What is California HealthCare Foundation’s true mission?
By Don McCanne

Following is a description of the California HealthCare Foundation from their own website:

“The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care.

“CHCF’s work focuses on informing health policy decisions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions.

“CHCF commissions research and analysis, publishes and disseminates information, convenes stakeholders, and funds development of programs and models aimed at improving the health care delivery and financing systems.”

And California HealthCare Foundation’s stated mission:

“Mission statement: to expand access to affordable, quality health care for underserved individuals and communities and to promote fundamental improvements in the health status of the people of California.”

Understanding the origin of California HealthCare Foundation (CHCF) is important. During the decades that Blue Cross of California was a non-profit entity, it received favorable tax treatment not available to for-profit insurers. When Blue Cross of California converted to a for-profit entity, becoming a subsidiary of WellPoint, it was decided that the accrued value of the tax subsidy should not be granted gratis to the new shareholders of WellPoint, but should utilized for the benefit of Californians since this vested interest rightfully belonged to them. It was decided that this could be accomplished by establishing the California HealthCare Foundation and the California Endowment. The funds would then be used to improve the health care system in California, benefiting the underserved, and, in fact, benefiting all Californians by “improving the delivery and financing systems.”

Mark D. Smith, MD, MPH, President and Chief Executive Officer of California HealthCare Foundation, has infused foundation funds into research and reports on health plans, managed care, insurance markets, MediCal and other aspects of our current system. But he has often expressed his view that a single, universal health insurance program is not an option for reform. In spite of the California Health Care Options Project study that demonstrated that single payer reform could provide affordable, comprehensive coverage for all Californians (a goal of CHCF), he seems to continue to exclude that option from CHCF activities.

Yesterday we saw an interesting example of this apparent bias. The Kaiser Daily Health Policy Report sends out summaries of important policy issues, published by The Advisory Board Company. One item yesterday included reference to a New York Times article on employers’ concerns about health care costs, along with reference to the USA Today editorial debate on two views of controlling health care costs. It ended with my comment that we need to throw out the wasteful, ineffective health plans and spend the money on patients instead.

The items of national interest are often repeated in their entirety in California Healthline, a similar publication of the California HealthCare foundation, also published by The Advisory Board Company. The article above was no exception except for one remarkable difference. The New York Times segment was carried, but the USA Today segment on controlling costs by replacing health plans with a public program was deleted and another USA Today story on reducing costs by exercising and eating well was substituted. Is it not unreasonable to ask what happened? Why was a statement highly unfavorable for health insurers such as Blue Cross deleted?

The health care crisis in California, and, indeed, in the nation has reached proportions such that reform is mandated. This is the time to be examining all options for reform. An informed state and national discourse are essential. The California HealthCare Foundation should be front and center as a resource on policy issues. And since they are utilizing funds that originated from California taxpayers, they have an ethical obligation to be certain that their process is as open and unbiased as possible.

It is reasonable to ask a few questions.

* Does Blue Cross/WellPoint still exert any control over this process that has deliberately excluded options that would remove Blue Cross as a player in the health care system?

* Do members of the board of directors have any conflicts of interest that might cause them to fail in their ethical obligation to support the interests of Californians and their health care system?

* Does Mark Smith have either an ideological bias, or a vested interest in California health plans, especially Blue Cross, that might disqualify him from administering ethically the California HealthCare Foundation in the interests of all Californians?

* Why did The Advisory Board Company take the unusual step of changing a portion of this one article for publication in California Healthline?

* What is California HealthCare Foundation’s true mission?

These and other questions I believe are quite reasonable. I don’t have the answers. Perhaps those in the media receiving this message may want to try to discover the answers. If you have friends interested in investigative reporting, you may want to forward this message to them.

The rest of us must intensify our efforts to demand fairness and openness in the process. We must be sure that the reform we end up with will be in the best interests of all patients.

