PNHP

Gettysburg panel discusses pros and cons of Pa. single-payer health care

Gettysburg panel discusses pros and cons of Pa. single-payer health care

A proposed system would give coverage to all.

By JACQUELINE PALOCHKO
The Evening Sun (Hanover, Pa.), Oct. 6, 2011

A few years ago, Dr. Dwight Michael would have said he was not in favor of a universal health care system in Pennsylvania.

He believed, like many of colleagues, that a person has the right to choose their health care provider. But the Gettysburg physician said his views changed after he saw so many of his patients face the “unfairness” of the system – especially during the economic downturn when so many lost their jobs and had no health insurance.

“We’re lead to believe that we have a great system in this country,” Michael said. “But we don’t.”

Opponents and supporters of health care reform attended a public meeting Thursday night in Gettysburg to discuss a single-payer system that would give universal coverage to all in Pennsylvania. With nearly every seat taken in a lecture room at Lutheran Theological Seminary, the panel included Michael, Dave Steil, president of the group Health Care 4 All Pennsylvania and state Rep. Dan Moul, R-Conewago Township.

A bill introduced in the state’s House and Senate in July 2009, would establish a system that is publicly funded but privately administered – similar to how Medicare works. Under the proposed system, individuals would be taxed 3 percent of their income, and businesses would be taxed 10 percent of their payroll.

Steil’s group is working to support the single-payer health care bill – known as the Family and Business Health Security Act. While no state has yet passed a single-payer health care bill, 26 do have proposals like the one in Pennsylvania.

“We cannot have a system that leaves people behind,” Steil said while talking about today’s health care problems.

And the proposed health care system would not leave anyone behind, Steil said. Even those who have no income at all and cannot be taxed would still receive health care. Or say a Pennsylvania resident is attending college out of state, Steil added – that individual would still receive care in the college’s state.

Moul, on the other hand, said the proposed system would take away a person’s right to choose what health care services they want. Additionally, the lawmaker said, he won’t support anything until he knows if it would be successful. Moul suggested an unbiased group conduct a study to see how well such a system would work in Pennsylvania.

Moul stressed that he was not expert on health care, but said he believes that if a child is sneezing and the parents bring the youngster to a doctor, taxpayers shouldn’t have to pay for that appointment.

“People who truly need health care will get it,” he said.

“It’s too bad Moul still looks at it like that,” Alan Olson, of Carroll Valley, said of Moul’s view on the proposed system.

Olson, a supporter of the single-payer health care bill, said he attended Thursday’s meeting because he’s very concerned about health care.

But even though Moul was on opposite sides with Michael and Steil, all three panelists did agree on one aspect.

“Our health care system is broken,” Moul acknowledged.

http://www.eveningsun.com/ci_19059408

Corporate control of drug pricing and distribution

Walgreen battle over drug prices will limit consumer choice

By David Lazarus
Los Angeles Times, October 7, 2011

Beginning Jan. 1, Walgreens will no longer fill prescriptions for Anthem Blue Cross members, meaning that they’ll have to switch to another drugstore if they want their insurance to keep covering their meds.

In this case, though, it’s not the insurance giant calling the shots. Instead, it’s Anthem’s pharmacy benefit manager, a St. Louis company called Express Scripts Inc.

The dispute between Walgreens and Express Scripts highlights how consumers can find their healthcare choices limited by the money-minded business decisions of big corporations.

(Express Scripts) is spending about $29 billion to acquire rival Medco Health Solutions Inc. If the deal passes regulatory muster, it would give Express Scripts control over about a third of the market for pharmacy benefits. Nearly 4 billion prescriptions are dispensed in the U.S. annually.

Obviously steps should be taken to keep medical costs down. Both Express Scripts and Walgreen say that’s what they’re trying to do.

But it’s hard not to think all we’re really seeing here is two large, profit-hungry corporate behemoths fighting over as much of our healthcare dollars as they can get their hands on.

Inevitably, prices will go up for consumers and choices will be further limited.

http://www.latimes.com/business/la-fi-lazarus-20111007,0,2128189,full.column

Congress turned the Medicare prescription business over to private pharmacy benefit managers under the fiction that they would increase choices and reduce costs. What did we get? Reduced choices in drugs covered, reduced choices in pharmacies, and prices much higher than the government obtains for the Medicaid and the VA drug programs. It’s only going to get worse, unless we finally decide that we’re ready to take over the financing of health care in America by establishing our own public insurance program.

IOM's disturbing report on "essential health benefits"

Essential Health Benefits: Balancing Coverage and Cost

Institute of Medicine
October 6, 2011

Abstract

The principle intent of the Patient Protection and Affordable Care Act (ACA) is to enable previously uninsured Americans to obtain health insurance. To accomplish this, in part, subsidized plans will be offered to low- and moderate-income individuals and small employers through health insurance exchanges. Plans qualified to be offered through exchanges must at minimum include “essential health benefits” (EHB). The ACA is not very specific on the definition of EHB except that such benefits shall include at least ten enumerated general categories and that the scope of the EHB shall be equal to the scope of benefits provided under a typical employer plan. The ACA requires the Secretary of the Department of Health and Human Services to define the essential health benefits.

