In Colorado, Disparity in Health Plan Prices Underscores Ambitions, and Limits, of Affordable Care Act

By Reed Abelson and Agustin Armendariz
The New York Times, January 19, 2015

An analysis by The New York Times shows that the cost of one midlevel silver plan in Colorado rose 36 percent west of the Rocky Mountains this year, while another dropped nearly 40 percent in the northeastern plains.

The law was intended to drive prices lower and broaden coverage through competition. While 10 insurers offer plans to individuals in Colorado through the state’s online marketplace, the law does not require insurers to offer all plans in all regions of a state.

The wild disparity in prices results from many insurers trying to attract more customers by pricing plans as low as they can. But it is not at all clear that the low prices will be sustainable, so prices may well swing sharply upward as time goes on.

The variations in premium prices are also a direct result of what the insurer-friendly health care law permits. Insurers can target territories, choosing areas within a given market where they can attract enough members and put together provider networks that will negotiate on price. In addition, insurers were given some protection by the federal government to reduce possible losses in the early years, so some are experimenting with very low prices that may not be sustainable over the long term.

And no one expects premium costs to stabilize anytime soon. Because buyers are so sensitive to price, the markets may experience cycles in which insurers alternately offer low premiums to attract customers and sharply raise them in later years to cover costs, experts said.

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Comment:

By Don McCanne, MD

Although medical underwriting for preexisting disorders supposedly has been eliminated, the insurers apparently are still taking advantage of the “underwriting cycle” – capturing the market by selling plans at a loss and then jacking up rates after the competition has been thinned out. This volatility results in uncertainties for patients in both their insurance costs and in the composition of the networks of covered providers.

And under single payer? Costs would be stable and fair since they are based on ability to pay, and provider choice would be assured. So do we leave the system under the control of the cutthroat insurers, or do we finally place our own public stewards in charge?

Second Convention of the Medical Committee for Human Rights, March 25, 1966

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” — Dr. Martin Luther King, Jr.

http://www.huffingtonpost.com/amanda-moore/martin-luther-king-health-care_b_2506393.html

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Oxfam, Issue Brief, January 19, 2015

Global wealth is increasingly being concentrated in the hands of a small wealthy elite. These wealthy individuals have generated and sustained their vast riches through their interests and activities in a few important economic sectors, including finance and pharmaceuticals/healthcare. Companies from these sectors spend millions of dollars every year on lobbying to create a policy environment that protects and enhances their interests further.

*  In 2014, the richest 1% of people in the world owned 48% of global wealth, leaving just 52% to be shared between the other 99% of adults on the planet.1 Almost all of that 52% is owned by those included in the richest 20%, leaving just 5.5% for the remaining 80% of people in the world.

*  The very richest of the top 1%, the billionaires on the Forbes list, have seen their wealth accumulate even faster over this period. In 2010, the richest 80 people in the world had a net wealth of $1.3tn. By 2014, the 80 people who top the Forbes rich list had a collective wealth of $1.9tn; an increase of $600bn in just 4 years, or 50% in nominal terms. The wealth of these 80 individuals is now the same as that owned by the bottom 50% of the global population, such that 3.5 billion people share between them the same amount of wealth as that of these extremely wealthy 80 people. In 2010, it took 388 billionaires to equal the wealth of the bottom half of the world‟s population; by 2014, the figure had fallen to just 80 billionaires.

*  In 2014 there were 1,645 people listed by Forbes as being billionaires. This group of people is far from being globally representative. Almost 30% of them (492 people) are citizens of the USA.

*  Between 2013 and 2014 billionaires listed as having interests and activities in the pharmaceutical and healthcare sectors saw the biggest increase in their collective wealth. Twenty-nine individuals joined the ranks of the billionaires between March 2013 and March 2014 (five dropped off the list), increasing the total number from 66 billionaires to 90, in 2014 making up 5% of the total billionaires on the list. The collective wealth of billionaires with interests in this sector increased from $170bn to $250bn, a 47% increase and the largest percentage increase in wealth of the different sectors on the Forbes list.