About CHCF: http://www.chcf.org/aboutchcf/

Kaiser Daily Health Policy Report on the New York Times article on employers’ health care costs, and on the USA Today debate on managing costs (requires registration): http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=16431&dr_c at=3

California Healthline on the New York Times article on employers’ health care costs, and on a substitute USA Today article on reducing costs by exercising and eating well (requires registration, and limited to California residents): http://www.californiahealthline.org/members/basecontent.asp?contentid=48118& collectionid=3&contentarea=23810

USA TODAY
3/6/2003
Editorial/Opinion

USA TODAY’s view:

Affordable remedies ignored as nation’s health woes soar

Perhaps the best measure of the depth of the nation’s health care troubles is this: Amid terror warnings, possible war with Iraq, a faltering stock market and a sluggish economy, a new poll says the public’s top worry is rising health care costs.

Some achievable steps:

* Lowering drug costs. * Cutting hospital bills. * Providing affordable insurance. * Helping consumers cut costs.

None of these cost-saving ideas alone will solve the nation’s health care problems. But bipartisan cooperation to enact them could prime the pump for more comprehensive reforms, improve the competitiveness of the health care marketplace and make consumers more aware of medical costs.

The country’s rising concerns about a broken health care system can’t be ignored indefinitely. Small repairs today can pave a path for bigger solutions tomorrow.

For the full USA TODAY editorial: http://www.usatoday.com/news/opinion/editorials/2003-03-05-our-view_x.htm

Opposing view:

Nationalize health care By Don McCanne

The continuing rise in health care costs is proof that our existing system of competing health plans has been incapable of controlling costs. Decades of attempts to improve coverage through a hodgepodge of private plans and public programs have resulted only in higher costs and greater numbers of uninsured. Current proposals that build on our existing system promise only higher costs and the perpetuation of the profound administrative waste that is unique in the world. We spend more on paperwork in our health care system than we do for our entire military budget – almost $400 billion.

Single-payer national health insurance, by contrast, would slow the growth of health-care costs well into the future. And it would ensure that everyone has access to comprehensive health care services.

What do we really want out of our health care system?

* We want affordability. Placing our health care system on a single budget would provide a mechanism to finally corral health care costs for all of us.

* We want our health-insurance dollars to be spent on patients, rather than private-health-plan bureaucracies. By eliminating administrative waste caused by the health plans and the costly burden they place on the system, we would free up more than enough to pay for coverage of the uninsured and truly comprehensive benefits for all.

* We want our health insurance always to be there. With a universal insurance program, we would never lose coverage because of a change in employment, early retirement or a financial setback that makes premiums unaffordable.

* We want to be free to choose our physicians and hospitals instead of being penalized for failing to use the provider chosen by the insurance company.

* We want to have access to care whenever we need it rather than when and where the insurance company dictates.

The marketplace will not serve us well in health care if we depend on health plans. They would continue to compete based on the price of their premiums. But with rising costs, plans can keep their premiums competitive only by shifting costs to patients in the form of fewer benefits and greater out-of-pocket payments. This would threaten the financial security of those with the greatest health care needs.

On the other hand, competition based on quality would be beneficial. Since we would have free choice of doctors and hospitals, the providers themselves would be motivated to compete for patients based on the quality of their services.

A single-payer system, funded at our current level of spending, would provide high-quality, comprehensive, affordable health care for everyone. But we can achieve this only if we throw out the wasteful, ineffective middlemen – the health plans – and spend the money on patients instead.

Don McCanne, M.D., is president of Physicians for a National Health Program.

http://www.usatoday.com/news/opinion/editorials/2003-03-05-oppose_x.htm

The White House
March 4, 2003
President to Announce Framework to Modernize and Improve Medicare

Excerpt from the Executive Summary:

Option 1-Traditional Medicare

Those who are satisfied with the current Medicare system will continue receiving their care as they do today with help for the high costs of prescription drugs. These beneficiaries will gain access to discounted drugs through a prescription drug discount card-estimated to achieve savings of 10-25% on the cost of prescription drugs-as well as coverage to protect them against high out-of-pocket prescription drug expenses. These new benefits will be provided at no additional premium.

Option 2-Enhanced Medicare

Enhanced Medicare will give seniors the same types of choices that are available to members of Congress and other federal employees. In every area of the country, Medicare beneficiaries will have multiple health plans from which to choose. These plans will offer prescription drug benefits, full coverage of preventive benefits, protection against high out-of-pocket drug costs, and cost sharing that does not penalize participants who need the most medical care. Again, the decision to choose Enhanced Medicare will be entirely up to each senior, and participants will be able to choose any doctor or any hospital they want for the treatment and care they need.