The Institute of Medicine (IOM) was asked by the Secretary to make recommendations on the methods for determining and updating the essential health benefits. Notably, the request was to focus on criteria and policy foundations for the determination of the EHB, not to develop the list of benefits. The IOM formed a committee of volunteers with varied perspectives and professional backgrounds; the committee held four face-to-face meetings and numerous conference calls. Broad public input was obtained. In two open workshops, the committee heard from more than 50 witnesses, and 345 comments were received in response to questions posted on the web. The consensus report then underwent rigorous external review in accordance with procedures established by the Report Review Committee of the National Research Council.

As the committee examined its charge, it saw two main questions for the Secretary: (1) how to determine the initial EHB package and (2) how to update the EHB package.

Defining the initial EHB package. In considering how to determine the initial EHB package, the committee was struck by two compelling facts: (1) if the purpose of ACA was to provide access to health insurance coverage, that coverage had to be affordable; and (2) the more expansive the benefit package was, the more it was likely to cost and the less affordable it would be. How to balance the competing goals of comprehensiveness of coverage and affordability was key.

The committee concluded that it was best to begin simply by defining the EHB package as reflecting the scope and design of packages offered by small employers today, modified to include the ten required categories. This package would then be assessed by criteria and a defined cost target recommended by the committee. The committee considered how four policy domains – economics, ethics, population-based health, and evidence-based practice – could guide the Secretary in determining the EHB package in general. From these policy foundations, the committee recommends: criteria to guide the aggregate EHB package; criteria to guide specific EHB inclusions and exclusions; and criteria to guide methods for defining and updating the EHB.

To ensure affordability and protect the intent of the ACA, the committee concluded that costs must be considered both in the determination of the initial EHB package and in its updating. Thus, the cost of the initial EHB package resulting from the previous steps should be compared to a premium target defined by the committee as what small employers would have paid, on average, in 2014. Committee members believe that absent a premium target, there would be no capacity to acknowledge the realities of limited resources and the ongoing need for affordability of the package. The EHB package should be modified as necessary to meet this estimated premium, including using a structured public deliberative process. In addition, the committee recommends that states operating their own exchanges be able to design a variant of the EHB package if certain standards are met.

Updating the EHB package. Both medical science and our understanding of how best to design insurance products will change over time. Thus, the committee recommends creating a framework and infrastructure for collecting data and analyzing implementation of the initial EHB; a National Benefits Advisory Council is recommended to give the Secretary advice on the research plan and on updates to the EHB package. The committee believes that the EHB package should become more fully evidence-based, specific, and value-based over time. In addition, as with the initial package, costs must be taken into account such that any service added to the package should be offset by savings, through either medical management or the elimination of inappropriate or outmoded services.

Finally, the committee noted that even with the use of a premium target, the affordability of the EHB package is threatened by rising medical costs in the United States overall and recommends that the Secretary, in collaboration with others, develop a strategy to reduce health care spending growth across all sectors.

http://iom.edu/Reports/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost.aspx

And from the IOM Report Brief:

One way to think about the EHB package is to compare HHS’s task to going grocery shopping. One option is to go shopping, fill up your cart with the groceries you want, and then find out what it costs. The other option is to walk into store with a firm idea of what you can spend and to fill the cart carefully, with only enough food to fit within your budget. The committee recommends that HHS take the latter approach to developing the EHB package and to keep in mind what small employers and their employees can afford. Employers who offer insurance packages make such choices now.

http://iom.edu/~/media/Files/Report%20Files/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost/essentialhealthbenefitsreportbrief.pdf

Comment: 

By Don McCanne, MD

From the start of the reform process it was understood that defining which essential benefits should be covered by the exchange plans would be controversial. What is no surprise is that, just as the process of writing the Affordable Care Act (ACA) was guided by the private insurance industry, this recommendation for establishing a process for determining essential benefits has the private insurance industry’s fingerprints all over it.

When ACA was developed, the large group employer health plans were functioning fairly well, so it was decided to include policies that would encourage the continuation of these plans. It was the market of small group and individual plans that was not functioning well. Benefits were quite skimpy, and underwriting practices prevented many from obtaining coverage in this market. Thus it was decided to establish state health insurance exchanges in which a market of better regulated and more standardized insurance products would be available.

When the Institute of Medicine tried to balance the essential health benefits package (EHB) with affordability what did they choose? They decided that affordability must come first, and then benefits selected to match the affordable premiums.

