PNHP

Health benefits should not be tied to jobs

Health benefits should not be tied to jobs

By Pamella S. Gronemeyer, M.D.
St. Louis Post-Dispatch, Letters, June 1, 2013

Last week, physicians and a pharmacy student who are members of Physicians for a National Health Program (Illinois and Missouri chapters) and the Illinois Single Payer Coalition joined thousands of United Mine Workers of America members to support their demand for continuation and fulfillment of the health and pension benefits that the miners have earned as benefits from their long years of working in mines while being exposed to the harmful effects of coal dust, which include the development of black lung disease or carcinomas.

The story of Patriot Coal and its pending bankruptcy hearing is not new but represents another effort of a corporation to both destroy a union and to deprive the laborers of their earned health and pension benefits. As physicians, we have all seen the lung disease created by mining and know how much coal miners need their health benefits. We strongly support them in their continued actions to secure their much-deserved earned benefits.

Once again, this fight points out the need for a Medicare for All program in the United States. If health benefits were not tied to jobs, no one would lose their benefits because an industry felt the need to manipulate the structure of interrelated companies and corporations to insure shareholder return and to subsequently inflict pain and suffering on workers who toiled for many years in underground mines.

Unions have worked very hard to make sure that their members have health benefits. However, they are facing increasing obstructions to their efforts. Deductibles and co-pays are being raised. Plans that eliminate coverage for hospital care are being developed.

If single-payer health care became a reality (HR 676), the American people would be the organized bargaining unit demanding and insuring that health care is a human right for all.

Dr. Pamella S. Gronemeyer resides in Glen Carbon, Ill.

http://www.stltoday.com/news/opinion/mailbag/letters-to-the-editor/health-benefits-should-not-be-tied-to-jobs/article_27a24bd9-9151-5cb7-8c23-fa0c6461321b.html

Medical Debt: A Curable Affliction Health Reform Won’t Fix

By David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H.
Communities & Banking, Summer 2013   

Millions of Americans are deep in medical debt. Unfortunately, the Affordable Care Act (ACA) will throw a lifeline to very few. According to the Congressional Budget Office, even after health reform is fully implemented in 2014, 30 million to 36 million people will remain uninsured. And tens of millions who do have insurance will have coverage that is too limited to ensure financial protection against an expensive illness. Many families will remain just one serious illness away from bankruptcy.

Medical Bankruptcies

In 2001, we began studying medical bankruptcy along with our colleagues Elizabeth Warren and Deborah Thorne. We directly surveyed debtors soon after they’d filed for personal bankruptcy. Back then, illness and medical bills contributed to about 50 percent of all personal bankruptcies and involved about 2.2 million debtors and their dependents.[1]

By 2007, when we repeated our study nationwide, medical bankruptcies had risen to 62 percent.[2] Significantly, most medical debtors were middle class. They had owned homes, had attended college, and had held responsible jobs. Seventy-eight percent even had health insurance, mostly private coverage — at least when they first got sick.

Why are so many middle-class, privately insured Americans swamped by medical costs? The reason is that private coverage has holes — unaffordable deductibles and copayments, as well as brief or nonexistent coverage of medical services like physical therapy. Moreover, since illness often reduces work-related income, families may experience a double whammy, as medical bills arrive just when the paychecks stop.

Medical bankruptcy is actually the tip of a much larger iceberg of medical indebtedness. For years, surveys have found that tens of millions of Americans struggle with medical debts and avoid needed care for fear of the cost. Recent surveys by Consumer Reports, for instance, have found that difficulty paying for medical care (including prescription drugs) is the top financial problem for American households.[3]

The number of Americans who struggle to pay for care has trended upward over time as health-care costs have soared and many health insurance companies have reduced the comprehensiveness of coverage. According to surveys by the Commonwealth Fund, the number of working-age adults (those 19 years old to 64 years old) reporting “problems paying” or “unable to pay medical bills within the past year” rose from 39 million to 53 million between 2005 and 2010.[4] In 2010, 30 million Americans were contacted by a collection agency about a medical bill, and 44 million were paying off medical debts over time.

A survey by the Center for Studying Health System Change estimated that 20.9 percent of all Americans lived in families that experienced a medical bill problem in 2010.[5] As in our bankruptcy surveys, insurance failed to offer enough protection. As many as 20.2 percent of nonelderly insured people lived in a family with medical bill problems.

Even relatively young Americans, few of whom suffer serious illnesses, are at high risk of medical debt. In a 2011 survey of young adults 19 years old to 29 years old, 51 percent of those without insurance reported medical bill or medical debt problems, as did 29 percent of those who were insured all year.[6] Sixteen percent of all young adults reported being contacted by a collection agency about a medical bill within the past year.

Medical bills often compromise more than just financial health. Considerable research, including our own, has found that families that experience medical bill problems are far more likely to delay needed medical care, skip filling a prescription, and report problems paying for other necessities. That is true whether or not the family has health insurance.

The high frequency of medical bankruptcy was often cited by advocates of health reform during the debate over the ACA. Yet the debate largely ignored the fact that most medical debtors actually have coverage. In order to protect Americans from bankruptcy, coverage must be truly comprehensive, that is, it must cover virtually 100 percent of all needed medical care. Unfortunately, the insurance policies mandated under ACA are required to cover only 60 percent of expected health-care costs.

Learning from Massachusetts

Our findings from surveys of debtors in Massachusetts before and after the implementation of that state’s health reform (the prototype of the national reform) make it clear that such limited coverage will do little to prevent medical bankruptcy.

Among Massachusetts bankruptcy filers in 2009, 53 percent cited illness or medical bills as a cause of their bankruptcy, a percentage that was statistically indistinguishable from the 59 percent figure we found before reform. Indeed, because the total number of bankruptcies had risen, the actual number of medical bankruptcies in the state increased from 7,504 in 2007 to 10,093 in 2009.[7] Surveys by others indicate that the reform had little impact on access to care.

Why are so many Massachusetts residents still suffering medical bankruptcies despite health reform? Although health-care reform cut the number of uninsured in the state by more than half (to about 219,000), much of the new coverage is so limited that serious illness still leaves families with medical bills they cannot pay.

