jennifer E. DeVoe, MD, DPhil; Carrie Tillotson, MPH; Lorraine S. Wallace, PhD
October 22/29, 2008

The association between coverage for parents and their children has been widely reported. When entire families have access to health insurance, children and adolescents not only benefit from more consistent insurance coverage but also have improved access to a regular source of care and higher rates of preventive services. If entire families cannot gain consistent coverage, it is most often their children who have insurance while the parents go uncovered, especially since the creation of the State Children’s Health Insurance Program (SCHIP). Less is known, however, about how commonly this pattern is reversed.

Although the weighted results of this survey indicated that the largest group of uninsured children and adolescents had uninsured parents, an estimated 27.9% of the uninsured children and adolescents had parents with health insurance. When weighted, these estimates represent 3 million children who had a coverage gap despite having at least 1 parent who had full-year coverage. More than a million of these children were without coverage for the entire year.

Evidence suggests that when family members are covered separately under different plans or when certain individuals have coverage and others do not, children’s health declines. Furthermore, if the assumption that insurance coverage is a “household good” is abandoned and the system shifts toward defining it as an “individual good,” we add layers of complexity for vulnerable families who must simultaneously learn different systems for enrollment and utilization of multiple insurance plans. Discordant patterns of family health insurance may become the norm rather than the exception; the current trend is certainly moving in that direction.

If families are better off covered under one plan but US society rejects a public health insurance program for all members of the family, the question of whether the employer-based model is sustainable may need to be revisited. In this study, the private system did not do a good job of providing coverage for entire families.

Incremental expansions in public insurance programs for children will continue to improve insurance rates in the short term. However, the longer-term solutions to keeping all children insured are likely to be more complicated. Unless health insurance coverage models are designed to keep entire families covered, some children will continue to get left behind.


It has long been recognized that one of the deficiencies of the children’s health insurance program (SCHIP) is that parents in these lower income families often remain uninsured. This study demonstrates that the reverse also occurs. Even though one or both parents may be insured, often through their employment, the children may be left without coverage, primarily due to eligibility and affordability issues.

This study also reinforces the principle that simply increasing the numbers of insured through patchwork programs is not an adequate goal. Our goal should be to ensure comprehensive, coordinated, continuous care for each individual and each family by establishing equitably-financed medical homes for everyone.

Stable, continuous, coordinated family care is almost impossible under the current system. Both employer-sponsored and individual private plans continue to change based on employment status, employer decisions on plans, variations in participation in provider networks, comprehensiveness of the benefits, employee ability to contribute to the premium, and other factors largely not under control of the individual. Public programs also have similar variations in networks and coverage, and, in addition, have changing eligibility requirements for enrollment sometimes related to legislative and administrative budget decisions.

Today almost no family has the same stable coverage for all family members from birth until the children leave the home (and for the parents after the children have left). Nor can they be assured that they will be able to continue their care with the same physicians, hospitals and other health care professionals.

The future looks bleak. Congressional leaders have promised to expand the SCHIP program, which will tend to perpetuate the instability and fragmentation of care. Then they will begin the effort to patch together the great multitude of private plans into some semblance of a social insurance program. They will fail miserably because the U.S. private plans, based on a business model, have no glue to hold them together. The private insurers will continue to fight to insure only the healthy – the eighty percent of people who use only twenty percent of health care – while selling us an excess of superfluous administrative services. They will dump on us most of the actual costs of health care – the eighty percent of health care spending – through taxes, cost shifting, or simply relying on our stretched-thin charity.

It is astounding that the policy community continues to pursue these fragmented, incremental reforms that pump up costs while leaving health care in a tattered, dysfunctional state. With a single payer national health program, at least the entire family would have affordable access to the professionals and hospitals of their choice. That would be a great start.

Marcia Angell on U.S. lessons for Canada

Posted by on Tuesday, Oct 21, 2008

Privatizing health care is not the answer: lessons from the United States

By Marcia Angell, MD
Canadian Medical Association
October 21, 2008

There are strong moves within Canada to make the Canadian health care system more like the US system by partially privatizing it. Those who favour this approach claim that the US system offers more choice and better quality of care and spares the public purse. Some proponents even go so far as to claim that it is more efficient. My purpose here is to disabuse Canadians of these myths by taking a close look at how the US system works and comparing it with the Canadian system.