Wait a minute! What is being made affordable? Health care or health plans? Skimpy benefits equate with unaffordable health care since much of health care has to be paid out-of-pocket simply because it is not part of the benefit package. By establishing the current benefits of existing small group plans as the standard essential benefits in the plans offered by the exchanges, the IOM has made a deliberate choice of making private health insurance pro
ducts affordable at the cost of making health care itself unaffordable for those purchasing their plans in the exchanges.

This is precisely what the private insurance industry wanted when it came to defining the essential health benefit packages. By making the austere small business packages the new standard, the insurers could keep their premiums low enough to ensure that they still had a market for their products. The insurers could care less what happens to patients when they actually need care, as long as their own market is protected.

It isn’t the insurers’ problem now since they have the prestigious Institute of Medicine telling the nation that we can’t have more than skimpy, spartan health care unless we are willing and able to pay for it out-of-pocket. Since most middle-income families can’t, they’ll just have to do without.

(Single payer systems do not cut benefits. They control spending through administrative efficiencies, global budgeting, price negotiations, elimination of coverage for detrimental services, and by planning and separate budgeting of capital expenditures.)

The Occupy Wall Street movement and single payer

By Katie Robbins

I am writing this on the bus to Washington, D.C., for the launch of the October 2011 movement. The past few weeks have been exhilarating to watch the growing Occupy Demonstrations gain momentum with increased solidarity from labor, faith groups, peace and justice organizations, and of course the health justice community.

Some people have been asking about how to engage with the Occupy Wall Street solidarity actions around the country, particularly around health care. I will share our experience in New York City.

The Occupy Wall Street Demo at Zuccotti Park is happening across the street from the offices of WellPoint, the largest health insurance company in the U.S. Two years ago, we held a sit-in at the offices of WellPoint to protest the obscene profits and patient abuse, while pointing to the need for single-payer health care.

Healthcare-NOW! NYC members have been petitioning, leafleting, and talking to human beings about single-payer health care regularly. The response has been excitement about our positive message and how to improve our society in a just and equitable way. People approach us to talk about our signs that say “Medicare for All” and “Health Care is a Human Right.”

Last night, a contingent of single-payer health care supporters joined 20,000 New Yorkers in a solidarity march with the Occupy Wall Street demonstration. [PNHP note: a 1-minute video showing the participation of physicians in yesterday’s action is available here, courtesy of Dr. SteveB at Daily Kos.] Some of the Wall Street demonstrators then made it to our public forum on single-payer health care at Church of the Ascension on the Upper West Side.

You don’t have to participate in civil disobedience to join the Occupy Demonstrations or sleep outside. You do have a responsibility to educate and share information about the movement for health justice and talk to people about how the health crisis affects them and their families.

You might consider bringing food, clothes, and card board for signs for those who are sustaining this peaceful occupation.

Together, we can show solidarity and create the kind of movement to meet the needs of the 99 percent, including winning a just and equitable health care system. Let me know if you’d like to talk about any other ideas to link up single-payer health care advocacy and #OccupyTogether actions. There are 503 cities participating in this movement as of right now. Find an event near you here: http://www.occupytogether.org/

Katie Robbins is national organizer for Healthcare-NOW! She can be reached at katie@healthcare-now.org.

IOM’s disturbing report on “essential health benefits”

Essential Health Benefits: Balancing Coverage and Cost

Institute of Medicine
October 6, 2011

Abstract

The principle intent of the Patient Protection and Affordable Care Act (ACA) is to enable previously uninsured Americans to obtain health insurance. To accomplish this, in part, subsidized plans will be offered to low- and moderate-income individuals and small employers through health insurance exchanges. Plans qualified to be offered through exchanges must at minimum include “essential health benefits” (EHB). The ACA is not very specific on the definition of EHB except that such benefits shall include at least ten enumerated general categories and that the scope of the EHB shall be equal to the scope of benefits provided under a typical employer plan. The ACA requires the Secretary of the Department of Health and Human Services to define the essential health benefits.

The Institute of Medicine (IOM) was asked by the Secretary to make recommendations on the methods for determining and updating the essential health benefits. Notably, the request was to focus on criteria and policy foundations for the determination of the EHB, not to develop the list of benefits. The IOM formed a committee of volunteers with varied perspectives and professional backgrounds; the committee held four face-to-face meetings and numerous conference calls. Broad public input was obtained. In two open workshops, the committee heard from more than 50 witnesses, and 345 comments were received in response to questions posted on the web. The consensus report then underwent rigorous external review in accordance with procedures established by the Report Review Committee of the National Research Council.

As the committee examined its charge, it saw two main questions for the Secretary: (1) how to determine the initial EHB package and (2) how to update the EHB package.

Defining the initial EHB package. In considering how to determine the initial EHB package, the committee was struck by two compelling facts: (1) if the purpose of ACA was to provide access to health insurance coverage, that coverage had to be affordable; and (2) the more expansive the benefit package was, the more it was likely to cost and the less affordable it would be. How to balance the competing goals of comprehensiveness of coverage and affordability was key.