Consider that the cheapest coverage available through the state’s health insurance exchange to a single 56-year-old Bostonian who is not eligible for subsidies (in other words, one who has an income above 300 percent of poverty) costs $4,744 and comes with numerous restrictions on which doctors’ and hospitals’ bills it will pay. If the policyholder is sick, the policy doesn’t start paying bills until after the policyholder has taken care of the $2,000 deductible. The patient also is responsible for about 20 percent of the next $15,000 in medical expenses.

Nationally, the Kaiser Foundation estimates that in high-cost regions like New England, the unsubsidized premium in 2014 under the ACA will run $10,585 with additional out-of-pocket costs adding up to $6,250.[8] Such costs will predictably leave tens of millions with large medical debts and drive more than a million into medical bankruptcy every year.

It doesn’t have to be that way. One Canadian study suggested that between 7.1 percent and 14.3 percent of Canadian bankruptcies are attributable to health problems or other misfortunes (such as floods).[9] And when journalist T.R. Reid questioned political leaders and health policy experts in several nations (all of which have some form of national health insurance) about the frequency of medical bankruptcy, he was told that they had none.[10] Other nations have virtually eliminated medical bankruptcy by making coverage both universal (covering everyone) and comprehensive (covering virtually all medical costs).

Given our research, we suggest that single-payer national health insurance should be the ultimate goal. A single tax-funded insurance plan in each region would pay for all needed care, without copayments or deductibles. Tens of billions in savings annually would accrue from reduced insurance overhead as private insurers (whose overhead averages 14 percent) make way for a Medicare-like program. Fee-for-service Medicare’s overhead is 2 percent, and overhead in the single-payer programs in Canadian provinces averages about 1 percent. Health-care providers could redirect the money now spent on billing-related paperwork to expanding and improving care.[11]

A single-payer reform is staunchly opposed by the health insurance industry and by drug companies. Nonetheless, in a recent survey carried out by the Massachusetts Medical Society,
the single-payer approach was the most popular option among Massachusetts physicians.[12] And in 2006, the last time a major poll asked what patients would prefer, 56 percent of the public favored a universal, tax-financed, Medicare-like program.[13]

Alternative health policies could virtually eliminate medical debt and free Americans from the shadow of combined financial ruin and illness — what Edward Kennedy termed the “double disaster.”[14]

David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H., are professors of public health at the City University of New York School of Public Health at Hunter College and visiting professors of medicine at Harvard University. Contact them at swoolhan@hunter.cuny.edu.

Endnotes

[1] David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler, “Illness and Injury as Contributors to Bankruptcy,” Health Affairs, http://content.healthaffairs.org/content/suppl/2005/01/28/hlthaff.w5.63.DC1.

[2] David U. Himmelstein, Deborah Thorne, Elizabeth Warren, and Steffie Woolhandler, “Medical Bankruptcy in the United States, 2007: Results of a National Study,” American Journal of Medicine 122, no. 8 (2009): 741–746, https://pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf.

[3] “Sluggish Economy Forces Americans to Cut Corners to Pay for Medication,” Consumer Reports, September 2012.

[4] Sara R. Collins, Michelle M. Doty, Ruth Robertson, and Tracy Garber, “Help on the Horizon: Findings from the Commonwealth Fund Biennial Health Insurance Survey of 2010” (report, Commonwealth Fund, Washington, DC, March 2011), http://www.commonwealthfund.org/Publications/Fund-Reports/2011/Mar/Help-on-the-Horizon.aspx.

[5] Anna Sommers and Peter J. Cunningham, “Medical Bill Problems Steady for U.S. Families, 2007–2010: Results from the Health Tracking Household Survey” (report, Center for Studying Health System Change, Washington, DC, December 2011), http://www.hschange.com/CONTENT/1268/1268.pdf.

[6] Sara R. Collins, Ruth Robertson, Tracy Garber, and Michelle M. Doty, “Young, Uninsured and in Debt: Findings from the Commonwealth Fund Health Insurance Tracking Survey of Young Adults, 2011” (report, Commonwealth Fund, Washington, DC, June 2012), http://www.commonwealthfund.org/ Publications/Issue-Briefs/2012/Jun/Young-Adults-2012.aspx..

[7] David U. Himmelstein, Deborah Thorne, and Steffie Woolhandler, “Medical Bankruptcy in Massachusetts: Has Health Reform Made a Difference?” American Journal of Medicine 124, no. 3 (March 2011): 224–228, http://www.ncbi.nlm. nih.gov/pubmed/21396505.

[8] See Kaiser Foundation Premium Calculator, http://healthreform.kff.org/ subsidycalculator.aspx.

[9] Jacob S. Ziegel, “A Canadian Perspective,” Texas Law Review 79, no. 5 (2001): 241–256.

[10] See “Sick around the World,” http://www.pbs.org/wgbh/pages/frontline/ sickaroundtheworld/etc/script.html.

[11] Steffie Woolhandler, Terry Campbell, and David U. Himmelstein, “Health Care Administration Costs in the U.S. and Canada,” New England Journal of Medicine 349 (2003): 768–775, https://pnhp.org/publications/nejmadmin.pdf.

[12] See Massachusetts Medical Society Physicians Workforce Study, http://www.massmed.org/AM/Template.cfm?Section=News_ and_Publications2&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=61512.

[13] See “Health Care in America 2006 Survey,” http://www.kff.org/kaiserpolls/upload/7572.pdf.

[14] 14 Edward M. Kennedy, In Critical Condition: The Crisis in America’s Health Care (New York: Simon & Schuster, 1972).

A PDF version of this article is available here.

Communities & Banking is a quarterly publication of the Federal Reserve Bank of Boston. The views expressed are not necessarily those of the Federal Reserve Bank of Boston or the Federal Reserve System. Information about organizations and upcoming events is strictly informational and not an endorsement.

California exchange plans take away provider choice

Insurers limit doctors, hospitals in state-run exchange plans

By Chad Terhune
Los Angeles Times, May 24, 2013

California’s health insurance rates for a new state-run marketplace came in lower than expected this week, but one downside for many consumers will be far fewer doctors and hospitals to choose from.

