Summary: The experience of a woman with breast cancer who loses her insurance perfectly illustrates the gaps and harms of our fragmented health insurance system. It’s a heart-rending plea for the US to adopt generous and efficient universal insurance as in wealthy countries around the world.

Medical debt ruined her credit. ‘It’s like you’re being punished for being sick’, NPR Shots, October 6, 2022, by Aneri Pattani

After a year of chemotherapy and radiation, doctors told Penelope Wingard in 2014 that her breast cancer was in remission. She’d been praying for this good news. But it also meant she no longer qualified for a program in North Carolina that offers temporary Medicaid coverage to patients undergoing active breast cancer treatment.

Wingard became uninsured. She’d survived the medical toll, but the financial toll was ongoing.

Bills for follow-up appointments, blood tests and scans quickly piled up. Soon, her oncologist said he wouldn’t see her until she paid down the debt.

“My hair hadn’t even grown back from chemo,” Wingard says, “and I couldn’t see my oncologist.”

Medical debt has sunk her credit score so low that she has struggled to qualify for loans, and applying for jobs and apartments has become a harrowing experience.

“It’s like you’re being punished for being sick,” Wingard says. …

Under the new [medical debt] policies, Equifax, Experian and TransUnion will remove from credit reports any paid debts or individual bills that were less than $500 and had gone to collections, even if unpaid. This doesn’t wipe out what people owe, but the idea is to remove the black mark of collections from their credit so they can more easily reach milestones like qualifying for a car or home loan ….

“Although the credit reporting companies have trumpeted this as a big change, the fact is they’re just removing the small stuff,” says Ryan Sandler, a senior economist with the Consumer Financial Protection Bureau. “They’re not maybe doing as good of a thing as their press releases would like you to believe.”

Wingard has worked as an after-school teacher and tutor, a COVID-19 contact tracer and a driver for a ride-hailing service, but none of those jobs has come with health insurance benefits. Wingard says she tried to buy private insurance on the marketplace several years ago, but her monthly premium would have been more than $200, which she can’t afford.

That left her on the hook for bill after bill after bill. Her credit report shows five pages of notifications from collection agencies representing doctor’s offices, hospitals and labs.

Nearly 20% with medical debt fear they’ll never pay it off.

Comment:

By Jim Kahn, M.D., M.P.H.

“It’s like you’re being punished for being sick.” I can’t get that thought out of my head.

When, when, when will our policymakers embrace the experience of dozens of countries around the world with universal insurance that doesn’t penalize people for getting sick? And that saves money in the process?

How much evidence do we need to collectively say, “American values” is no excuse for a fragmented, inequitable, punitive, harmful, and wasteful financing system?

When will we become sane and kind about how we pay for health care?

http://healthjusticemonitor.org…

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Summary: A commentary by researchers highlights inequalities in the financing of hospitals: those serving mainly Black patients have substantially lower capital investment and payment levels. This is structural racism, reflecting a long history of discriminatory programs and policies.

Hospital financing in black and white, STAT News, September 20, 2022, by Gracie Himmelstein, Joniqua Ceasar, and Kathryn E.W. Himmelstein

During our training as doctors, we have rotated through safety-net hospitals, elite academic medical centers, and private clinics. The resources for patient care and comfort were sumptuous in some facilities, spartan in others. The differences were often night and day or, as we quantified in a later analysis, black and white: we cared for far more white patients at highly resourced facilities and many more Black patients and other patients of color at those with fewer resources.

While the 1964 Civil Rights Act forbade hospitals from discriminating based on race, segregation persists. According to Medicare data we analyzed, a relative handful of hospitals — just 10% of all hospitals — provide three-quarters of all care for Black people covered by Medicare.

We found that in hospital care, as in public education, separate usually means unequal. The hospitals in which Black people account for a large share of inpatients have relatively meager facilities — as measured by the dollar value of the buildings and equipment — and are much less likely than other hospitals to offer expensive, high-tech, and often life-saving services like cardiac catheterization labs, or even routine ones like cardiac rehab programs. The term “structural racism” seems particularly apt for these systematic inequalities in hospitals’ bricks, mortar, and equipment.