PDF version:

Those who are well informed on health policy are quite aware of the advantages and disadvantages of the health care financing systems in both the United States and Canada. Although the greater effectiveness and efficiency of the Canadian single payer system are well understood by supporters of a national health program in the United States, there has been a reluctance to use the positive features of the Canadian experience as an example of what we could achieve here. Why? Inevitably, bringing up Canada results in challenges that are a distraction from the primary message on reform.

The opponents of reform in the United States, along with their reactionary Canadian colleagues, are driven by ideology. They will not allow health policy science to interfere with their anti-government message. They do not seek the truth. Instead, they craft messages that paint a terribly inaccurate picture of the Canadian health care system. Sometimes their messages are based on exceptions or on minutia that may represent real problems, but then they present those facts as if they taint the entire health care system with rot. Other times, they simply do not tell the truth. You can cite several examples of lies that have been told so often about the Canadian system that they have been accepted as the truth here in the United States.

This is why Marcia Angell’s article is so important. She presents a broad overview of the two systems, explaining why the U.S. system is so expensive yet ineffective when compared to the Canadian system. She does address some of the failings in Canada, but also explains why the Canadian financing system is better equipped to address those problems than is the dysfunctional, fragmented U.S. financing system.

This article should be downloaded so that it can be used to help inform those who have been misled by the intense anti-government propaganda campaign of the opponents of single payer reform.

It is now widely recognized that we are in a global recession of historic proportions, raising comparisons with the Great Depression of the 1930s. The failures of deregulated markets, whether in housing, banking or other industries, has become obvious to all. So far the private health insurance industry has not been called to account, but its day is coming soon.

As the country grapples with an economy in free fall and as discussions of federal bailouts of financial institutions go forward, what are we doing about health care reform, an industry which consumes over 16 percent of our GDP? In short, not enough. The two presidential candidates have incremental proposals which would cost more and still not provide universal access to health care.  Both would prop up a failing insurance industry as if it provided added value over public financing.

The Lewin Group has just completed an analysis of the Obama and McCain proposals. The Obama plan would try to increase regulation of the insurance industry (which has never been effectively done), would expand and further subsidize public markets, and would offer a new public option modeled after the Federal Employees Health Benefit Plan (FEHBP), which all members of Congress have (its premiums are going up by 13 percent in 2009). The McCain proposal  would reduce regulation over insurance markets, expand the use of tax credits, and subsidize new high-risk pools (which already haven’t worked well). The Obama proposal would reduce the projected number of uninsured Americans of  48.9 million in 2010 by 26.6 million if fully implemented in that year, while the McCain proposal would reduce that number by 21.1 million.  And at what cost?  – – – $1.17 trillion from 2010 to 2019 for the Obama plan and $2.05 trillion for the McCain plan.

We already know that deregulated health insurance markets do not work in the public interest.  We will never get affordable health care for all Americans by propping up its role.  These examples show how much it fails comparisons with public financing (traditional Medicare) in terms of efficiency, costs, value, and equity.
•  Administrative overhead five to nine times higher than Medicare
•  Benefits reduced by medical underwriting vs standard benefits for all Medicare beneficiaries
•  Avoids coverage of sicker people, while Medicare covers all eligibles
•  Profiteering on backs of insured, with allegiance to shareholders,  versus not-for-profit Medicare
•  Fragmentation of insurance pools into many thousands of smaller risk pools by 1,300 private insurers versus one risk pool of 300 million Americans
•  Much larger bureaucracy (eg. while its market fell by 1 percent between 2000 and 2005, the private insurance workforce grew by one-third, mostly involved with “denial management”)

While the so-called “debate” over health care reform heats up in political dialogue, the only real option to reform health care – – – single-payer national health insurance (NHI) – – – is being largely overlooked. It is a hidden fix in plain view, but politicians and the media still remain beholden to corporate interests which profit from a deregulated health care marketplace. Compared to the proposals of both presidential candidates, NHI will actually SAVE MONEY (about $350 billion a year) while assuring universal access to care for everyone. This saving is made possible by administrative simplification, shifting to a not-for-profit mode, bulk purchasing of drugs, medical devices and other medical supplies, and elimination of waste by not covering harmful or ineffective services.