*  During 2013, the pharmaceutical and healthcare sectors spent more than $487m on lobbying in the USA alone. This was more than was spent by any other sector in the US, representing 15% of $3.2bn total lobbying expenditures in 2013. In addition, during the election cycle of 2012, $260m was spent by this sector on campaign contributions. Twenty-two of the 90 pharmaceutical and healthcare billionaires are US citizens.

http://www.oxfam.org/sites/www.oxfam.org/files/file_attachments/ib-wealth-having-all-wanting-more-190115-en.pdf

Comment:

By Don McCanne, MD

In 1966, Martin Luther King, Jr. famously noted that injustice in health care was the most shocking and inhumane form of inequality. The Oxfam brief issued today – Martin Luther King, Jr. Day – gives some insight as to how well we are fulfilling his dream of social justice for all. We are seeing exponential increases in wealth inequality and the fastest expansion of that inequality is in the pharmaceutical and health care sectors.

Are we still learning from him, or have we given up?

Medicare at 50 — Origins and Evolution

By David Blumenthal, M.D., M.P.P., Karen Davis, Ph.D., and Stuart Guterman, M.A.
The New England Journal of Medicine, January 14, 2015

Many Americans have never known a world without Medicare. For 50 years, it has been a reliable guarantor of the health and welfare of older and disabled Americans by paying their medical bills, ensuring their access to needed health care services, and protecting them from potentially crushing health expenses. However, as popular as Medicare has become, Congress created the program only after a long and deeply ideological struggle that still reverberates in continuing debates about its future.

Future Challenges

Medicare is a much larger, more comprehensive, and more complex program than it was in 1965. In its response to cost and quality concerns, it has also become much more assertive in trying to improve the performance of the national health care system. For much of its history, Medicare just paid bills. Now, it has joined private-sector insurers in the effort to manage care as well.

Despite these changes, however, Medicare continues to face major challenges, which will be discussed in more detail in part two of this series. Perhaps the most important of these challenges is its cost. Growth in Medicare spending per beneficiary has slowed sharply in recent years, and although that slowdown is projected to continue over the next few years, the growth in total program spending is projected to outpace that in the overall economy as the retiring baby-boom generation increases the number of beneficiaries. This will put more pressure not only on Medicare finances but also on the federal budget, with Medicare spending projected to rise as a share of federal revenues from 17% in 2014 to 27% in 2050 and to approach 40% by the end of the century.

The current structure of Medicare is anachronistic and unnecessarily complex. Most employers offer their employees a comprehensive benefit package that includes hospital care, physician services, and prescription drugs. Medicare, in contrast, offers its beneficiaries fragmented coverage, with separate parts for each of these services. As a result of its substantial deductibles and the lack of a ceiling on out-of-pocket costs, most beneficiaries purchase supplemental private insurance to cover gaps in Medicare. Low-income beneficiaries, unable to afford care provided through substantial cost sharing in Medicare, can enroll in Medicaid to obtain help in paying Medicare premiums and out-of-pocket costs, but each state has its own income and asset rules. As a result, the complexity of the current insurance system for the elderly becomes truly startling. This complexity frustrates efforts to coordinate care for the sickest and frailest patients and to create an understandable and consistent set of incentives for providers.

Despite the importance of Medicare in improving its beneficiaries’ access to care, the program does have substantial limitations in coverage. These limitations result in large out-of-pocket payments for the most vulnerable beneficiaries. Although Medicare covers some rehabilitation services and limited home care, it does not pay for extended long-term services and supports, a gap that surprises many elderly persons and their families when they need such care. Medicaid does cover these benefits but only for the poorest elderly. The role of Medicare in addressing growing societal needs for long-term services remains uncertain.

These and other issues suggest that preserving and strengthening Medicare over the next 50 years will continue to require active, wise, and humane policy development. Such a task would be a challenge for the federal government under any circumstances but particularly if the current intense partisan divisions persist.

http://www.nejm.org/doi/full/10.1056/NEJMhpr1411701

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Comment:

By Don McCanne, MD

Although Medicare is the most popular health insurance program in the nation, it still has some serious deficiencies. As an example, 27 percent of Medicare beneficiaries spend more than 20 percent of their income for out-of-pocket health care expenses.

There are two pressing reasons why efforts should be made to strengthen Medicare. The most obvious is that current Medicare beneficiaries should have at least the level of financial security and health security that citizens of other nations receive through their health care financing systems.

The other reason is that Medicare is thought by many to be a natural model for a national health program that covers everyone. It is important that the model be improved so that we can do away with wasteful and inefficient supplementary programs such as Medigap coverage, retiree health benefits, Medicare Advantage plans, and Part D drug plans, and, while we are at it, eliminate the financial barriers of cost sharing that impair access to care. Once we have an improved Medicare we can combine it with the other important features of a single payer national health program, finally realizing our dream of an expanded and improved Medicare for all.