The President’s framework will ensure that the benefits offered under Enhanced Medicare are sufficiently attractive to seniors, relative to traditional Medicare, to guarantee that Enhanced Medicare is a viable system.

Option 3-Medicare Advantage

Seniors will also have the option of enrolling in low-cost and high-coverage managed care plans, similar to those available today under Medicare. Medicare Advantage will include plans that offer a subsidized drug benefit, and all plans will be able to offer extra benefits, as many private plans do today.

Excerpt from the Conclusion:

To improve, Medicare must have the benefit of modern health care delivery systems and methods that have proven successful in the private sector. The President’s initiative will introduce private sector innovation and competition to the Medicare system to help keep costs reasonable, ensure high quality care and begin to address Medicare’s long-term financial challenges.

While Medicare must be modernized and improved to meet the needs of its current participants, the program must also be made sustainable for future generations. Given the financial challenges Medicare faces in the future, changes to the Medicare program we make today must not exceed our nation’s means to deliver them tomorrow.

http://www.whitehouse.gov/news/releases/2003/03/20030304-1.html

Comment: To understand the administration’s proposal, we must keep in mind what this program to “modernize” Medicare is intended to accomplish. Regardless of all of the rest of the rhetoric, the sole intent is to reduce the federal (taxpayer) contribution to the health care of the Medicare beneficiaries. Period. All of the wonderful, free-market rhetoric is designed to distract us from this precise goal. With that in mind, let’s look at the three options offered (though not in order).

Option 1 – Traditional Medicare: The traditional Medicare program is inadequate. The lack of pharmaceutical coverage is a glaring example. The traditional Medicare program needs more funds, precisely what the administration is avoiding. So we will see no recommendations for an expansion of benefits in the traditional program.

But to meet campaign promises, they propose introducing a worthless discount prescription card, and they propose to provide the wealthy with protection for high drug costs by providing coverage only after spending many thousands of dollars on drugs. For very low income individuals, they’ll cover up to $600 worth of drugs. It is uncertain if this paltry coverage reflects the value that they assign to the unfortunate individuals in this sector of society.

A second reason that they do not want to add more benefits to the traditional program is that want to use those benefits to lure beneficiaries out of the traditional program and into private plans.

Option 3 – Medicare Advantage: This is the current Medicare + Choice program. It was a failure. It worked only as long as the plans could limit their exposure to high costs by selectively marketing to a healthy sector. But the plans failed to provide the administrative efficiencies promised, and ended up costing the government more, on a risk adjusted analysis. The only way that it could be salvaged is to increase taxpayer funding beyond that of the traditional program, again the opposite of the administration’s goal. They’ve decided to let this program fade away.

Option 2 – Enhanced Medicare: As promised, this is the proposal similar in design to the Federal Employees Health Benefit Plan, “the plan that the members of Congress have.” This is basically the Breaux-Frist-Thomas-Jindal premium support proposal. It is a defined contribution concept, though some defenders dispute the terminology.

An important sentence in the White House release: “Beneficiaries who enroll in an average priced plan in their region would pay a premium for the medical portion of their coverage equal to the Part B premium.” Clearly this confirms that individuals who desire more comprehensive benefits, or who wish to reduce their financial exposure, will have to bear the costs of that additional coverage in the form of higher premiums. So the wealthy are well cared for in this proposal.

What about those individuals who do not have the resources to purchase more comprehensive coverage? What will their program offer? A clue: “To provide an array of choices in benefit design and to encourage plan innovation, plans will be free to structure their offerings differently, provided the benefit meets a basic federal standard. “Plan innovation with flexibility in offerings” should make us worry. Spartan plans will surely become the “averaged priced” plans. And we can only speculate that an administration that doesn’t have any money for anything else, certainly will not have enough money to fund more than the very lowest tier of services that is the “basic federal standard.”

Then the politicians will ask why we should be spending more on traditional Medicare patients than we do on the “basic federal standard.” And of course their solution will be to cut funding of the traditional program.

This scheme does not reduce the costs of health care; it merely shifts the costs from the federal government to the Medicare beneficiary. The majority will be unable to afford their portion of costs should they be faced with a major medical disorder.