The gains to our country will be immense with NHI.  All Americans will have a new sense of security about their own health care, morale will improve, and social solidarity will be advanced.  U.S. business also has much to gain.  Employers will pay less than they do now to insure their workers, will have a healthier workforce, and will be better able to compete in global markets.  So given our serious economic downturn, don’t we now have an economic imperative, combined with our long-standing moral imperative, to enact a not-for-profit public financing system for health care, coupled with a private delivery system?  Such a plan is not radical or utopian; it is conservative in being more efficient,  less expensive, and offering more value than what we now have. NHI is not socialistic, in the same way that public financing of schools, police, fire protection, Medicare, and the Veterans Administration are not.  And it can do much more for the country than spending billions to bail out industries that have proven themselves unworthy of public investment.  We all have an opportunity in the next weeks and months to force a new Congress to do the right thing.


Adapted from Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It, 2008 by John Geyman. With permission of the publisher, Common Courage Press

Buy Do Not Resuscitate: http://www.commoncouragepress.com/index.cfm?action=book&bookid=376

  • Comments Off on In Global Recession, Health Care Reform Which Saves Money Is An Economic Imperative

As the recession (?depression) unfolds, the state’s financial crisis will surely deepen. Inevitably, further health budget cuts lie ahead. Unfortunately, the first round of cuts follows the same pattern pursued by the Patrick administration in the past: loudly declare your concern for the poor, while quietly shredding the health care safety net they depend on.

A little noticed feature of the first stage of health reform shipped additional millions of Medicaid dollars to the rich and powerful teaching hospitals and drained them from primary care. In a widely trumpeted move the state upped Medicaid rates for inpatient care – a change that mainly benefited Partners and other financially healthy institutions that provide expensive tertiary care services. (In 2007, the MGH reported a surplus of $354 million, while Brigham and Women’s Hospital had a surplus of $48 million in the second quarter of 2008). But at the same time Medicaid and free care pool payments for outpatient services were shrunken, dealing a body blow to cash-strapped institutions that provide a large volume of primary care to the poor.

On top of this, the state withheld tens of millions promised in the legislation to Cambridge Health Alliance (CHA) (disclosure – that’s where I work) – the only public hospital system left in the Commonwealth. The cash shortage has already cost CHA millions in interest costs.

The latest round of cuts inflicts further wounds on CHA and Boston Medical Center – the other large safety net provider in eastern Massachusetts. Not only will Medicaid rates for the future be cut, the state is demanding a refund of $100 million from past payments to those two systems.

At CHA we’re seeing more uninsured patients than ever, but our funding from the state has been slashed by tens of millions. In the second quarter of 2008 alone we lost $25 million, hundreds of health workers have already been laid off and clinic closures are in the offing.

In the months ahead, tens of thousands of workers in Massachusetts will lose their jobs – and their health insurance coverage. Many will need safety net and subsidized care. The costs of subsidized coverage under Commonwealth Care will predictably rise and the state’s fiscal condition will deteriorate even further. The promise of universal coverage will be broken – and the safety net that cared for the uninsured for decades before health care reform will be left a shadow of its former self.

What are the alternatives? In the short term: cut from the wealthy teaching hospitals that have been racking up huge surpluses for years, rather than the poor ones that are already staggering. In the long term: implement a single payer system that saves billions on profit and bureaucracy, and use the savings to cover the poor and to upgrade coverage for the rest of us.

In “A Dangerous Plan for Health Care” Roger Hickey hopes that an advertisement in the New York Times might help rescue private health insurance from its own failings. But where does the danger really lie?

With exuberance Hickey makes a strange assertion: that “the employer-based health care system” in the United States is “the one part of our insurance system that works.”

Say what? Not the Veterans’ Administration, when it boasts the best primary care outcomes in the United States? Not Medicare, when it covers 45 million people yet keeps overhead below 3%?

But Hickey instead issues a false alarm, warning of “dangerous” proposals like those made by McCain, Bush and Company, calling them “ideas off the shelf of right-wing think tanks.” These proposals call for things like federal deregulation of the health insurance industry, taxes on employee health insurance benefits and initiatives based upon personal responsibility — when costly illness strikes … go shopping! (And go bankrupt.)

But these schemes are a joke. Not funny — simply a joke. Such notions, lacking any basis in reality, will not come into reality. They amount to ideological assertions.