The committee concluded that it was best to begin simply by defining the EHB package as reflecting the scope and design of packages offered by small employers today, modified to include the ten required categories. This package would then be assessed by criteria and a defined cost target recommended by the committee. The committee considered how four policy domains – economics, ethics, population-based health, and evidence-based practice – could guide the Secretary in determining the EHB package in general. From these policy foundations, the committee recommends: criteria to guide the aggregate EHB package; criteria to guide specific EHB inclusions and exclusions; and criteria to guide methods for defining and updating the EHB.

To ensure affordability and protect the intent of the ACA, the committee concluded that costs must be considered both in the determination of the initial EHB package and in its updating. Thus, the cost of the initial EHB package resulting from the previous steps should be compared to a premium target defined by the committee as what small employers would have paid, on average, in 2014. Committee members believe that absent a premium target, there would be no capacity to acknowledge the realities of limited resources and the ongoing need for affordability of the package. The EHB package should be modified as necessary to meet this estimated premium, including using a structured public deliberative process. In addition, the committee recommends that states operating their own exchanges be able to design a variant of the EHB package if certain standards are met.

Updating the EHB package. Both medical science and our understanding of how best to design insurance products will change over time. Thus, the committee recommends creating a framework and infrastructure for collecting data and analyzing implementation of the initial EHB; a National Benefits Advisory Council is recommended to give the Secretary advice on the research plan and on updates to the EHB package. The committee believes that the EHB package should become more fully evidence-based, specific, and value-based over time. In addition, as with the initial package, costs must be taken into account such that any service added to the package should be offset by savings, through either medical management or the elimination of inappropriate or outmoded services.

Finally, the committee noted that even with the use of a premium target, the affordability of the EHB package is threatened by rising medical costs in the United States overall and recommends that the Secretary, in collaboration with others, develop a strategy to reduce health care spending growth across all sectors.

http://iom.edu/Reports/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost.aspx

And from the IOM Report Brief:

One way to think about the EHB package is to compare HHS’s task to going grocery shopping. One option is to go shopping, fill up your cart with the groceries you want, and then find out what it costs. The other option is to walk into store with a firm idea of what you can spend and to fill the cart carefully, with only enough food to fit within your budget. The committee recommends that HHS take the latter approach to developing the EHB package and to keep in mind what small employers and their employees can afford. Employers who offer insurance packages make such choices now.

http://iom.edu/~/media/Files/Report%20Files/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost/essentialhealthbenefitsreportbrief.pdf

From the start of the reform process it was understood that defining which essential benefits should be covered by the exchange plans would be controversial. What is no surprise is that, just as the process of writing the Affordable Care Act (ACA) was guided by the private insurance industry, this recommendation for establishing a process for determining essential benefits has the private insurance industry’s fingerprints all over it.

When ACA was developed, the large group employer health plans were functioning fairly well, so it was decided to include policies that would encourage the continuation of these plans. It was the market of small group and individual plans that was not functioning well. Benefits were quite skimpy, and underwriting practices prevented many from obtaining coverage in this market. Thus it was decided to establish state health insurance exchanges in which a market of better regulated and more standardized insurance products would be available.

When the Institute of Medicine tried to balance the essential health benefits package (EHB) with affordability what did they choose? They decided that affordability must come first, and then benefits selected to match the affordable premiums.

Wait a minute! What is being made affordable? Health care or health plans? Skimpy benefits equate with unaffordable health care since much of health care has to be paid out-of-pocket simply because it is not part of the benefit package. By establishing the current benefits of existing small group plans as the standard essential benefits in the plans offered by the exchanges, the IOM has made a deliberate choice of making private health insurance products affordable at the cost of making health care itself unaffordable for those purchasing their plans in the exchanges.

This is precisely what the private insurance industry wanted when it came to defining the essential health benefit packages. By making the austere small business packages the new standard, the insurers could keep their premiums low enough to ensure that they still had a market for their products. The insurers could care less what happens to patients when they actually need care, as long as their own market is protected.

It isn’t the insurers’ problem now since they have the prestigious Institute of Medicine telling the nation that we can’t have more than skimpy, spartan health care unless we are willing and able to pay for it out-of-pocket. Since most middle-income families can’t, they’ll just have to do without.

(Single payer systems do not cut benefits. They control spending through administrative efficiencies, global budgeting, price negotiations, elimination of coverage for detrimental services, and by planning and separate budgeting of capital expenditures.)