People who want UCLA Medical Center and its doctors in their health plan network next year, for instance, may have only one choice in California’s exchange: Anthem Blue Cross. Another major insurer in the state-run market, Blue Shield of California, said its exchange customers will be restricted to 36% of its regular physician network statewide.

Paul Markovich, chief executive of Blue Shield, said renegotiating with hospitals and physician groups for lower reimbursements was a key factor for insurers in holding down rates. Medical providers are sometimes willing to accept lower payments in return for higher patient volume from these narrow networks.

And Cedars-Sinai Medical Center, one of Southern California’s most prestigious and expensive hospitals, said it’s not included in any exchange plans at the moment.

Those types of exclusive arrangements, increasingly tight networks and outright exclusions are becoming more common as insurers and government officials search for ways to hold down rising medical costs.

More employers have been adopting these narrower networks and the government’s overhaul of the individual insurance market is accelerating the trend.

http://www.latimes.com/business/la-fi-health-rates-deals-20130525,0,4396720.story

Comment:

By Don McCanne, M.D.

There was quite a celebration amongst Affordable Care Act (ACA) enthusiasts when California, a leader in health care financing innovation, announced that premiums for plans to be offered through the state exchange would not increase sharply over current health plan rates. What is now evident is that the anticipated increases were at least partially offset by further limiting the number of in-network hospitals and physicians, made possible by insurers negotiating lower provider payments in exchange for a promise of greater volume.

This exposes the big lie of the ACA promise of “Choice.” As has been stated so many times, the choice we really want – the choice of health care professionals and institutions – was taken away by the insurers by means of their restricted networks of providers.

Now choice is being restricted even further by narrowing down these networks of providers. These further restrictions in choice are also being adopted in the employer-sponsored market. It can be anticipated that narrow networks will become the new standard in health plans.

At least the traditional Medicare program does not restrict patients to networks, though the private Medicare Advantage plans do. It is true that physicians can totally opt out of Medicare, but very few do. If an improved version of the traditional Medicare program covered all of us, this injustice of taking away patient choice would not exist.

Immigrants heavily subsidize Medicare

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, May 31, 2013

This week the prestigious journal Health Affairs published a new study that shows that “immigrants, particularly noncitizen immigrants, heavily subsidize Medicare.” The lead author is Harvard-based Dr. Leah Zallman; her co-authors include co-founders of Physicians for a National Health Program, Drs. Steffie Woolhandler and David Himmelstein, among others.

The article’s title summarizes its overall finding: “Immigrants contributed an estimated $115.2 billion more to the Medicare Trust Fund than they took out in 2002-09.” Appearing at a time when immigration has become a burning issue, the study has been welcomed by the media as a man-bites-dog story.

Across the United States and around the world news items have reported the study’s findings. Perhaps this is because, regrettably, immigrants are still too often portrayed as freeloaders who don’t deserve to compete for jobs and social benefits. It is one thing to recognize such attitudes as abject ignorance or old-fashioned bigotry. It is another to use the federal government’s own data to quantify the contribution made by immigrants to one of the nation’s most important social programs.

Dr. Zallman and her team found that in 2009 immigrants contributed $33.1 billion to Medicare Hospital Insurance Trust Fund, or 14.7 percent of all contributions, and were responsible for $19.3 billion of its expenditures, making a surplus contribution of $13.8 billion that year. Meanwhile contributions and expenditures by the U.S.-born left a $30.9 billion deficit.

As Dr. Woolhandler said of the study: “The numbers completely contradict the widely held misperception that immigrants are a drain on the health system. Reducing immigration would worsen Medicare’s financial woes.”

With Medicare woes also so prominent in the mainstream discussion, we might also note the irony that President Obama’s administration has deported more immigrants per day than any of its predecessors. (The Washington Post mentioned earlier this month that over 1,100 human beings are deported from the United States daily.)

Immigrant rights groups have long pointed to the economic gain the U.S. could realize, both in extra revenue and avoided expenditures if deportations were halted and a path to legal residence and/or citizenship were opened. After all, the great majority of undocumented immigrants not only work, thus generating wealth, but are paid with a paycheck, with taxes removed from their pay like everyone else.

In the Health Affairs article the authors write: “Having ourselves witnessed immigrants dying needlessly because of lack of health care, we (and many of our colleagues) are motivated by the belief that all patients have a human right to health care. But economic concerns — including the worry that immigrants are driving up U.S. health care costs — have often dominated the debate over immigration.”

It is my hope that the needs of human beings — concerns about what kind of society we would like to see for our children and their children — will come to dominate the discussion instead. Everyone living in the United States should have equitable access to comprehensive, high-quality health care, “everybody in, nobody out.”

We all recognize that the intersection between immigration, health care and social policies in the United States has profound human consequences for millions of individuals. And we should also recall that the point of a democracy should be to provide the essentials for life and liberty for all of its inhabitants.

If we take a close look at the economics of immigration and the Medicare program, and take this study’s findings to heart, we can see that the least we might do would be to base health and social policies upon the facts, not ignorance.

The article is available for free at the Health Affairs website until June 3.

Dr. Andrew Coates practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

You can listen to Dr. Coates’ radio broadcast here:
http://www.wamc.org/post/andrew-coates-immigrants-heavily-subsidize-medicare

Help less fortunate, expand Medicaid

By Jack Bernard and Neil Shulman
The Atlanta Journal-Constitution, May 30, 2013

In a fruitless effort, the radical Republicans in the U.S. House of Representatives have once again pushed through a repeal of “socialist” Obamacare — for the 37th time. This is partisan politics at its finest, since Obamacare is simply an update of Romneycare, a thoroughly Republican concept based on private insurance first introduced by former Republican presidential candidate Bob Dole in more reasonable times.

As health care professionals with many decades of experience, we do not believe that Obamacare (the Affordable Care Act or ACA) is the best solution for our ills. Although it will not provide insurance for all Americans, it is at least a move in the right direction regarding access — especially if Republican governors like ours stop playing politics and accept the federal money to expand Medicaid.