For those who wish to be reminded of the key features of single payer that should be combined with an improved Medicare, a brief list is at this link:

https://www.pnhp.org/resources/key-features-of-single-payer

The Rise in Health Care Coverage and Affordability Since Health Reform Took Effect

By Sara R. Collins, Petra W. Rasmussen, Michelle M. Doty, and Sophie Beutel
The Commonwealth Fund, January 15, 2015

Abstract 

New results from the Commonwealth Fund Biennial Health Insurance Survey, 2014, indicate that the Affordable Care Act’s subsidized insurance options and consumer protections reduced the number of uninsured working-age adults from an estimated 37 million people, or 20 percent of the population, in 2010 to 29 million, or 16 percent, by the second half of 2014. Conducted from July to December 2014, for the first time since it began in 2001, the survey finds declines in the number of people who report cost-related access problems and medical-related financial difficulties. The number of adults who did not get needed health care because of cost declined from 80 million people, or 43 percent, in 2012 to 66 million, or 36 percent, in 2014. The number of adults who reported problems paying their medical bills declined from an estimated 75 million people in 2012 to 64 million people in 2014.

Conclusion

For the first time since it was launched in 2001, the Commonwealth Fund Biennial Health Insurance Survey has found significant declines in the number and share of U.S. adults who lack health insurance. The survey also finds evidence to suggest that the coverage gains are allowing working-age adults to get the health care they need while reducing their level of financial burden because of medical bills and debt.

But, while there were minor improvements reported by insured adults in cost-related access and medical bill problems, rates of these problems remain high, especially among adults with low incomes. Prior Commonwealth Fund survey results have found that the increasing size and prevalence of high deductibles and copayments in private health plans, including employer-based plans, is leading many people with low and moderate incomes to avoid or delay needed health care. Excessive cost-sharing for Americans across all insurance types could jeopardize improvements in access to care and medical bill burdens documented in the survey.

States’ decisions to reject the Medicaid expansion have left large numbers of the poorest Americans in the country without health insurance. Since the survey was fielded in July, one additional state has expanded its program, seven others are in discussions to move to forward, and still others may follow their lead this year.

http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2015/jan/1800_collins_biennial_survey_brief.pdf

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Comment:

By Don McCanne, MD

The media reports on the new Commonwealth Fund study are celebrating the reduction in the numbers who remain uninsured and the reductions in the financial consequences of being uninsured, supposedly proving that the Affordable Care Act is working. What is difficult to celebrate is confirmation that there are still 66 million people who did not get needed health care because of cost, and there are 64 million people who still reported problems paying their medical bills.

Rather than celebrating a modest improvement in the statistics we should be be using this report to condemn the gross inadequacies of the Affordable Care Act that leave in place the financial barriers that have negatively impacted over 60 million people, and have the potential to have the same negative impact on tens of millions more should they incur a need to access the health care system.

For those who say, “But this is working,” it is not working for the vast majority for whom our prior system fell cruelly short. Continuing this highly flawed experiment constitutes unethical experimentation when we know that a single payer system with full prepaid financing will remove the financial barriers and hardships that are perpetuated by the Affordable Care Act.

When you have a forest fire, you don’t pull out the candle snuffers; you call in the tankers. Likewise, when our health care financing system is leaving tens of millions broke and without adequate care, you don’t tweak what we have; you mobilize a powerful system that actually would work – an improved and expanded Medicare for all.

CO-OP (Consumer Operated and Oriented Plan) Health Plans under the Affordable Care Act

PNHP, Quote of the Day, July 18, 2011

From the comment by Don McCanne:

The proposed rule has now been released for the establishment of CO-OPs under the Affordable Care Act. The CO-OPs are private, nonprofit organizations that sell insurance, like HMOs and PPOs, under the same rules as the other private insurers. The most important difference is that a CO-OP is controlled by a board of directors that is elected by the individuals enrolled in the CO-OP.

These are new organizations, and, as such, require a new infusion of capital to meet the reserve requirements for future claims. These are the same requirements that have been established by the states for other private insurers already competing in the marketplace.

Private, for-profit insurers have the capability of establishing start-up costs and solvency reserves by selling shares of stock. Since the CO-OPs are nonprofit, they don’t have this resource to tap. Recognizing this, the Affordable Care Act included provisions for government loans for start-up costs and other loans for solvency (reserve funds for future claims). It is important to understand that these are not grants but are loans that must be repaid, with interest, within five years for start-up loans and fifteen years for solvency loans.