Undocumented immigrants under the Affordable Care Act

Undocumented Immigrants, Left Out Of Health Reform, Likely To Continue To Grow As Share Of The Uninsured

By Stephen Zuckerman, Timothy A. Waidmann and Emily Lawton
Health Affairs, October 2011

The increase in undocumented immigration between 1999 and 2007 contributed to an increase in the number of uninsured people in the United States. During this period, the number of undocumented immigrants increased from an estimated 8.5 million to 11.8 million, leading to an estimated additional 1.8 million uninsured. These uninsured and undocumented immigrants were estimated to represent 27 percent of the overall increase of 6.9 million uninsured people during this period. Undocumented immigrants accounted for one in seven of the uninsured in 2007, up from one in eight in 1999. These undocumented immigrants will not be eligible for public insurance or any type of private coverage obtained through exchanges under the Affordable Care Act of 2010. As a result, members of this group will eventually constitute a larger percentage of the uninsured population, unless other policy actions are taken to provide for their coverage, or their immigration status is changed.

http://content.healthaffairs.org/content/30/10/1997.abstract

Comment:

By Don McCanne, MD

Under a properly designed single payer national health program, the financing of the health care system and the delivery of care are totally separated. Everyone contributes funds to the system based on ability to pay, including undocumented immigrants. Everyone who needs health care receives health care, including undocumented immigrants.

During the national dialogue on health care reform, a vociferous component of our society opposed including health insurance coverage for undocumented immigrants, and Congress complied with their wishes. The reason often given was that they were “illegals” (an unfortunate pejorative term). They committed the crime of coming to this country illegally, so they shouldn’t receive the benefit of health care, so the argument goes.

But is denying health care to those who commit crimes really our national policy? Hardly. Individuals who commit crimes severe enough to result in imprisonment are automatically granted health care. Anyone who shows up at an emergency room in need of urgent care is given that care, regardless of immigration status.

From a practical standpoint, in a microsimulation study that we did as part of the California Health Care Options Project, we showed that, under a single payer model, providing comprehensive care for absolutely everyone, including undocumented immigrants, would actually reduce our total health care spending. All immigrants, documented or not, would participate like everyone else – paying into the system and receiving care when needed.

Regardless of all this, what should be the overriding principle is the concept of social justice, specifically health care justice. No person in the community should be singled out for any reason whatsoever to be excluded from gaining access to the practitioners of the healing arts. A just society would guarantee that access for everyone, regardless of ability to pay or immigration status.

Meet the Bay State’s Uninsured

The national media pass on an important story

By Trudy Lieberman
Columbia Journalism Review, Campaign Desk, Sept. 26, 2011

Last week the Census Bureau released new numbers showing that 5.6 percent of the population in Massachusetts remained without health insurance coverage. That’s a 42 percent drop in the number of the state’s uninsured since the law took effect in 2006. A new study by the Cambridge Health Alliance, one of the state’s safety net providers, showed who was left out, putting a human face on those without insurance. The findings are illuminating given that the Bay State’s health law is the model for the national law, which takes full effect in 2014, and the Romney-Perry feud often flares up around the topic of health reform in the state.

The local press, primarily the Boston Globe and WBUR, covered the story; the national media whiffed on its implications for federal reform. If reform in Massachusetts cut the number of uninsured roughly in half, the same is likely to happen nationally, according to government data. The latest Census Bureau numbers show that nearly fifty million people have no health coverage; the Congressional Budget Office estimates about twenty-three million will be still be uninsured later in the decade. It was as if the national media has forgotten that Massachusetts is a harbinger of what will happen nationally. Or perhaps it’s easier for the national media to cover the he said/he said back and forth between Perry and Romney.

Writing on WBUR’s CommonHealth blog, Carey Goldberg started with an intriguing lead that showed she could sniff out a story — and showed why others should, too: “You figure that when a press release comes in from Physicians for a National Health Program, it has an agenda. But that doesn’t negate the value of the research it highlights—which, in this case, was a paper from Harvard Medical School researchers just out in the Journal of General Internal Medicine.”

Researchers surveyed 431 patients who sought care in the emergency department of the Cambridge Health Alliance and conducted in-person interviews with 189 who were uninsured. Their results show that fragmentation still exists in a system built on employer-sponsored coverage. Gobs of paperwork also still exist, and private insurance remains unaffordable for many — even with government tax subsidies. The key points from the study are these:

• Finding affordable coverage is hard. One-third of the respondents said they were uninsured because they could not buy affordable coverage. Half the sample said that the mandate to buy coverage prompted them to look for insurance, but they couldn’t find any they could afford.

• Two-thirds of the uninsured were working, but only one-quarter of them had employer coverage.

• Some declined employer coverage because of its cost. The state requires an employer to cover only 20 percent of the annual family premium and 33 percent of an individual premium. The authors suggest that if the trend continues that requires employees to pay more out-of-pocket, even fewer employees will take their employers’ coverage.

• One-third of the respondents said they were uninsured because they lost their coverage. People receiving subsidized coverage must re-enroll every year. If they don’t get the paperwork sent in within ten days, they lose coverage.

• Eighty-five percent of the uninsured qualified for state-subsidized insurance, but still one-third were without coverage, suggesting, the authors say, “that for some working poor, even heavily subsidized insurance premiums may be unaffordable.”