We cannot just let our fellow citizens suffer, expecting the free market to miraculously change and take care of the problem of the uninsured, as has been proposed by Reps. Paul Ryan, Paul Broun and others. The percentage of uninsured has risen drastically in the U.S. and even faster in Georgia, where 22 percent of the population is uninsured.

Here are two examples of how the current system simultaneously mistreats patients while wasting money — problems that can be alleviated by immediate Medicaid expansion:

• A woman graduates with huge college debt, getting a job as a waitress with no health insurance. A pimple on her skin turns dark. She goes to an ER, where the doctor tells her to see a dermatologist. Because she’s broke, she applies to Medicaid, which sends her a letter stating that she is ineligible; she has to be even poorer or disabled from her disease. The cancer spreads and, six months later, she is admitted to a hospital on Medicaid. After $100,000 of health care, she is sent to hospice to die. She is 29 years old.

• A 47-year-old security guard is admitted to a hospital with severe shortness of breath and elevated high blood pressure. Within three days, he is discharged, with $68,000 in medical bills. His doctors know that his blood pressure will zoom back up without the needed blood pressure meds. However, he has no money, and the hospital is not required to give him meds, so he doesn’t get any. He is sick, exhausted and alone. His blood pressure zooms back up, and he bleeds in his eyes, becoming blind. Now, he is disabled and eligible for Medicaid.

In the words of the civil rights leader Philip Randolph: “A community is democratic only when the humblest and weakest person can enjoy the highest civil, economic and social rights that the biggest and most powerful possess.”

We must choose what sort of a nation we will be: a country of compassion, or a Darwinian society in which the strong ruthlessly trample the weak. If we Americans view ourselves as the moral beacon of the world, then we must take care of the less fortunate here at home. In the short term, we must fully implement Obamacare, including expanding Medicaid. Longer term, the most effective solution is Medicare for all, not just those over 65.

Jack Bernard, a Republican from Jasper County, is a retired senior health care executive and was Georgia’s first director of health planning. Neil Shulman is associate professor of medicine at Emory University Medical School.

http://blogs.ajc.com/atlanta-forward/2013/05/30/expand-medicaid-2/?cxntfid=blogs_atlanta_forward

Spend money on universal care not costly exchange

By Thomas Gottlieb, M.D.
Health Policy Solutions (Colo.), May 29, 2013

Coloradans need health care. It’s a basic human right. Yet as we get more information about Colorado’s new health insurance exchange, it seems less certain that people will get the health care they need.

The exchange, also called a marketplace, seems more complex every day. I wonder if Coloradans who need the help most will even be able to understand this new system, much less figure out how to get care.

There is a simple solution. We need universal health care, specifically a public single-payer health system that would assure all of us who need care can access it.

The complexity of implementing and understanding the reforms required under the federal Affordable Care Act (ACA) also known as Obamacare, has become more apparent in recent days. Health Care for All Colorado, the state’s leading advocacy group for a universal public single-payer system, contends that this complexity will lead not only to unnecessary confusion for patients and caregivers but also to increased costs for premiums and other administrative costs that will continue to drive the cost of health care ever higher.

Obamacare regulates health insurance companies.  Its major values include 1) a definition of basic health plans, 2) expanding Medicaid, 3) a progressive funding plan, 4) and expanded benefits for Coloradans who previously were excluded.  However, its implementation is complex.

Coloradans need access to quality health care, not more access to the complexity of hundreds of various iterations of for-profit health insurance policies with high premiums, co-pays and deductibles as well as potentially life-threatening gaps in coverage. Watching as the state spends more than $200 million setting up the ACA exchange with all of this complexity defies logic when investing those many millions in the actually providing health care seems so much more logical and critical.

By now, many Coloradans have been seeing the Connect for Health Colorado advertising that precedes the Oct. 1 opening of the Colorado marketplace for health insurance.  While the ads may make it seem as though shopping for insurance will be a wholly positive experience, the release of more details portends more difficult sailing for those wishing to navigate the new waters of the exchanges being set up to comply with the ACA.

It has been widely reported that Coloradans looking for health insurance will have 17 companies competing for their business with more than 800 different plan variations offered through the state’s new health exchange and on the open market.  Yet as more details have come in, the complexity seemed to be increasing.  We also have many questions about costs for premiums and the availability of plans that provide affordable options for quality care which the ACA’s name seems to suggest and its intent seemed to promise.

We must move to a more sensible and simple system to cover everyone in our state.  Our group advocates for a universal public single-payer health system that would cover all Colorado residents and eliminate the need for the complexity of private insurance sold on the exchanges or purchased and provided through employers.

Another one of our leaders, Nathan Wilkes, who also serves on Colorado’s health exchange board, summed it up well when he recently said, “The rates under the ACA are pretty much guaranteed to be slightly higher because insurers are now required to cover higher-risk people they used to turn away before. The insurers will spin any increases as being due to the additional mandates, but studies show that their additional costs should only be minimal. The private insurers are wasteful, irrelevant dinosaurs creating huge, systemic administrative costs while adding little or no value to the provision of actual health care in Colorado.  Where the rates are the same or lower than before, it is likely because the insurers found ways to limit coverage by shifting more medical costs to the people through higher co-pays/coinsurance, higher deductibles, higher cost sharing for prescriptions, reduced provider networks, and other coverage limits.”

A search of Colorado’s Division of Insurance website shows a lengthy list of the companies and plans that have filed for inclusion on the Colorado marketplace/exchange, but searching for the rate filing information and then understanding those documents points to the complexity of the process and the plans. The plan Health Care for All Colorado advocates has no such complexity or huge variation of rates to decipher.

Health Care for All Colorado leaders and members will be educating, advocating and supporting the push to bring ballot initiative No. 12 to the 2014 ballot for Colorado’s voters to take advantage of the state innovation provisions of the ACA and to create a more comprehensive universal sustainable public and truly affordable health system for all Coloradans.