Think about that. The CO-OPs are required to compete with the private insurers under the same terms, while having the additional requirement of paying back these loans. Since their only revenue source is premiums for the insurance they are selling, these loan costs that their competitors don’t have will have to be recovered through higher premiums. Under these terms, how could they possibly compete with the private insurers?

There are many other issues. How long would it take to establish a critical threshold of enrolling enough members to create a viable entity? Since it is likely that the CO-OPs would be subject to adverse selection (enrolling a larger share of patients with greater health care needs), there would be further upward pressure on their premiums (death spiral) since current risk adjustment tools do not recover the full excess losses (as if health care is a “loss”).

It’s too bad. CO-OPs should have offered us the opportunity to establish altruistic health care organizations. Instead, the politicians bent over backwards not only to keep the government out of these programs, but also to protect the private insurers’ marketplace by being sure that the CO-OPs were not allowed a fair playing field by saddling them with insurmountable debt.

We needed a seat at the table.

https://www.pnhp.org/news/2011/july/co-op-consumer-operated-and-oriented-plan-health-plans-under-the-affordable-care-act

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Health Insurance Startup Collapses In Iowa

By Clay Masters, Iowa Public Radio
NPR/Kaiser Health News, January 14, 2015

CoOportunity Health has failed. The Affordable Care Act set aside funding for health care co-ops, to enable the organizations to compete in places where there aren’t many insurers. CoOportunity Health was the second largest co-op in the country in terms of membership, and one of the largest in terms of the federal funding it received.

But then CoOportunity hit a kind of perfect storm, says Peter Damiano, director of the University of Iowa’s public policy center. First, the co-op had to pay a lot more medical bills than those in charge expected.

“CoOportunity Health’s pool of people was larger than expected, was sicker than expected,” Damiano says. “So their risk became much greater than the funds that were available,”

When the Obama administration in late 2013 allowed people to keep the insurance plan they already had, many customers happy with Wellmark stayed put. Damiano says this meant many of the customers who flocked to CoOportunity tended to be… people with expensive health problems who’d had trouble paying for insurance before, in the market Wellmark dominated.

“It was always going to be a challenging market to try to reach,” says Damiano, “and on top of that, the whole idea of co-ops was relatively new and experimental. But it was to try to create competition, on that private sector approach,” says Damiano.

According to Nick Gerhart, Iowa’s insurance commissioner… the co-op thought it was going to get more federal money. “On December 16 around 4 o’clock we were informed they weren’t going to get any further funding,” he says. “Nothing was pulled — it just wasn’t extended further.”

“Ours was the second largest in the country, so you’ve got to look at it that way.” Gerhart says. “If the second largest can’t make it, how viable are the other ones? I don’t know. But at the end of the day they didn’t have enough capital to support 120,000 members.”

http://kaiserhealthnews.org/news/health-insurance-startup-collapses-in-iowa/

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Comment:

By Don McCanne, MD

Those of us who watched closely as the health care reform process unfolded were outraged by many of the decisions made by the members of Congress. As single payer supporters we were denied a seat at the table. Regardless, we still tried to inform the process but we were routinely ignored. “What you guys want is just not politically feasible.”

Look what I wrote July 18, 2011: “It’s too bad. CO-OPs should have offered us the opportunity to establish altruistic health care organizations. Instead, the politicians bent over backwards not only to keep the government out of these programs, but also to protect the private insurers’ marketplace by being sure that the CO-OPs were not allowed a fair playing field by saddling them with insurmountable debt.”

Now look at what happened to CoOportunity – the second largest co-op in the country. Not only did they enroll patients with greater health care needs, as we predicted, but the government loans were inadequate to maintain its viability. The success in enrolling large numbers of members accelerated the demise of this co-op, but what about the others? With the premiums they receive, how will they be able to pay for the health care services of a higher risk population plus service their loans at the same time – loans that competing private insurers do not have to face?

It isn’t that we didn’t know how to design a proper health care financing program. We clearly did – single payer. What is tragic is that the Affordable Care Act was designed to take special care of the private insurance industry while supposedly showing some vague, deceptive semblance of improving access and affordability for the patients served, though caring for patients was certainly a lower priority than catering to the private insurers.

With 30 million people being left uninsured, and with the establishment of a new insurance standard of unaffordable under-insurance, our members of Congress sure did a crappy job – not just crappy but far worse – it was callous and inhumane.