Hickey raises the threat of right-wing “reform” because the rhetorical device gives him permission to attempt the impossible: to rush to the defense of employer-sponsored health coverage. Ironically he undermines his conclusions by straying too close to the deplorable facts about private health insurance.

“Those who have insurance are paying higher costs for policies that often have gaping holes in coverage,” Hickey exclaims. “And insurance companies flat-out refuse to sell coverage to those already sick. And businesses, large and small, are burdened with rising costs.” He also bemoans that “millions of dollars the insurance and pharmaceutical industries spend on lobbying and political contributions have only served to prop up a failing system and drown out the voices for change.”

Yet somehow Mr. Hickey draws a crucial distinction between employer-sponsored private health insurance and buying private health insurance as an individual: “dismantling the one part of our insurance system that somewhat works, forcing everyone to buy health insurance on their own, hardly seems a step forward for most people.”

Therefore, he concludes:

“… we need clear rules requiring private insurance companies to cover everyone – even those with pre-existing conditions. And we need the security of knowing we can keep our current health plan, or we can choose a public plan like Medicare, so we’re not at the mercy of the same profit-driven companies that got us into this mess!”

There is some wishful thinking, and some deception too, that if people could only “choose a public plan like Medicare” the public entity could hold the private industry in check, or even that it could grow like Topsy and magically morph into single payer. Yet there is no evidence to support these assertions. The most likely outcome, based upon the bitter experience of several states, as well as the effort to privatize Medicare, would be a failed reform.

To summarize: Hickey argues that the economic crisis and the past failures of private health insurance have renewed a conservative call to dismantle employer-sponsored health insurance. Therefore, the government should rescue the private health insurance industry through regulation. In other words, to answer the conservatives, Hickey offers another ideological assertion, known as Health Care for America Now.

In order to improve the health of the inhabitants of the United States we must rise above a contest of ideological assertions. Meaningful reform will mean measurable progress, facts, evidence. Yes, it will take a social movement. Improving health care must become a question of understanding the evidence — and having confidence that our fellow human beings can and will do the same.

Look at the evidence: reforms based upon regulating and expanding private health insurance have failed, in many forms, many times over many years. This is because because private health insurance stands in contradiction to caring for the sick and preventing illness among the healthy.

A single-payer program is not only eminently feasible (over 40 years ago Medicare was put in place within a year!), but has the economy to save costs by eliminating preposterous administrative waste, reduce disparities by redirecting resources, improve quality by redirecting resources, protect the caregiver-patient relationship by eliminating a tangle of red tape, allow free choice of care providers because if everybody is in and nobody is out then everybody is in — while providing access to care for everyone in the United States.

Because of the evidence, moral imperative is on our side. Society should offer every person the best possible chance at health. The public should set health priorities. Profit-making should be banished when it comes to caring for the sick. Access to health care should not be tied to a job.

Public opinion is on our side. People are ready for a change. It is not only a degree of frustration with insurance companies, but rising expectations about our nation’s promise.

Meanwhile our children need to see a dentist. Our parents need home health aides. Prescription drugs have become a racket. In short, everyday experience makes the case for single payer.

The idea that regulation of private health insurance is the best we might hope for amounts to a dangerous plan for health care. It is a far cry from a “people’s movement” — and it simply will not work.

We need single payer now. HR 676.

Hawaii's "crowd out" crowds out children

Posted by on Monday, Oct 20, 2008

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.

Hawaii ending universal child health care

By Mark Niesse
The Miami Herald
October 17, 2008

Hawaii is dropping the only state universal child health care program in the country just seven months after it launched.

Gov. Linda Lingle’s administration cited budget shortfalls and other available health care options for eliminating funding for the program. A state official said families were dropping private coverage so their children would be eligible for the subsidized plan (Keiki Care).

“People who were already able to afford health care began to stop paying for it so they could get it for free,” said Dr. Kenny Fink, the administrator for Med-QUEST at the Department of Human Services. “I don’t believe that was the intent of the program.”


Although Hawaii’s Keiki Care for uninsured children was promoted as a program that would ensure that all children had health care coverage, it never would have achieved universality, partly because of various eligibility and enrollment issues. Also the coverage was not as comprehensive as coverage under Medicaid. Nevertheless, it did provide limited coverage for about 2,000 of the state’s uninsured children (out of an uncertain number estimated between 3,500 and 16,000).