• Only about six percent said they were uninsured because they didn’t think they needed coverage; in other words, there were few “free riders.” That’s an important point to remember next time the candidates declare that people like to take risks by being uninsured.

Several months ago, a group called PHI, which works to improve conditions for workers who provide long-term care, released a study that meshes with the Cambridge Health Alliance findings. PHI found that while many employers offered coverage, workers were not taking it. About half of the workers surveyed were not eligible for employer coverage because they worked part time or had to satisfy a waiting period for coverage. About one-third of employers raised the level of cost-sharing for their workers. The media showed little interest in this study as well.

“If you don’t find out what the old polices have done, it’s a prescription for bad policy going forward,” says Steffie Woolhandler, one of the Cambridge study authors. Woolhandler and her colleagues offered suggestions for improvement like increasing employer incentives to cover a greater portion of premium costs, reducing cost-sharing for low-wage workers, and making the enrollment process easier. William Woo, who was the editor of the St. Louis Post Dispatch, once told me there’s a master narrative the press follows. Examining the shortcomings of Massachusetts health reform doesn’t fit the master narrative—at least so far.

http://www.cjr.org/campaign_desk/meet_the_bay_states_uninsured.php

Undocumented immigrants under the Affordable Care Act

Undocumented Immigrants, Left Out Of Health Reform, Likely To Continue To Grow As Share Of The Uninsured

By Stephen Zuckerman, Timothy A. Waidmann and Emily Lawton
Health Affairs, October 2011

The increase in undocumented immigration between 1999 and 2007 contributed to an increase in the number of uninsured people in the United States. During this period, the number of undocumented immigrants increased from an estimated 8.5 million to 11.8 million, leading to an estimated additional 1.8 million uninsured. These uninsured and undocumented immigrants were estimated to represent 27 percent of the overall increase of 6.9 million uninsured people during this period. Undocumented immigrants accounted for one in seven of the uninsured in 2007, up from one in eight in 1999. These undocumented immigrants will not be eligible for public insurance or any type of private coverage obtained through exchanges under the Affordable Care Act of 2010. As a result, members of this group will eventually constitute a larger percentage of the uninsured population, unless other policy actions are taken to provide for their coverage, or their immigration status is changed.

http://content.healthaffairs.org/content/30/10/1997.abstract

Under a properly designed single payer national health program, the financing of the health care system and the delivery of care are totally separated. Everyone contributes funds to the system based on ability to pay, including undocumented immigrants. Everyone who needs health care receives health care, including undocumented immigrants.

During the national dialogue on health care reform, a vociferous component of our society opposed including health insurance coverage for undocumented immigrants, and Congress complied with their wishes. The reason often given was that they were “illegals” (an unfortunate pejorative term). They committed the crime of coming to this country illegally, so they shouldn’t receive the benefit of health care, so the argument goes.

But is denying health care to those who commit crimes really our national policy? Hardly. Individuals who commit crimes severe enough to result in imprisonment are automatically granted health care. Anyone who shows up at an emergency room in need of urgent care is given that care, regardless of immigration status.

From a practical standpoint, in a microsimulation study that we did as part of the California Health Care Options Project, we showed that, under a single payer model, providing comprehensive care for absolutely everyone, including undocumented immigrants, would actually reduce our total health care spending. All immigrants, documented or not, would participate like everyone else – paying into the system and receiving care when needed.

Regardless of all this, what should be the overriding principle is the concept of social justice, specifically health care justice. No person in the community should be singled out for any reason whatsoever to be excluded from gaining access to the practitioners of the healing arts. A just society would guarantee that access for everyone, regardless of ability to pay or immigration status.

Most large health plans fall short on quality

New rankings make choosing health insurance easier

By Steven Findlay
Consumer Reports Health.org, October 4, 2011

When it comes to health insurance, a familiar name and lots of members don’t guarantee quality or customer satisfaction, according to new rankings of health-insurance plans from the National Committee for Quality Assurance that we published today.

Our analysis of the NCQA rankings found that the five largest national insurers—Aetna, Cigna, Humana, Kaiser Permanente, and United Healthcare, plus the mostly state-based Blue Cross Blue Shield plans—account for about 75 percent of the 390 ranked private plans, but only 36 percent of the top 50.

Biggest isn’t best. United is the nation’s largest health-insurance company, but none of its private plans rank among the top 100, and most occupy the bottom half.

http://news.consumerreports.org/health/2011/10/new-rankings-make-choosing-health-insurance-easier.html

NCQA Health Plan Report Card
http://reportcard.ncqa.org/plan/external/plansearch.aspx

Comment: 

By Don McCanne, MD

The big health insurers that are dominating most of the markets fall short on NCQA quality standards, except for Kaiser Permanente. No surprise. What is surprising is that we continue to tolerate this mediocrity merely because an improved Medicare for all is not politically feasible. How about changing the politics?