Race-based inequities in hospital resources are the legacy of slavery, discrimination, and health care financing policies that directed resources to white communities and away from communities of color. The current-day hospital payment system continues to cement these inequities by assigning different dollar values to the care of different patients: lower values for care delivered to people who are uninsured or covered by Medicaid, and higher values to care for the privately insured and patients with Medicare — especially those able to pay deductibles, copayments, and coinsurance.

Black people are more likely to be consigned to the lower-value group. Far more Black people are uninsured or rely on Medicaid than white people, and Black workers are less likely than white workers to have job-based private insurance. Fewer privately insured Black families have the financial assets needed to cover the often substantial out-of-pocket costs of an insured hospital stay. This payment structure incentivizes hospital leaders to favor services and outreach efforts that attract lucrative — and predominantly white — patients.

… Hospitals caring for large shares of Black patients were paid $283 less for each day of a patient’s hospital stay compared to other hospitals. As a result, while many hospitals realized profits from their inpatient care, Black-serving facilities ran in the red…

Equalizing funding would have required $14 billion in additional payments to Black-serving hospitals in 2018 (the most recent year for which data were available), or about $25 million per Black-serving hospital. …

That the U.S. hospital payment system values different patients differently — and hence penalizes Black-serving hospitals — is a policy choice, and an unusual one among wealthy nations. In most other wealthy nations, even those like Germany with hundreds of different insurance plans, a single fee schedule applies to all patients. In the U.S., the second-class status of those covered by Medicaid was baked in at the outset when, in the midst of the Civil Rights era, Congress chose to separate coverage for the poor (many of whom were Black) from that of the elderly (most of whom were white). Medicare offered seniors a federal plan modeled on Blue Cross coverage, while Medicaid, passed simultaneously, relegated the poor to a welfare-based program largely controlled, even today, by state governments, some of them explicitly racist.

That the current hospital financing system assigns a lower dollar value to the care and lives of Black patients is a largely hidden but pernicious form of structural racism. Health reforms should equalize payments among patients and hospitals, and repair the damage of past policies by directing investments to resource-starved facilities that have long served Black communities.

Comment:

By Jim Kahn, M.D., M.P.H.

This important commentary by health services researchers highlights how hospitals that serve predominantly Black populations are financially compromised. They have 40% lower investment in facilities and receive 22% lower payments for services than hospitals which serve mainly White populations. This is the inequitable effect of a health care financing mix that systematically underpays for Black patient populations, who are more likely to be covered by Medicaid or uninsured.

For those interested in more technical detail, see the two academic articles: capital assets of $5,197/patient-day at black-serving hospitals, $5,763 at Hispanic-serving hospitals, and $8,325 at other hospitals and mean revenues were $283 lower/patient day and mean profits were $111/patient day lower at Black-serving hospitals.

The authors point out that in Germany, with its many private insurers, a single fee schedule applies to all patients, preventing these kinds of inequities. Other strengths of the German system: the insurers sell a standardized broad benefit plan, with no profit (they can profit from a small market in voluntary supplemental insurance).

In the US, this kind of parity and simplicity would be most easily achieved with a single payer system. Health insurers here would never accept the not-for-profit and one-product constraints applied in Germany.

A final note: It’s wonderful to see this important work from two offspring of legendary single payer advocates and researchers (and HJM bloggers) David Himmelstein and Steffie Woolhandler.

http://healthjusticemonitor.org…

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Summary: The vexing experience of finding health insurance hits the nearly 26-year-olds as they must exit parents’ health plans. Their focused dilemma echoes our collective dilemma: so many insurance options, all of them flawed. What we need is one high quality option: single payer.

For 20-Somethings, a Confusing Rite of Passage: Finding Health Insurance, The New York Times, September 30, 2022, by Isabella Simonetti

Whether they are 25 and about to age out of a parent’s plan or entering the work force for the first time, young Americans are tasked with making crucial decisions about their health care at a time when they may have little understanding of how insurance works.