The initiative title reads, “Shall there be an amendment to the Colorado constitution concerning the provision of one public health insurance program to allow all Colorado residents access to a single standard of health care as a matter of human right and public good, and, in connection therewith, requiring the General Assembly to enact legislation creating a public health insurance plan, requiring the Colorado department of revenue to collect a premium not to exceed 9 percent of an individual’s income to fund the plan, and prohibiting the control or administration of premiums by a for- profit, nonpublic entity or corporation?”  If the Colorado Constitution defines health care as a human right, then our governor and legislators will be held responsible to fulfilling this right.

This Saturday, June 1, Health Care for All Colorado will welcome U.S. Rep. John Conyers, Jr., to our annual meeting as our featured speaker and to help us kick off our “Health Care is a Human Right” campaign in Colorado.  Mr. Conyers is the chief author of HR676, the national improved and expanded Medicare for all bill, and he will speak at 7 p.m., at the First Plymouth Congregational Church at Hampden and Colorado Boulevard in Englewood.  The public is welcome. For more information on the public universal single-payer health care system we support, please visit www.healthcareforallcolorado.org

Dr. Thomas Gottlieb is president-elect for the Health Care for All Colorado Foundation. He trained as a biochemist at the University of Colorado Boulder and as a physician at the CU School of Medicine. He worked for the Indian Health Service, the CU Division of Clinical Pharmacology, as medical director for the Denver Neighborhood Health Center and in private practice.

http://www.healthpolicysolutions.org/2013/05/29/opinion-spend-money-on-universal-care-not-costly-exchange/

Immigrants subsidize our Medicare program

Immigrants Contributed An Estimated $115.2 Billion More To The Medicare Trust Fund Than They Took Out In 2002–09

By Leah Zallman, Steffie Woolhandler, David Himmelstein, David Bor and Danny McCormick
Health Affairs, June 2013

Abstract

Many immigrants in the United States are working-age taxpayers; few are elderly beneficiaries of Medicare. This demographic profile suggests that immigrants may be disproportionately subsidizing the Medicare Trust Fund, which supports payments to hospitals and institutions under Medicare Part A. For immigrants and others, we tabulated Trust Fund contributions and withdrawals (that is, Trust Fund expenditures on their behalf) using multiple years of data from the Current Population Survey and the Medical Expenditure Panel Survey. In 2009 immigrants made 14.7 percent of Trust Fund contributions but accounted for only 7.9 percent of its expenditures—a net surplus of $13.8 billion. In contrast, US-born people generated a $30.9 billion deficit. Immigrants generated surpluses of $11.1–$17.2 billion per year between 2002 and 2009, resulting in a cumulative surplus of $115.2 billion. Most of the surplus from immigrants was contributed by noncitizens and was a result of the high proportion of working-age taxpayers in this group. Policies that restrict immigration may deplete Medicare’s financial resources.

Conclusion

Having ourselves witnessed immigrants dying needlessly because of lack of health care, we (and many of our colleagues) are motivated by the belief that all patients have a human right to health care. But economic concerns—including the worry that immigrants are driving up US health care costs—have often dominated the debate over immigration. Our data offer a new perspective on these economic concerns.

Policies that reduce immigration would almost certainly weaken Medicare’s financial health, while an increasing flow of immigrants might bolster its sustainability. Because Social Security’s eligibility criteria and payroll tax–based funding closely track those of Medicare, our findings support the argument that immigration helps sustain Social Security.

Providing a path to citizenship for currently undocumented immigrants would affect Medicare’s finances in multiple ways. It would likely increase payroll tax collections by reducing immigrants’ “off the books” employment and removing barriers that keep them out of higher-paying jobs. But in the long term it would probably increase the number of immigrants eligible for Medicare, and hence expenditures on their behalf.

However, the age structure of the immigrant population is far more important than either of these factors. Encouraging a steady flow of young immigrants would help offset the aging of the US population and the health care financing challenge that it presents.

http://content.healthaffairs.org/content/early/2013/05/20/hlthaff.2012.1223

Comment:

By Don McCanne, M.D.

Everyone should have health care when needed. Immigrants are taxed to support our Medicare program, yet many of them are prohibited from participating in Medicare, Medicaid, and the state insurance exchanges currently under development. Not fair.

We should have a universal health care financing system – covering all of us – in which we pay in, based on ability, and draw out, based on medical need. As long as immigrants are an integral part of our society, they should be included on the same basis.

A Simpler, Better Solution

By David Himmelstein and Steffie Woolhandler
The New York Times, Room for Debate, May 29, 2013

Gordon Schiff, an expert on medical quality, frequently admonishes: “Avoid workarounds.” It’s better to fix system defects than to force doctors and nurses to squander time and creativity (and to court disaster) by sidestepping problems like broken equipment, missing charts or computer bugs.

The Affordable Care Act is a giant workaround. Overwhelming evidence says that public insurers like Medicare (with overhead costs of 2 percent) are more efficient than private ones (overhead of private Medicare Advantage plans is 14 percent). And multiple insurers means multiple contracts, with varying coverage, billing procedures, documentation requirements, etc. – all of which force doctors and hospitals to waste billions more. The obvious fix is to cut out the insurance middlemen and cover everyone under a single public program paid for by taxes – with equal coverage for all. But the insurance lobby blocked that, so instead the Affordable Care Act took the Rube Goldberg route.

If your income is below $31,321 for a family of four (133 percent of the poverty line), you will get Medicaid (unless you live in a red state that declined the federal assistance, like Texas or Alabama). And “Medicaid” nowadays means a privately run Medicaid H.M.O. But make one dollar more (or if Junior moves out, leaving a family of three) and Medicaid disappears; now you’re shopping for subsidized private insurance in the state-run exchange. That’s not a rare occurrence: 28 million adults cross the 133 percent line annually.

In the exchange, “bronze” plans look cheapest – at first glance. But if your income is under 250 percent of poverty there are special discounts for copayments, but only in “silver” plans.

Move from 400 percent of poverty to 401 percent, and individual premiums rise $2,303. Can’t quit smoking? Add $3,365.

Stop paying your premium? You’ll stay enrolled for three months, but your insurer only has to pay your medical bills for one month.

The health care law’s consumer protections apply to everyone, except the 58.5 percent of private sector workers whose employers self-insure.