Should Medicare policy be crafted to improve the utilization of resources for the benefit of patients, or should it be designed simply to reduce federal funding of the program? It looks like the Bush administration has decided that Medicare should be added to list of programs to be sent off to the guillotine for a blunt trimming.

The New York Times
March 2, 2003
A New Health Plan Works, at Least for the Healthy
By Beth Kobliner

Last fall, Mrs. Welborn, 32, a senior training specialist in corporate development, signed up for a new kind of health coverage, called a health reimbursement arrangement, or H.R.A. As part of the plan, her employer, CompuCom Systems, an information technology service provider in Dallas, has given her a $2,000 health care savings account that she can use to pay for medical care.

But Mrs. Welborn’s new plan also comes with a hefty deductible of $3,400. That means that if she spends more than her allotted $2,000 in the account this year, she will be liable for the next $1,400 of expenses. After she reaches the deductible, the insurance plan kicks in; it will cover 80 percent of costs, if network doctors are used, and 60 percent if not.

But if any of the $2,000 remains in her account at year-end, she can add it to the next $2,000 CompuCom will set aside for her in 2004. Mrs. Welborn… can have a maximum of $6,000 in her account.

Consumer-driven plans are variations on P.P.O.’S and H.M.O.’s, but with two important differences: they carry considerably higher deductibles, often around $1,500 for individuals and $3,000 for families; and employers cushion these higher deductibles at the front end, by financing individual cash accounts ranging from a few hundred to several thousand dollars.

http://www.nytimes.com/2003/03/02/business/yourmoney/02MEDS.html

Comment: Medical savings accounts (MSAs), tax free medical accounts backed up by high deductible (catastrophic) insurance, have long been supported by those who claim that we will bring health care costs under control only when we make patients sensitive to costs by spending their own funds. Once their medical savings are depleted, then the catastrophic plans will cover all costs. But this is really a fantasy, as we’ll see below.

For several reasons, insurers and employers have been reluctant to offer these products. But an IRS ruling last year authorized the version called health reimbursement arrangement (HRA). One of the features that made HRAs more attractive is that the unused funds could be rolled over from year to year. It is important to note that employers retain ownership of the HRA. Unspent funds on job termination are not converted into a cash or retirement benefit for the employee, but remain with the employer. So it really is a pooled fund source with a low spending cap per individual or family. Since the accumulation of funds will stop when the maximum is reached ($6000 in the example in the article), the family would be motivated to be sure that the funds are spent or they will fail to receive additional contributions and will eventually lose what’s left anyway. Since most healthy families spend less than the amount placed in the HSA, they will be motivated to increase their utilization of health care services, the exact opposite of the intended result.

The high deductible coverage offered with these HSAs also raises concerns. These catastrophic plans are not indemnity plans that “cover 100% of costs after the deductible is met.” They are PPO and HMO managed care plans, using contracted providers. Some plans may allow patients to use their own non-contracted providers, but only with severe financial penalties.

Let’s look at an example using the numbers in the article: a $2000 HSA, with a $3400 deductible, and then a PPO with 80% for network providers and 60% for providers outside of the network. What is not mentioned is that this is 80% or 60% of the allowed fee. The contracted provider is required to adjust off the disallowed balance, but, of course, the non-contracted provider can demand the full fee.

Now let’s say that the patient needs an $85,000 coronary bypass. The university center in town has a cardiovascular surgery program noted for its excellent outcomes. The other hospital in town is being investigated for doing a very large number of bypass surgeries that appear to have been unnecessary. But because of the higher cost of care at academic centers, the charges will be $108,000 instead. Although this may be a somewhat extreme example, it is realistic. And most of us would certainly opt for what we perceive to be better care, especially for our loved ones.

How do the numbers work out? Let’s make one more assumption. The PPO has contracted with the hospital under investigation for a fee of $56,000 for the package, a reasonable fee since the PPO can offer that facility a high volume of insured patients. But the PPO has repeatedly failed to negotiate a similar contract with the academic center, which then remains a non-contracted provider.