Depending on the situation, a young adult might weigh these choices: staying on a parent’s plan till 26, joining an employer-sponsored health insurance plan or buying coverage on their state’s marketplace. Someone with an income up to 138 percent of the federal poverty level may even qualify for Medicaid, which offers free or inexpensive health care for low-income Americans, including pregnant women and seniors. The next open enrollment period (the period when you can sign up for coverage) for marketplace plans that comply with the A.C.A. runs from Nov. 1 to Jan. 15, 2023 for most states. Many employers offer open enrollment periods, too, that are typically in the fall, but the timing varies from company to company.

The marketplace plans offer different tiered private insurance options with government subsidies for people whose income falls below a certain threshold. While the service is mainly available through Healthcare.gov, some states, including California and Pennsylvania, operate their own websites. Although the open enrollment period is fixed, those who have experienced a so-called qualifying event, like losing insurance through an employer or being forced off a parent’s insurance after a 26th birthday, have 60 days from that event to enroll in a marketplace plan. If you miss the cutoff, you will have to wait until the next enrollment period, unless there has been a major event like a natural disaster.

For those deciding whether or not to join an employer plan, it is wise to compare its cost and coverage with that of a parent’s plan. If a parent’s plan is cheaper and offers better coverage, asking your parents if they will share the cost with you might be the best solution.

Be careful about taking on the cheapest plan an employer offers, because often that will mean having to pay a higher annual deductible before coverage kicks in.

Among employer plans, there may be the option to choose between a Preferred Provider Organization plan and a Health Maintenance Organization plan. A P.P.O. plan generally is more expensive on a monthly basis but may offer more out-of-network coverage, which could be necessary if you have specific medical needs. An H.M.O., though, is typically less expensive and includes a smaller group of providers.

Comment:

By Don McCanne, M.D.

The 26-year-old seems to have the epitome of American style health care coverage: a conglomeration of market plans, government plans, and government subsidies, with qualifications varying based on personal circumstances. Thus, medical benefits can vary, financial protection can vary, and eligibility for health care professionals and institutions can vary, resulting in unstable care access security and unstable financial security in the face of health care needs. On top of that, the 26-year-old also has an obligation through the tax system to help pay for the health care of others through government programs such as Medicare, Medicaid, the VA, county hospitals and clinics, and so forth.

It seems that the 26-year-old would be much better served by an efficient system that would automatically provide health care whenever needed and that was funded equitably based on ability to pay through progressive taxes. Of course, that would be of benefit not only at 26, but also throughout life as a well-designed single payer program such as Medicare for All.

Instead, we offer the American 26-year-old this highly dysfunctional, expensive hodgepodge of a health care financing that has far worse outcomes than in other wealthy nations. Wouldn’t they prefer care nirvana through single payer?

At 85, with some recent medical setbacks, I’ve been granted a gift of a little extra time, and I’m going to use it to shout to the heavens for a sane, humanitarian health care system for all of us. I am not alone. Remember, the Commonwealth Fund recently noted that a majority of Americans want President Biden and Congress to make health care spending a top priority this year, and many polls show 2/3 support for single payer.

When I was president of PNHP, John Conyers brought us single payer Medicare for All legislation. It would be only a matter of time to move it through the legislative process. What happened? Special interests. And they have continued to prevail ever since. It’s time for Congress respond to the needs of the people instead. It’s time to give citizen action life. Our voices need to finally drown out those of the special interests. To the streets!

http://healthjusticemonitor.org…

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Summary: The 2022 Commonwealth survey of US health insurance tells a dismal story. 43% of adults 19-64 are inadequately insured; 46% report skipping care for financial reasons; and 42% have medical bill problems or debt. Our cobbled-together, profit-driven insurance approach is failing spectacularly and horrendously in its primary mission: providing access to care.