Employers who do not offer coverage must pay a fine, unless you work less than 30 hours a week, averaged over three months, or maybe 12 months.

Small employers can get help with premiums, unless they buy coverage through a Taft-Hartley Fund.

Got it? We don’t either. And there’s much more arcane detail that can mean life or death for thousands, penury or plenty for millions.

Government already pays two-thirds of total health costs, but much of that money takes a detour through a maze of private insurers. This manufactured complexity sows confusion and adds huge expense – the cost of a workaround.

David Himmelstein and Steffie Woolhandler are professors at the City University School of Public Health at Hunter College and visiting professors at Harvard Medical School. They are co-founders of Physicians for a National Health Program.

http://www.nytimes.com/roomfordebate/2013/05/29/is-obamacare-too-complicated-to-succeed/a-single-payer-system-would-be-better-than-obamacare

Immigrants help Medicare stay solvent

By Noam N. Levey
Los Angeles Times, May 29, 2013

WASHINGTON — Immigrants in the United States both legally and illegally are helping sustain Medicare, contributing about $14 billion more a year to the federal health program for the elderly than they use in medical services, a new study indicates.

The surplus generated by immigrants contrasts sharply with deficits caused by native-born Americans, as medical care for elderly beneficiaries depletes Medicare’s reserves more quickly than working-age U.S. natives can refill them.

The report — published Wednesday in the journal Health Affairs as Congress debates immigration overhaul legislation — does not calculate the full impact of immigrants in the country illegally on all government healthcare programs.

But the authors estimate that these immigrants are helping to support the Medicare program because many pay taxes, while they are ineligible to receive benefits.

“Our study should raise skepticism about the widespread assumption that immigrants drain public healthcare resources,” said Dr. Leah Zallman, an internist and Harvard Medical School instructor who is lead author of the report.

Most legal immigrants, like U.S. citizens, become eligible for Medicare benefits at 65 if they have worked at least 40 quarters in this country. That means many immigrants who today sustain the program will someday draw benefits. But the authors note that, as long as immigration continues, immigrants should not be drain on the program.

“Policies that reduce immigration would almost certainly weaken Medicare’s financial health, while an increasing flow of immigrants might bolster its sustainability,” the study concludes.

Medicare, which covers about 50 million retired and disabled Americans, is funded partly through payroll taxes that employers and employees pay into a trust fund.

But that fund is slowly being drained as a wave of Baby Boomers retires and healthcare costs continue to rise, if more slowly than in past years. Medicare’s main trust fund is projected to run in the red in 2024.

The new report suggests this deficit is being driven entirely by native-born Americans because the number of retirees is increasing more rapidly than the working-age population.

Today, less than 60% of the U.S.-born population is 18 to 64. By contrast, nearly 80% of foreign-born residents are in their prime working years.

The United States is home to an estimated 40 million foreign-born residents, among whom about 11 million have entered the country illegally or overstayed their visas.

Every year, about 1 million immigrants become legal permanent residents, according to the Department of Homeland Security. Nearly 95% of these new immigrants are under age 65.

By looking at census data, researchers were able to estimate that people born abroad likely paid about $33 billion in payroll taxes to the Medicare trust fund in 2009. The researchers then used Medicare data to estimate that immigrants were responsible for about $19 billion of the program’s medical expenses that year.

Similar surpluses were identified in the previous seven years, leading researchers to calculate that immigrants contributed $115 billion more to Medicare than they consumed in medical services between 2002 and 2009.

U.S.-born people, by contrast, were responsible for a nearly $31-billion Medicare deficit over the same period.

Zallman said the data did not allow researchers to determine how much of the Medicare surplus was generated by immigrants who are in the country illegally, though previous research by the Social Security Administration has estimated that these immigrants contribute billions of dollars to the nation’s retirement programs.

Immigrants in the country illegally often use fake Social Security numbers to work. They and their employers in turn pay Social Security and Medicare payroll taxes, though these immigrants are banned from receiving Medicare benefits.

The new healthcare law also bars immigrants in the country illegally from receiving other health benefits, including insurance subsidies that will be available to millions of low- and moderate-income Americans next year.

Children and pregnant women in the country illegally do qualify for government healthcare assistance through the Medicaid program in some states.

Unlike Medicare, Medicaid is funded almost entirely by general tax revenues collected by state and federal governments.

http://www.latimes.com/news/politics/la-pn-immigrants-medicare-stay-solvent-20130529,0,3048046.story

See additional coverage of the Health Affairs study at The New York Times, Reuters, The Wall Street Journal, The Washington Post, Kaiser Health News, Modern Healthcare, MedPage Today, Bloomberg News, NBC Latino, The Hill, Becker’s Hospital Review, National Journal, and CBS News, among other media outlets.

Immigrants subsidize Medicare recipients, study says

By Kelly Kennedy
USA Today, May 29, 2013

WASHINGTON — Immigrants contributed about $115 billion more from their paychecks to the Medicare Trust Fund than they took out over a seven-year period in the last decade, according to researchers at Harvard Medical School.

As the Senate debates a new immigration bill and House Republicans work toward a bill that restricts access to government services for unauthorized immigrants who become legal citizens, the researchers concluded in a study released Wednesday that restricting immigration could deplete the fund.

Researchers looked at data from 2002 to 2009.

“The assumption that immigrants are just a drain has been a part of the argument that people should be denied services,” said Leah Zallman, lead researcher and an instructor at Harvard Medical School. “Immigration policy has been closely linked to Medicare’s finances.”

Studies had shown that immigrants use less health care than U.S.-born people, including in government programs, but no one had looked at their contributions to those programs.

In 2009, the researchers found, immigrants contributed $13.9 billion more to the Medicare Trust Fund than they used, while U.S.-born people spent $31 billion more than they contributed. Immigrants, Zallman said, essentially subsidize U.S. health care.

“I was surprised by the degree of subsidy,” Zallman said. “We didn’t see any changes in the amount of the [immigrant] subsidy each year, but there was a decline in net contribution of U.S.-born citizens.”