In designing incremental reform measures, many in the policy community insist that programs must be designed to prevent crowd out. Crowd out is a phenomenon in which individuals will drop out or be pushed out of an existing program, such as employer-sponsored coverage, in order to be enrolled in another program, such as Keiki Care. Administrators who wish to minimize spending in public programs frown upon crowd out.

Although this program is only seven months old, and, to be eligible, children must have been uninsured for at least six months, it is unlikely that crowd out was a significant contributor to the very modest enrollment rates.

Most economists consider crowd out to be undesirable because the numbers of individuals crowded out of existing coverage are subtracted from the total in the alternative program to determine the net gain in numbers covered. That might be important if your only goal were to increase the numbers with coverage, but aren’t there other desirable goals? Hint: In 1966, was it really detrimental that Medicare crowded out coverage in the private insurance sector for those over 65?

Keiki Care is yet another example of an incremental program designed to approach the goal of universal coverage a single step at a time. Although these programs are reported as successes, the long-term trend is that almost all measurements continue to demonstrate deterioration in affordability and coverage.

As long as we continue down the path of patch-work incremental reform, we are going to continue to hear alarms sounded over crowd out, adverse selection, moral hazard, medical loss ratios, investor return, lack of price transparency, high premiums due to excess regulation of private plans, and on and on, and we will never reach our goal of affordable health care for everyone.

It’s time to dump the perverse policies that serve the interests of others, and adopt policies that would serve the interests of patients – a single payer national health program.

Underinsurance in Massachusetts

Posted by on Friday, Oct 17, 2008

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.

The Impact of Health Reform on Underinsurance in Massachusetts: Do the insured have adequate protection?

By Sharon K. Long
Urban Institute
October 2008

In an attempt to protect individuals from underinsurance, as part of that health reform effort Massachusetts established a standard for “minimum creditable coverage” (MCC) that outlines the key benefits that must be included in an individual’s health insurance plan if it is to satisfy the state’s new individual mandate for health insurance coverage. The required benefits, which are intended to protect those with insurance from high health care costs, include preventive and primary care, prescription drugs, a maximum on the annual deductible and a maximum on out-of-pocket spending, among other things.

In brief, underinsurance means that an individual’s health insurance does not adequately protect him or her from high health care costs in the event of a serious illness or accident. A complete assessment of the adequacy of insurance coverage requires detailed information on the coverage and cost-sharing provisions of the individual’s health insurance plan. Given the data available in our survey, we are limited to a narrower focus that considers the individual’s out-of-pocket (OOP) heath care costs. (Note that this is OOP costs for health care beyond the premium that the individual pays to purchase private coverage.) High OOP health care costs provides a conservative, lower-bound estimate of underinsurance as it only captures inadequate insurance coverage for those who had high health care costs in the last year. Consequently, this measure of underinsurance does not include any of the individuals with similar health insurance coverage who did not have high health care costs during the year.

We follow the approach used by Schoen et al. (2005, 2008) and use two standards to assess underinsurance:

(1) Having OOP costs of 10 percent or more of family income–a threshold that has been used in prior studies of underinsurance, and

(2) Having OOP costs of 5 percent or more of family income for low-income families (defined as those with family income less than 200 percent of poverty)–a threshold for financial risk that is consistent with cost-sharing provisions in the State Children’s Health Insurance Program (SCHIP).

Given the limitations of our data, the measure of underinsurance reported here provides a conservative measure of the extent of underinsurance in Massachusetts.

Drop in Underinsurance. In fall 2006, at least 4 percent of all working-age adults with full-year insurance coverage in Massachusetts were underinsured under the first definition of underinsurance (10 percent or more of family income in OOP health care costs) and at least 7 percent were underinsured under the second definition. Under health reform, the share of insured adults who were underinsured under both definitions dropped by about 2 percentage points between fall 2006 and fall 2007, down to about 3 percent and 6 percent underinsured, respectively.


Results restated in a summary by The Commonwealth Fund:

In fall 2006, 7.3 percent of all Massachusetts adults were underinsured (using the definitions above: out-of-pocket costs equal to 10% or more of income for higher-income people, 5% or more for lower-income people). After the enactment of health reform, that share declined to 5.6 percent.