The State of U.S. Health Insurance in 2022 (Findings from the Commonwealth Fund Biennial Health Insurance Survey), The Commonwealth Fund, September 19, 2022, by Sara R. Collins, et al

Highlights

* Forty-three percent of working-age adults were inadequately insured in 2022.

* Twenty-nine percent of people with employer coverage and 44 percent of those with coverage purchased through the individual market and marketplaces were underinsured.

* Forty-six percent of respondents said they had skipped or delayed care because of the cost, and 42 percent said they had problems paying medical bills or were paying off medical debt.

* Half (49%) said they would be unable to pay for an unexpected $1,000 medical bill within 30 days, including 68 percent of adults with low income, 69 percent of Black adults, and 63 percent of Latinx/Hispanic adults.

* Sixty-eight percent of Democrats, 55 percent of Independents, and 46 percent of Republicans said President Biden and Congress should make health care costs a top priority in the coming year.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

We are all too familiar with these statistics demonstrating the inadequacy of our health care coverage in the United States – in spite of having the policy expertise and ample wealth to cover everyone. Indeed, doing so would save us money, by slashing the insane and insanely costly complexity.

Comprehensive health care reform is commonly dismissed because we lack the political support for it. But the survey finds that two-thirds of Democrats, and almost one-half of Republicans, want President Biden and Congress to make health care costs a top priority in the coming year!

With all of our other problems, that kind of support constitutes a mandate! Let’s get on with it!

http://healthjusticemonitor.org…

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Summary: The patients are poor. The hospital chain is not-for-profit. Thus, no question about charging them, they get free care. Nope. Advised by business consultants, they devised a system to aggressively pursue payment. Result: debt, debt collectors, & financial hardship.

Profits over Patients: They Were Entitled to Free Care. Hospitals Hounded Them to Pay. The New York Times, September 24, 2022, by Jessica Silver-Greenberg and Katie Thomas

In 2018, senior executives at one of the country’s largest nonprofit hospital chains, Providence, were frustrated. They were spending hundreds of millions of dollars providing free health care to patients. It was eating into their bottom line.

The executives, led by Providence’s chief financial officer at the time, devised a solution [guided by the consulting firm McKinsey & Co.]: a program called Rev-Up.

Rev-Up provided Providence’s employees with a detailed playbook for wringing money out of patients — even those who were supposed to receive free care because of their low incomes, a New York Times investigation found.

If patients did not pay, Providence sent debt collectors to pursue them.

More than half the nation’s roughly 5,000 hospitals are nonprofits like Providence. They enjoy lucrative tax exemptions; Providence avoids more than $1 billion a year in taxes. In exchange, the Internal Revenue Service requires them to provide services, such as free care for the poor, that benefit the communities in which they operate.

But in recent decades, many of the hospitals have become virtually indistinguishable from for-profit companies, adopting an unrelenting focus on the bottom line and straying from their traditional charitable missions.

Previously, when treating patients who were on Medicaid, Providence eventually waived any outstanding portion of their bill. In 2019, Providence stopped doing that. Medicaid patients were sent to debt collectors instead.

“They just want to make sure that they never come back to that hospital and they tell all their friends never to go back to that hospital,” said Dean A. Zerbe, who investigated nonprofit hospitals when he worked for the Senate Finance Committee under Senator Charles E. Grassley.

Comment:

By Don McCanne, M.D.

Those who believe that charity provided by our nonprofit hospitals is one major reason that we do not need a humanitarian method of funding health care in our nation should read in full this New York Times exposé. It provides a compelling example of how the US health care system places profits – oops since Providence is not-for-profit, “operating margins” and high executive salaries – over patients. As if medical suffering is not enough, we compound that with financial suffering.