Most large health plans fall short on quality

New rankings make choosing health insurance easier

By Steven Findlay
Consumer Reports Health.org, October 4, 2011

When it comes to health insurance, a familiar name and lots of members don’t guarantee quality or customer satisfaction, according to new rankings of health-insurance plans from the National Committee for Quality Assurance that we published today.

Our analysis of the NCQA rankings found that the five largest national insurers—Aetna, Cigna, Humana, Kaiser Permanente, and United Healthcare, plus the mostly state-based Blue Cross Blue Shield plans—account for about 75 percent of the 390 ranked private plans, but only 36 percent of the top 50.

Biggest isn’t best. United is the nation’s largest health-insurance company, but none of its private plans rank among the top 100, and most occupy the bottom half.

http://news.consumerreports.org/health/2011/10/new-rankings-make-choosing-health-insurance-easier.html

NCQA Health Plan Report Card
http://reportcard.ncqa.org/plan/external/plansearch.aspx

The big health insurers that are dominating most of the markets fall short on NCQA quality standards, except for Kaiser Permanente. No surprise. What is surprising is that we continue to tolerate this mediocrity merely because an improved Medicare for all is not politically feasible. How about changing the politics?

Medicaid/CHIP patients are shoved out of the office faster

The Effects of Public Health Insurance Expansions

The National Bureau of Economic Research
NBER Digest OnLine, October 2011

In the United States, public health insurance programs cover over 90 million individuals. Changes in the scope of these programs, such as the Medicaid expansions under the recently passed Patient Protection and Affordable Care Act, or in the generosity of these programs, may affect physician behavior.

In “The Doctor Might See You Now: the Supply Side Effects of Public Health Insurance Expansions” (NBER Working Paper No. 17070), Craig Garthwaite finds that after the 1990s implementation of the State Children’s Health Insurance Program (SCHIP) – a partnership between federal and state governments intended to increase insurance coverage for low-income Americans under the age of 19 – more physicians participated in the program, but their total number of hours spent with patients declined as a result of shorter office visits.

Garthwaite finds that there were fewer visits that lasted more than 10 minutes after this public program expansion. The evidence on shorter office visits is consistent with economic models of physician behavior in a system with both public and private payers.

The negative effects of reductions in physician labor supply, such those observed in this study, may be particularly important for Medicaid patients because they are covered by a program that is increasingly not accepted by physicians.

http://www.nber.org/digest/oct11/w17070.html

Comment: 

By Don McCanne, MD

Most of us who support a single payer national health program do so primarily because it would provide high quality, comprehensive care for everyone. Although the Affordable Care Act will not cover everyone, much of the expansion in coverage that it does accomplish is through increased eligibility for the Medicaid and CHIP programs, chronically underfunded welfare programs. This study demonstrates that such an approach does result in a system with at least two tiers, the lower tier patients facing shorter visits and a decline in access to participating physicians.

There is already enough money in our health care system to provide a single level of comprehensive, high quality care for everyone. We should reject the concept of a separate, underfunded, lower tier program for low-income individuals and families, with a higher tier of great care for the rest of us (though the Affordable Care Act certainly doesn’t ensure that either).

The Flaws in the “Affordable” Care Act and How to Remedy Them

By Dr. Paul Clay Sorum
The Journal of County Administration, July/August 2011

The Accountable Care Act (ACA) has many good features (described by Erika Martin and Courtney Burke in the previous issue of the Journal of County Administration) (see also, the Kaiser Family Foundation’s summary).[1] It asserts the principle that everyone should have health insurance and—by expanding access to Medicaid and requiring most people who don’t have public insurance to purchase it (if, as expected, the Supreme Court upholds this provision)— expands access to some sort of health insurance. It tries to prevent the most predatory practices of at least some private insurers. It offers a few, if temporary, plums to primary care providers. It pays for a variety of worthwhile, if limited, experiments in changing how care is paid for and delivered.

But the ACA is hardly revolutionary. The lawmakers chose to fiddle with, prop up, and make additions to an already complicated and tottering structure rather than to tear it down and put its pieces back in a more rational and solid manner. Accordingly, the ACA does not change—indeed it tries to reinforce— the basic structure of US health insurance, with its primary reliance for the non-elderly population on employer provided private health insurance.

The US Census Bureau’s determination of the health insurance coverage of Americans during the year 2009 (i.e., prior to the passage of the ACA) is shown in Table 1.[2] The classification of “no insurance’ meant being without insurance all year; those who were uninsured only part of the year were counted in the insured categories. Note that, since many people’s  coverage changed during the year, the percentages of private insurance, government insurance, and no insurance add up to greater than 100%.

