By Laurie Tarkan
WellBeeFile, Jan. 24, 2014
Dr. Stephanie Woolhandler, a member of Physicians for a National Health Program, which advocates for a single payer national health program, is professor in the CUNY School of Public Health at Hunter College. WellBeeFile (WBF) interviewed her about her views on the Affordable Care Act and its rollout.
WellBeeFile: As an advocate of single payer national health program, do you think that the Affordable Care Act is a step in that direction?
Steffie Woolhandler: The ACA will expand Medicaid (the joint federal-state program for the poor). Medicaid is better than no insurance, but does not provide fully adequate coverage. Medicaid reimbursements tend to be so low that many doctors refuse to accept it. In addition, Medicaid managed care plans tend to have very narrow networks of providers. So this expansion will ameliorate some of the suffering of poor Americans, but does not provide a model for a universal, high quality health system.
WBF: What do you think is good about the ACA?
SW: As mentioned above, Medicaid expansion will be an improvement over what we have in 2013. In addition, the ACA places some good new regulations on private insurers, such as the elimination of pre-existing condition exclusions and the removal of lifetime caps. Previously, several thousand privately insured Americans each year reached their cap (typically $500,000 to $1 million) and then their insurance stopped paying their medical bills. Banning these grossly unfair private insurance practices is particularly important for non-elderly people who experience severe illness such as cancer.
WBF: Do you think the website problems have occurred because of the sheer number of private companies on the exchanges?
SW: The website problems reflect the immense complexity of health financing under the ACA. This is not just a problem of a multiplicity of insurers (indeed, in some markets there are just one or two insurers), but also the byzantine complexity of the eligibility, coverage, and subsidy rules. We know that a single payer would entail dramatically lower administrative burdens and costs. Traditional Medicare was rolled out in just eight months during the fall of 1965 and spring of 1966, in an era before computers. Traditional Medicare (i.e. excluding the private Medicare Advantage plans) has overhead of about 2 percent, as does Canada’s national health insurance program. Private insurance plans are allowed to have overhead of 15 percent to 20 percent under the ACA.
WBF: What do you think is problematic about the ACA?
SW: The worst aspect of the ACA is that 32 million Americans will remain uninsured after the ACA is fully implemented. The ACA reinforces the role of the private insurance industry which is responsible for the complexity and high administrative costs of the current system.
WBF: Do you think older individuals will be able to find affordable health insurance?
SW: Some middle-class people 50-64 years old will be able to afford the new coverage; some won’t. People with incomes within 250 percent of the poverty line will receive substantial subsidies to help them afford coverage. Above 250 percent (and particularly above 400 percent) of poverty, insurance will be quite expensive.
WBF: Do you have any recommendations for people when sorting through the different medal plans?
SW: On some exchanges, there are many variations of similar plans. First of all, if your income is between 138 percent and 250 percent of poverty, you must purchase a Silver plan to be eligible for a second set of subsidies to offset co-payments and deductibles. For anyone else, lower cost premiums will almost always translate into higher out-of-pocket costs. Unfortunately, it is almost impossible to figure out what your total costs (including premiums and out-of-pocket costs) will be under any given plan, since that depends so much on what illnesses or injuries befall you in the next year.