They found that immigrants ages 18 to 64 on average contributed only about $100 less a year than did U.S.-born people, which is contrary to conventional wisdom that immigrants don’t earn enough to contribute. Both U.S.-born citizens and immigrants older than 64 contributed less than they used: $3,333 for the U.S.-born and $2,099 for immigrants.

“We should carefully examine these assumptions that have led to denial of care,” Zallman said. She said the study was unable to include undocumented immigrants who paid into the system illegally through fake Social Security numbers.

The difference comes because there are more immigrants of working age than retirement age. The U.S.-born population is aging at a faster rate than it is creating a workforce to pay into the fund. Immigrants often go home after they retire or they’re ineligible to receive benefits because of their immigrant status, Zallman said.

“Baby Boomers are coming into retirement,” she said. “We’re not seeing that same decline in the immigrant population.

“Immigration policy has been closely linked to Medicare’s finances,” she said. The authors said allowing legal status for undocumented immigrants could mean more “on-the-books” employment, as well as higher-paying jobs. That, in turn, could mean more money for the fund.

“Encouraging a steady flow of young immigrants would help offset the aging of the U.S. population and the health care financing challenge that it presents,” states the report, which was published in the magazine Health Affairs.

A recent Heritage Foundation study predicted the United States would lose $6.3 trillion if it passed the Senate immigration law. The law would legalize 11 million unauthorized immigrants. One of the authors of the study was later found to have argued in his doctoral dissertation at Harvard in 2009 that immigrants naturally have a lower IQ than the “native white population” of the USA.

http://www.usatoday.com/story/news/politics/2013/05/29/immigration-health-costs-less-than-us-born/2367507/

See additional coverage of the Health Affairs study at The New York Times, Reuters, Los Angeles Times, The Wall Street Journal, The Washington Post, Kaiser Health News, Modern Healthcare, MedPage Today, Bloomberg News, NBC Latino, The Hill, Becker’s Hospital Review, National Journal, and CBS News, among other media outlets.

Immigrants give more to Medicare than they receive, a study finds

By Sabrina Tavernise
The New York Times, May 29, 2013

Immigrants have contributed billions of dollars more to Medicare in recent years than the program has paid out on their behalf, according to a new study, a pattern that goes against the notion that immigrants are a drain on federal health care spending.

The study, led by researchers at Harvard Medical School, measured immigrants’ contributions to the part of Medicare that pays for hospital care, a trust fund that accounts for nearly half of the federal program’s revenue. It found that immigrants generated surpluses totaling $115 billion from 2002 to 2009. In comparison, the American-born population incurred a deficit of $28 billion over the same period.

The findings shed light what demographers have long known: Immigrants are crucial in balancing the age structure of American society, providing an infusion of young, working-age adults who support the country’s aging population and help cover the costs of Medicare and Social Security. And with the largest generation in the United States, the baby boomers, now starting to retire, the financial help from immigrants has never been more needed, experts said.

Individual immigrant contributions were roughly the same as those of American citizens, the study found, but immigrants as a group received less than they paid in, largely because they were younger on average than the American-born population and fewer of them were old enough to be eligible for benefits. The median age of Hispanics, whose foreign-born contingent is by far the largest immigrant group, is 27, according to the Brookings Institution. The median age of whites in the United States is 42.

The study, which was published on the Web site of the journal Health Affairs on Wednesday, comes as Congress considers legislation that would eventually give legal status to the country’s 11 million unauthorized immigrants. The legislation has sparked a vigorous debate about whether immigrants ultimately contribute more than they receive from the federal budget. One of the sticking points has been whether immigrants should be eligible for government programs, including health benefits, before they qualify for citizenship, but while they are on the path to getting it.

The study was concerned only with Medicare, the federal program that accounts for about a fifth of all American health care expenditures. Experts said that the study’s findings served as a useful reminder that immigrants, at least for now, are extending the life of the beleaguered program, not hastening its demise.

“There’s this strong belief that immigrants are takers,” said Leighton Ku, the director of the Center for Health Policy Research at George Washington University. “This shows they are contributing hugely. Without immigrants, the Medicare trust fund would be in trouble sooner.” The belief prevails, for example, among some opponents of immigration reform.

The study did not grapple with the health care costs of immigrants over their full lifetimes, a calculation that economists say is critical to understanding their long-term impact on the federal budget.

“It’s just a snapshot of a point in time,” said Paul Van de Water, a visiting fellow at the liberal-leaning Center on Budget and Policy Priorities.

The study drew on two nationally representative federal surveys from the Census Bureau and the Department of Health and Human Services. Researchers included the contributions of legal residents who were not citizens, a group that is eligible for Medicare if certain requirements are met; unauthorized immigrants; and citizens who were born abroad.

It was not clear how much of the surplus was made up of earnings by immigrants in the country illegally, who are ineligible for most government programs.

The finding “pokes a hole in the widespread assumption that immigrants drain U.S. health care spending dollars,” said Leah Zallman, an instructor of medicine at Harvard Medical School and the lead author of the study.

Similar calculations have been made for Social Security. The chief actuary of the Social Security Administration, Stephen C. Goss, estimated that immigrants in the country illegally, some of whom assume fake Social Security numbers to provide cover for employers, generated a surplus of about $12 billion for the Social Security Trust Fund in 2010.

But that equation would change if unauthorized immigrants were to gain legal status under a new law and eventually began collecting Social Security once they were of retirement age. One major policy question is how much that might cost, experts said.

The Heritage Foundation, a conservative institute, estimated that the legislation’s changes, if implemented, could cost taxpayers more than $6 trillion. Critics of that calculation said it did not take into account the economic benefits that would arise from taking millions of people out of the shadow economy.

Mr. Goss, in a letter this month to Senator Marco Rubio, a Florida Republican, said that the legislation’s effect on the long-term health of Social Security would be positive in the long term.

Immigrants tend to be healthier than American-born citizens, and have lower mortality rates, research has found. Dr. Ku said there was evidence that individual immigrants actually use less health care than native-born Americans. He has calculated, for example, that immigrants’ medical costs were 14 percent to 20 percent less than those who were born in the United States, even after controlling for other factors such as emergency room visits and insurance coverage, which fewer immigrants have.