Many news reports now tout the success of the Massachusetts health care reform program in reducing the numbers of the uninsured, even though falling far short of universal coverage. This new report also suggests that the rate of underinsurance may have declined, an important point since it was feared that efforts to make the plans more affordable would defeat the financial security that the plans should provide.

Massachusetts already had higher regulatory standards for their insurance products, but to be certain that coverage would be adequate under this program, they established a standard for “minimum credible coverage,” with benefits “intended to protect those with insurance from high health care costs.” How well has that worked?

Using estimates that omit many instances of underinsurance, this study shows that the rate of underinsurance is still over three-fourths of the rate that existed before the program was initiated. A program that eliminates less than one-fourth of the problem targeted should not be considered a successful program.

Of particular concern is that those individuals who are currently healthy, the majority of all insured, were not considered to be underinsured even if their coverage is not adequate to protect them against financial hardship should they develop significant medical problems in the future. Since one of the most important functions of insurance is to protect against unforeseen losses, the incidence of underinsurance is far greater than this study would indicate.

Massachusetts really needs to take another look at the single payer model of reform. By design, single payer includes everyone and eliminates the financial hardships of underinsurance. Their current reform model will always fall short of those goals.

Medicaid reform for the clairvoyant

Posted by on Tuesday, Oct 14, 2008

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.

Florida’s Medicaid Reform: Informed Consumer Choice?

By Teresa A. Coughlin, et al
Health Affairs
October 14, 2008

Until recently, Medicaid recipients within a state typically had access to the same set of benefits. Recent federal changes, however, move Medicaid in a new direction by allowing states to offer different benefit packages to different Medicaid recipients and to emphasize consumer choice and personal responsibility.

Under reform, participating plans are now allowed to offer different benefit packages and impose different levels of cost sharing for nonpregnant adult enrollees, subject to state approval. Although plans must include all mandatory Medicaid benefits and most optional benefits, services can vary in amount, duration, and scope.

As a result, enrollees are newly required to consider differences in benefit packages when making a choice of plans. They must also consider other plan differences such as preferred drug lists, provider networks, and prior authorization requirements.

After Florida implemented reforms, a sizable minority of recipients were not even aware that they were enrolled in a reform plan, and many did not understand how their plan worked.


Medicaid was designed as a welfare program to pay for all necessary care for those who could not otherwise afford it. The program has not worked as well as it should, primarily because of chronic underfunding. Access has been impaired because of the lack of providers willing to participate in a program that often doesn’t even pay overhead expenses.

With the problem defined as such, the most obvious solution would be to increase funding to a level that would pay expenses and provide fair compensation. That is not a realistic solution since welfare programs are highly vulnerable to political efforts to control government spending.

Another solution would be to remove the welfare stigma by eliminating Medicaid and enrolling the participants in a program with comprehensive benefits that would cover all of us. We do keep talking about that, but political inertia continues to prevail.

So now we have an element in our society which suggests that we should shift the spending decisions to the individual, not only for Medicaid beneficiaries, but for all of us. Since almost none of us could afford the costs of significant health problems, we still need to rely on risk pooling. Understanding that, the consumer-directed advocates then suggest that our choice be amongst various health plans as a proxy for decisions on health spending.

With a market of various plans from which to choose, all we need to know is what unknown major acute or chronic disorder we will develop next year, if any. Once we know that, we can choose a plan that includes the specialists who have expertise in our undetermined problem. We can choose a plan with a hospital that provides the specific services that we will need and will be accessible to us. We can choose a plan that includes in its formulary the unknown expensive drugs that we will need. Finally, if we were to develop an expensive problem, we can avoid plans with high deductibles and other cost sharing provisions that might wipe out our personal assets.

What nonsense! Since none of us can predict the future, we cannot possibly choose the precise plan that eventually we may or may not need. Yet we are already headed down that path. The individual market is rife with these ridiculous choices, and employers are headed in that direction as they shift to high deductible plans and small individual cash accounts that could never pay for major medical problems.

Haven’t we had enough of these screwball ideas? We already have the money to pay for comprehensive, high quality care for everyone. Let’s throw out the crackpots and establish our own program that actually would work: a single payer national health program.