The solution is really simple. We can establish a single, efficient, publicly administered fund that pays for all of our health expenses based on medical need. We can fund that pool equitably based on ability to pay through progressive taxes. There would be no need for a hospital administrative staff to sic bill collectors on the indigent nor for any of the other inhumane medical business practices prevalent in our society merely because we have failed to adopt this simple, humanitarian approach:  single payer through an improved version of Medicare that applies to All. It is astonishing that we haven’t adopted it long ago.

http://healthjusticemonitor.org…

Ed note: The NYT just published a second article on the harmful profit-maximizing behavior of not-for-profit hospitals. HJM will return to this topic soon … – JGK

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Summary: A NY Times video op-ed describes how the GOP is taking steps to control the US electoral process at multiple levels, ultimately deciding key elections and thus subverting fair representation. This echoes years of health insurers and other profit-seekers increasingly controlling US healthcare at multiple levels, deciding medical services rules and payments and thus subverting broad access to care.

Inside the Completely Legal G.O.P. Plot to Destroy American Democracy (video), NY Times, September 21, 2022, by Johnny Harris and Michelle Cottle

The Opinion Video film above aims to unpack one of the most dire threats to democracy, which includes a sophisticated plot to control not only who can vote, but which votes get counted.

… Mr. Trump and his Republican enablers have been working to rig future elections to their advantage. (Of course it’s the people shrieking most loudly about fraud that you really need to watch.) The former president has convinced his followers that … the only way to save America is for MAGA patriots to take over the system to ensure that the “right” candidates win going forward. His allies have been busy engineering such a legal takeover, and key pieces of the plan are already in place.

In this short film, we shine a light on those machinations, so that those who care about democracy can act to stop them.

Comment:

By Jim Kahn, M.D., M.P.H. and Kenneth Colón

There’s a jarring parallel between current GOP tactics to control the voting process and longstanding efforts by for-profit health insurers, drug companies, and large provider organizations to control the care process.

As presented vividly by the NY Times video op-ed, the GOP – reacting to adamant but evidence-free claims of vote fraud in the 2020 presidential election – is laying the groundwork for creating such evidence in 2022 and 2024. They’re installing large numbers of Republican voting staff and officials to generate a flood of spurious claims of voting irregularities. This will create delay and doubt, setting the stage for GOP election officials to select (not elect) the winners. Thus, voters are deprived of their voice, and majority rule is overturned. It’s legal so far, but destroys democratic norms in blind pursuit of victory.

Similarly, corporations – leveraging adamant but evidence-free claims that unconstrained utilization drives high health spending – are advancing the role of for-profit models in healthcare. Insurers are the main offenders, pushing up the prevalence of high profit capitation in Medicare and Medicaid. Drug companies, pharmacy-benefit managers, and large provider groups are quite pleased to join in. The corporate players adopt slick business mechanisms throughout, ensuring that big slices of health care money are delivered to shareholders at each step. Tactics include narrow networks, risk adjustment and selection gaming, flawed denials of prior authorizations and bills, secret pricing contracts, and huge deductibles and cost-sharing for beneficiaries. This deprives patients of broad access to care, driving up illness and death rates. It’s legal, but immoral.

Preserving democracy and saving healthcare are linked – elevating fairness and empowerment of the majority over the interests of the few.

http://healthjusticemonitor.org…

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Summary: A study of sarcoma states in the title that “non-private” insurance slows access and worsens outcomes. Except that it turns out “non-private” means uninsured and Medicaid, and “private” includes Medicare. This flawed approach muddles discussion and sends the wrong message.

Patients With Bone Sarcomas of Lower-Extremity and Non-Private Insurance Linked with Higher Amputation Rates, Worse Outcomes, OncLive, September 5, 2022, by Gina Mauro

Amputation is an independent predictor of poor outcomes among patients with high-grade bone sarcoma of lower extremity, and non-private insurance was found to be linked with increased likelihood of amputation and an advanced stage at presentation in this patient population, according to results of a National Cancer Database study that were published in Annals of Surgical Oncology.

Study author R. Lor Randall, MD, who is the David Linn Endowed Chair for Orthopaedic Surgery and professor and chair of the Department of Orthopaedic Surgery, University of California Davis Health, discussed the analysis.