The numbers? The employer funded HSA pays the first $2000. The patient pays the next $1400, when the deductible is met. The allowed amount, $56,000, minus the deductible of $3400, leaves a covered amount of $52,600. Since the center is not contracted, the PPO pays 60% or $31,560 and the patient pays $21,040. But the patient is also responsible for the disallowed charges of $108,000 minus $56,000, or $52,000. So this HRA with a catastrophic plan that “covers expenses after the deductible is met,” results in an out-of-pocket expenses for the patient of a total of $84,240. That is quite a tab for an $85,000 procedure, especially for a family with an income of $42,228 per year (median household income 2001, US Census Bureau).

Under the best circumstances, the patient would pay the $1400 share of the deductible and 20% of the contracted rate, with the balance being adjusted off. That would still amount to $11,920, an almost unaffordable amount for a median income household.

Who would elect these plans? Individuals that shop for plans based on premium alone might select them because the premiums for high deductible coverage are lower. Those that are better informed may still elect these plans, gambling that they would remain in good health. But those that develop a major acute medical problem will lose their bet. Individuals with significant chronic disorders would not select HSAs but would select more comprehensive plans. Concentrating higher cost patients into more comprehensive plans will drive up premiums, threatening affordability of comprehensive coverage for the rest of us.

Private indemnity insurance has been priced out of the market and is gone forever. The fragmented system that we are left with can only perpetuate and compound the inequities that characterize our system today. We already have enough money in the system to provide comprehensive services for everyone, but the only way we can ever obtain value for that already invested is to establish a single, equitable risk pool. Why do we keep delaying the inevitable?

Aetna
Press Release
February 11, 2003
Aetna Reports Fourth Quarter And Full-year 2002 Results

“In 2002, Aetna improved its financial performance,” said John W. Rowe, M.D., chairman and CEO. “This success was built on a seven-point reduction in the medical cost ratio (MCR), as well as lower administrative costs. This decline in MCR was driven by three factors: reduction of membership with historically higher MCRs … (premium increases)… (and changing contracts and benefits).

Full-year 2002 results for Health Care show operating earnings, excluding other items, of $361.6 million, compared with an operating loss, excluding other items, of ($161.9) million for full-year 2001, primarily reflecting improved underwriting results, driven by an increase in the premium yield and a decline in the medical cost trend, combined with continued reductions in operating costs and a decrease in amortization of intangibles.

“Aetna delivered on its promises in 2002, and we believe the company is now firmly re-established as a top-tier competitor in the health care arena,” President Ronald A. Williams said. “Our broad operational goal for 2003 and beyond is to build on our competitive advantages and grow profitably.”

http://www.aetna.com/news/2003/pr_4thquarter2002_earnings.htm

Comment: Building success on reduction of membership with higher medical cost ratios, and increasing the premium yield with a decline in medical cost trends was accomplished by withdrawing from high cost markets and pricing plans with high cost patients out of the market. Eliminating beneficiaries that actually need health care will allow Aetna to fulfill its goal of building on their competitive advantages and grow profitably.

Should we criticize a corporation for reducing losses and improving profits? No. It is their obligation to their shareholders to do precisely that.

Should we criticize health care policymakers for insisting that we continue to build on this system that thrives by excluding from coverage those with the greatest health care needs? No, criticism is not enough. We need to dismiss them and replace them with policymakers that will design a health care funding system that has a mission of actually meeting the health care needs of all of us.

Uwe Reinhardt responds to Deborah Socolar on her comments about price disparities:

In connection with price disparities in health care, I wonder what Deborah Socolar means when she uses the term “free market” in her sentence:

“If it were a free market, competition would mean prices would tend to converge (as happens with, say, prices in pizza parlors).”

A distinguishing characteristic that sets pizzas apart from, say, coronary bypasses is that the former can, in principle, be resold among customers while a CABG cannot. Absent a resale market for CABGs (and most other health services), the stage is set for price discrimination, that is, charging different customers different prices for the same thing.

Now, if CABGs and other health services were perfectly standard commodities that are purchased in a national market (i.e., Jones does not care whether his or her CABG is procured in Holy Mercy in San Diego or Apex Hospital, Inc. in Dallas or Womens and Brigham in Boston), then there might still be price convergence. That is why hotel rates quoted to conventions tend to converge across areas with similar climatic and other characteristics.