(Please do not confuse my use of “screwball” and “crackpot” as insensitive terms that in the past have been used inappropriately to describe unfortunate individuals with mental health problems. Here the terms simply refer to cruel, inhumane, and sometimes greedy humanoid life forms that may be found groveling around in Washington, D.C.)

Nobel Laureate Paul Krugman on single payer

Posted by on Monday, Oct 13, 2008

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.

One Nation, Uninsured

By Paul Krugman
The New York Times
June 13, 2005

Harry Truman tried to create a national health insurance system. Public opinion was initially on his side: Jill Quadagno’s book “One Nation, Uninsured” tells us that in 1945, 75 percent of Americans favored national health insurance. If Truman had succeeded, universal coverage for everyone, not just the elderly, would today be an accepted part of the social contract.

But Truman failed. Special interests, especially the American Medical Association and Southern politicians who feared that national insurance would lead to racially integrated hospitals, triumphed.

Sixty years later, the patchwork system that evolved in the absence of national health insurance is unraveling. The cost of health care is exploding, the number of uninsured is growing, and corporations that still provide employee coverage are groaning under the strain.

So the time will soon be ripe for another try at universal coverage. Public opinion is already favorable: a 2003 Pew poll found that 72 percent of Americans favored government-guaranteed health insurance for all.

But special interests will, once again, stand in the way. And the big debate among would-be reformers is how to deal with those interests, especially the insurance companies. These companies played a secondary role in Truman’s failure but have since become a seemingly invincible lobby.

Let’s ignore those who believe that private medical accounts – basically tax shelters for the healthy and wealthy – can solve our health care problems through the magic of the marketplace. The intellectually serious debate is between those who believe that the government should simply provide basic health insurance for everyone and those proposing a more complex, indirect approach that preserves a central role for private health insurance companies.

A system in which the government provides universal health insurance is often referred to as “single payer,” but I like Ted Kennedy’s slogan “Medicare for all.” It reminds voters that America already has a highly successful, popular single-payer program, albeit only for the elderly. It shows that we’re talking about government insurance, not government-provided health care. And it makes it clear that like Medicare (but unlike Canada’s system), a U.S. national health insurance system would allow individuals with the means and inclination to buy their own medical care.

The great advantage of universal, government-provided health insurance is lower costs. Canada’s government-run insurance system has much less bureaucracy and much lower administrative costs than our largely private system. Medicare has much lower administrative costs than private insurance. The reason is that single-payer systems don’t devote large resources to screening out high-risk clients or charging them higher fees. The savings from a single-payer system would probably exceed $200 billion a year, far more than the cost of covering all of those now uninsured.

Nonetheless, most reform proposals out there – even proposals from liberal groups like the Century Foundation and the Center for American Progress – reject a simple single-payer approach. Instead, they call for some combination of mandates and subsidies to help everyone buy insurance from private insurers.

Some people, not all of them right-wingers, fear that a single-payer system would hurt innovation. But the main reason these proposals give private insurers a big role is the belief that the insurers must be appeased.

That belief is rooted in recent history. Bill Clinton’s health care plan failed in large part because of a dishonest but devastating lobbying and advertising campaign financed by the health insurance industry – remember Harry and Louise? And the lesson many people took from that defeat is that any future health care proposal must buy off the insurance lobby.

But I think that’s the wrong lesson. The Clinton plan actually preserved a big role for private insurers; the industry attacked it all the same. And the plan’s complexity, which was largely a result of attempts to placate interest groups, made it hard to sell to the public. So I would argue that good economics is also good politics: reformers will do best with a straightforward single-payer plan, which offers maximum savings and, unlike the Clinton plan, can easily be explained.

We need to do this one right. If reform fails again, we’ll be on the way to a radically unequal society, in which all but the most affluent Americans face the constant risk of financial ruin and even premature death because they can’t pay their medical bills.


With today’s announcement that Paul Krugman is the 2008 recipient of the Nobel Prize, it seems appropriate to distribute once again one if the most important articles he has ever written, and the message could not be more timely.

Although economics is considered to be an amoral science, Paul Krugman and Uwe Reinhardt have proven to us that even economists can have a heart.

Celebrate Paul Krugman’s award by sharing his single payer article with others. Economics with a heart. Now isn’t that something.

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