“This is an insightful study in that it shined a light on the fact that patients who are uninsured, or don’t have commercial payers, have a higher predilection for amputation for bone sarcomas around the lower extremity, which basically means that they’re probably getting access to care later than many other patients. This is a new finding, and it is basically saying that those who don’t have the resources and access that many do, or those with third-party payers, are really going to suffer worse outcomes because of that.”

Comment:

By Don McCanne, M.D.

Even the title of the original academic article, “Non-Private Health Insurance Predicts Advanced Stage at Presentation and Amputation in Lower Extremity High Grade Bone Sarcoma: A National Cancer Database Study,” suggests that insurance coverage must be private if we are to achieve timely access to care for urgent medical problems.

But this really reflects the incorrect definition of “non-private health insurance” in the original research. “Patients with no insurance and on Medicaid, and patients on Medicare and with private insurance were grouped together. This was done as patients presenting with no insurance to a healthcare facility are enrolled in Medicaid.”

Thus “privately insured” actually includes Medicare whereas “non-private” encompasses just uninsured and Medicaid patients – whom we already knew face significant barriers to care. (Their press release referred to Medicare as a non-commercial contract, further confusing matters.)

It is unfortunate that the authors framed this study as an inferiority of public versus private insurance. The real problem is not the lack of private insurance, it is rather the lack of universal timely access that a well-designed and well-managed public single payer could bring to all of us. The misleading methods and title used by the UC Davis team suggests that we still have ground to cover in disseminating the basics of health policy justice.

http://healthjusticemonitor.org…

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Summary: A representative multi-year survey of US adults found medical debt in 18% of households, with higher risk for those with no insurance, high deductible private insurance, or Medicare Advantage. Medical debt worsened social determinants of health: more food insecurity, inability to pay for housing and utilities, and eviction or foreclosure.

Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US, JAMA Network Open, September 16, 2022, by David Himmelstein, et al.

From the Abstract:

Among 51 872 adults surveyed regarding 2017, 40 784 regarding 2018 and 43 220 regarding 2019, … 10.8% (95% CI, 10.6-11.0) of individuals and approximately 18.1% of households carried medical debt. Persons with low and middle incomes had similar rates; 15.3% (95% CI,14.4-16.2) of uninsured persons had debt, as did 10.5% (95% CI, 10.2-18.8) of the privately-insured. In 2018 the mean medical debt was $21 687/debtor (median $2000 [IQR, $597-$5000]) … hospitalization, disability, and having private high-deductible, Medicare Advantage, or no coverage were risk factors associated with medical indebtedness …

Acquiring medical debt between 2017 and 2019 was a risk factor associated with worsening social determinants of health, with odds ratios (ORs) of 2.20 (95% CI,1.58-3.05) for becoming food insecure; 2.29 (95% CI, 1.73-3.03) for losing ability to pay rent or mortgage; 2.37 (95% CI, 1.75-3.23) for losing ability to pay utilities; and 2.95 (95% CI, 1.38-6.31) for eviction or foreclosure in 2019.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

A raft of previous studies have established that each year millions of Americans suffer catastrophic financial harm from medical debt, and it’s no surprise that people needing hospitalization, the uninsured, and those with disabilities are at highest risk.  So what’s new here? (Disclosure: we’re study authors)

Two findings stand out.  Individuals with Medicare Advantage coverage are, like the uninsured, at high risk of running up medical debts.  And second, that incurring medical debts causes housing and food insecurity – key social determinants of health.

Health system leaders and policy wonks often point to poor housing and nutrition as root causes of ill health, and they’re right.  But they conveniently avoid noting that the health care system itself is a big contributor to housing problems and food insecurity.  As we note in this article, “Unaffordable medical bills … contribute to a downward spiral of ill-health and financial precarity.”

Practicing medicine in American is akin to bailing a boat as the ship’s owners – i.e. the people who make health policy and run our medical institutions – continually drill holes in the hull.

Our patients desperately need national health insurance.

http://healthjusticemonitor.org…

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