But CABGs and other health care are not at all perfectly standard commodities and they are not traded competitively over large national markets. Price convergence in a “free” (unregulated?) market would be unlikely to obtain.

Only in highly regulated market with either administered prices set more or less unilaterally by the buy side (Medicare, Medicaid) or uniform prices negotiated by large bodies representing individual buyers and seller, respectively, (Germany) would price discrimination disappear. Even then price might or might not reflect costs.

Uwe Reinhardt

To Quote of the Day list members:

It should not have surprised me to receive the responses that objected to the poetry expressing opposition to the war, but it did. I mistakenly believed that those who support health care reform would also support activities designed to prevent the premature death and suffering characteristic of a war that most of the citizens of the world believe is avoidable.

For those that did complain, I wish to thank you for being willing to express your thoughts on this highly controversial topic. I also wish to apologize in advance for the fact that my comments to follow will not end the controversy.

I sent the message out after the Bush administration announced a second condition for preventing the war, a regime change in Iraq. Since it seems that we are only days away from war, I believed that our stridency must increase. I believe that an effort to prevent this war must be the first priority of everyone at this moment. Our work on health care reform can continue, but it is a task that will never be completed though, hopefully, we will have major breakthroughs such as the eventual establishment of a universal single payer.

The decision to send the poems to the Quote of the Day list was mine and mine alone. Although I am president of Physicians for a National Health Program, and most of the messages are posted on the PNHP website, technically they are my personal project and not a project of PNHP. It is appropriate that PNHP publishes my comments since my personal views coincide precisely with the policies developed and supported by PNHP. I’m not saying that I’m always right on target since I’m only human, and I have no staff to critique my views before I send them out. But I am saying that, to those who were offended, please direct your ire exclusively toward me and not to PNHP.

Because I sent the anti-war message to a list that is for health policy issues, I certainly can be criticized for having sent out spam. And for that I do sincerely apologize.

Although I erred in my selection of the forum in which to express my views, I did not err in my expression of those views. For speaking up on this issue, I cannot apologize.

Many undoubtedly were offended by the particular poems that I selected from the thousands on the Poets Against the War website. The poems suggested that the president’s decision-making process on the issue of the war is no more sophisticated than that of a young child. With all of the options available, our president is down to a list of only two. Either Saddam Hussein walks, or we attack. Even a child can understand that expanded inspections until hell freezes over would be a much better option, but that has already been rejected by President Bush.

Ardent supporters of Mr. Bush might be expected to be offended by my remarks. But I am more offended by their callous disregard of the people of Iraq and disregard of our standing in the international community. No political personality is worth protecting at that price.

I will not use the Quote of the Day list for any further comments on the war. I intend to limit the list to health policy issues. But for those of you who believe that I have already exceeded my bounds to the degree that you want off the list, you can unsubscribe at http://two.pairlist.net/mailman/listinfo/quote-of-the-day, or you can send me an e-mail directly at don@mccanne.org.

For those who agree with me, more stridency please!

Don McCanne

Deborah Socolar, MPH, Co-Director, Health Reform Program, Boston University School of Public Health, comments on price disparities, using the example in the comments about the deficiencies of health reimbursement arrangements:

Here’s one thought on a issue you touch on. Some might quibble with saying that this is an $85,000 procedure — “out-of-pocket expenses for the patient of a total of $84,240. That is quite a tab for an $85,000 procedure” — since one place is CHARGING $108K and the other $56K. It would of course also be quite a tab for even a $108K procedure.

But further — the price disparities help highlight the point that in today’s unfree market, where big buyers have the market power to negotiate discounts, charges tend to bear little relationship to costs, and the uninsured and those in smaller plans face big cost-shifts, subsidizing those who could often afford to pay more. If it were a free market, competition would mean prices would tend to converge (as happens with, say, prices in pizza parlors). Of course today’s such wild disparities in prices make it absurd to think that people can do very much to price the care they think they might need in the coming year and estimate their o-o-p costs to help decide on plan/”level” of coverage, etc…even assuming no major changes in health status. (Obviously folks just all need comprehensive coverage…)

And in a rational system, although I hope we’d pay for much care through global budgets, prices in cases where we do pay for individual services would bear a close relation to costs.

Health Reform Program, Boston University School of Public Health: http://www.healthreformprogram.org/