The study found that average expenditures among immigrant Medicare enrollees in 2009 were $3,923, lower than the average $5,388 expenditure among the American-born. The difference, however, was just shy of statistical significance, because of wide variations in medical expenditures and the small numbers of immigrant enrollees, which made the study’s margin of error wide.

Robert Rector, a senior research fellow at the Heritage Foundation, who is an author of the institute’s report earlier this month, said that looking at Medicare alone was not very useful, as it was just one slice of the entire entitlement pie. And the large immigrant youth population, which the study spends most of its time on, is familiar, he said.

“It’s a yawner of a study,” he said. “Young people don’t get Medicare. We don’t need several Ph.D.s to tell us that.”

Others defended the findings, saying that they showed immigrants were helping prop up the country’s retirement funds at the critical point when baby boomers were starting to retire.

“They’ll be paying into the system at the very time it is most strained,” said Patrick Oakford, a researcher on economic and immigration policy at the Center for American Progress, a liberal-leaning institute. He estimated that the average undocumented immigrant was 34 and therefore would not retire until 2046. 

http://www.nytimes.com/2013/05/30/health/immigrants-give-more-to-medicare-than-they-receive-a-study-finds.html?pagewanted=all&_r=0

See additional coverage of the Health Affairs study at USA Today, Reuters, Los Angeles Times, The Wall Street Journal, The Washington Post, Kaiser Health News, Modern Healthcare, MedPage Today,Bloomberg News, NBC Latino, The Hill, Becker’s Hospital Review, National Journal, and CBS News, among other media outlets.

Immigration Reform And The Financial Health Of Medicare

By Leah Zallman and Danny McCormick
Health Affairs blog, May 29, 2013

Politicians on Capitol Hill are currently engaged in policy disputes about two thorny issues that many see as closely linked: immigration reform and controlling runaway health care costs. The pervasive wisdom is that immigrants, many of whom are low-income, unauthorized and uninsured, rely on uncompensated care and Medicaid and drain medical resources that are predominantly contributed by native-born Americans though taxes. Curbing immigration, the argument goes, will reduce reliance on government-funded health services and help our nation reduce its healthcare spending.

This argument makes intuitive sense, but it fails to account for two key factors: immigrants contribute to health care financing — sometimes heavily — and they spend less — a lot less.

Our study, published today as a Health Affairs Web First article, examines these variables as they relate to the Medicare program and finds evidence that contradicts the pervasive wisdom. We calculated the total dollars contributed to and received from the Medicare Hospital Insurance Trust Fund (“Trust Fund”), which pays primarily for inpatient care, for both immigrants and U.S. born citizens. We found that between 2002 and 2009, immigrants contributed $115.2 billion in excess of what they utilized. During this same time frame, US born persons withdrew $28.1 billion more than they contributed. Although we could not measure the contributions to the Supplementary Medical Insurance Trust Fund (which primarily pays for outpatient care), we examined average expenditures by immigrants and US-born persons to this fund and found that immigrants spent less than US born persons: $175 per year less on average.

Immigrants generate a surplus for the Medicare Trust Fund primarily because many of them are working-age adults likely to participate in the labor force, a combination that generates large payroll tax payments. Immigrants with legal status contribute to the Medicare Trust Fund through payroll taxes under valid Social Security numbers. In addition, undocumented immigrants often contribute payroll taxes under Social Security numbers tied to invented names or belonging to someone else, because employers must report, but needn’t verify, a Social Security number for all employees. In spite of these contributions, many immigrants never receive services under Medicare, either because they are ineligible for Medicare since they did not work the required 40 quarters, or because they return to their country of origin before reaching the age of Medicare eligibility, 65.

Policy Implications

Our findings have implications for immigration reform policy. First, it is clear that policies that reduce immigration would almost certainly weaken Medicare’s financial health. The Medicare Trustees estimate that the Trust Fund will be exhausted within a decade. This has already led to drastic cost-cutting measures. Further weakening of Medicare’s finances through restriction of immigration could result in new taxes or government borrowing, restrictions on covered services, or increased cost sharing for patients with Medicare. The consequences of these latter two changes would almost certainly result in worse access to timely and effective care for millions of Medicare recipients.

Second, providing a path to citizenship for the estimated 11 million undocumented immigrants would affect Medicare’s finances in several ways. In the long term, it would likely increase the number of Medicare-eligible immigrants, and thus outlays on their behalf. On the other hand, it would probably increase immigrants’ payroll tax payments by reducing “off the books” employment and reducing barriers to higher paying jobs. However, these impacts are likely dwarfed by the age structure of the immigrant population. That is, encouraging a steady flow of young immigrants would help offset the health care financing challenges resulting from the aging of the US population.

The assumption that immigrants are a net drain on the health care economy has not only been used to argue for stricter limits on immigration, but also to deny access to medical care through government sponsored programs. For example, low-income immigrants who have legally been in the country for less than five years are banned from receiving Medicaid, even as they pay taxes. Many of these low-income immigrants find private insurance unaffordable, remain uninsured, and consequently forgo needed care. The fact that immigrants substantially subsidize the Medicare Trust Fund, which is responsible for 22 percent of all US health care spending, should cause us to rethink the prevailing descriptions of immigrants as net takers of health care resources and should, on grounds of fairness, prompt us to be less quick to deny access to care for immigrants through other public programs.

Leah Zallman, MD, MPH is a Junior Scientist at the Institute for Community Health at the Cambridge Health Alliance and an Instructor of Medicine at the Harvard Medical School.

Danny McCormick, MD, MPH is an Assistant Professor of Medicine at Harvard Medical School, Director of the Division of Social and Community Medicine in the Department of Medicine at the Cambridge Health Alliance, co-director of the Harvard Medical School Fellowship in General Medicine and Primary Care and he leads the Department of Medicine’s general medicine research team.

http://healthaffairs.org/blog/2013/05/29/immigration-reform-and-the-financial-health-of-medicare/?utm_source=rss&utm_medium=rss&utm_campaign=immigration-reform-and-the-financial-health-of-medicare