The ACA maintains this reliance on employers and on private insurance: it requires employers with more than 50 employees to offer health insurance, either through private companies or through the new state run insurance exchanges, and the state-run exchanges will also offer to individuals without employer provided or government insurance the choice among a set of private plans. Table 2 shows the estimates by the Urban Institute and Robert Wood Johnson Fund of the changes for the non-elderly population when the law’s provisions about coverage are fully implemented in 2014.[3]
Congress’s decision, for political and ideological reasons, to maintain the fundamental structure of the US health care system is the ACA’s major, perhaps fatal, flaw. It contributes to a multitude of more specific flaws.

Flaws in the ACA

First, the system set up by the ACA is much too complex. Patients (or their employers) and providers will still have to deal with, waste time over, and get frustrated by the dozens of private and public insurers, most with multiple different and ever-changing plans and sets of rules. Medicaid will still be means-tested, i.e. potential enrollees will still have to prove they are poor enough. The new law will add to this complexity by creating the health exchanges, also means tested, which will be allowed to be different in each state (although all will have to fulfill the law’s requirements). It has been calculated that 50% of adults with family incomes below 200% of the federal poverty level will bounce between eligibility for Medicaid or for the exchanges as their incomes fluctuate during the year.[4] The requirement to purchase insurance requires mechanisms, mostly through income tax returns, to find, penalize, or give exemptions to people who fail to purchase health insurance. Furthermore, to compensate for some of its deficiencies, the law had to add a variety of fixes, such as a temporary pool for who are uninsurable because of preexisting conditions, a set of rules to reduce predatory practices by private insurance companies, and a federal watchdog to make sure that states regulate insurance premium increases adequately.[5] Because of this complexity, the law is hard to understand and hard to defend to the public, and, in spite of provisions to get private insurance companies to agree on common rules, it will increase rather than decrease the administrative costs of health care.

Second, change is coming much too slowly. It will take some eight years for the system to be rolled out completely (although most is to be done by the end of 2014).[6] In contrast, Medicare was instituted in less than a year. The reasons for the delay are the complexity of the changes—in particular, the need for each state to set up a health exchange—and the political calculation, I assume, of trying to reduce opposition to change by doing it very slowly (in particular, to spread out the costs of implementation).[ 7] This calculation was, however, short-sighted because of largely foreseeable political and economic events. Midterm elections commonly turn against the party in power, especially when the gain of Democratic seats in the House in 2008 came in usually Republican-voting districts. With the loss of the Democratic majority in the House, the Republican opponents of the reform have the opportunity to delay and derail—by withholding funding if not by repealing— as many of the provisions as possible. If the Republicans have their way, especially if they win the White House too, we may be left with a partial ACA, which may be worse than outright repeal of the whole act. Moreover, with the financial collapse that President Obama inherited and the resulting economic recession— and the ensuing debt crises on the state and federal levels—the state and federal monies, as well as (to a lesser extent) the business profits, required to expand health care are no longer there. The result is continuing pressure to reduce benefits and increase patient financial responsibilities in both tax-supported and employer supported plans—we can see that happening already[8]—and rising opposition to major expansion of health insurance, at least of government- financed insurance.[9]

Third, the ACA will not reduce costs. On the one hand, most of the excess “administrative” costs of the private insurance company—for insurers and for providers (the most recent estimate was just published online in Health Affairs[10]—such as for marketing, submitting and processing claims, obtaining prior approvals for services, and paying shareholders (for for-profit insurers) will persist, even if the law tries to limit them slightly by promoting common insurance forms and requiring “medical loss ratios” (the percentage of premiums spent on actual health care) to be at least 85% for group plans and 80% for individuals. In addition, as mentioned above, the Medicaid program and the state insurance exchanges will still require costly and burdensome means testing, the insurance exchanges will create an additional administrative layer, and the law requiring people to buy insurance will have to be enforced. The Urban Institute estimates that, if the ACA had been fully implemented in 2010, total spending on acute health care for the non-elderly by the government, employers, and individuals would have increased by 4.5%.[3] The Netherlands, which privatized its health care system in 2006 (creating a system similar to that envisioned by the ACA), has found that this “managed competition” is unpopular and has increased costs.[11] On the other hand, the much-ballyhooed experiments in new ways to deliver and pay for medical care—pay-for-performance, medical homes, accountable care organizations, and the like—are still experiments, promising in small projects but untested as ways to reduce costs on a large scale.[12]

The Commonwealth Fund had, in its optimistic assessment of a panoply of similar reform proposals, concluded that, together, they could bend the cost curve, but not prevent costs from rising faster than GDP.[13] Not surprisingly, therefore, the percentage of GDP devoted to
health care is expected to rise from 17.6% in 2009 to 18.1% in 2014 (when the state health exchanges are implemented and residents are required to have health insurance) to 19.8% in 2020.[14] The money to pay for care must come from somewhere. If governments and employers are unwilling to pay more, patients will either have to pay more or do without the medical services they expect. The Affordable Care Act is, therefore, affordable neither for the country nor for the patients.

Fourth, the ACA will not only leave millions still without insurance— the Urban Institute estimates 8.3% of non-elderly adults[3]—but it is likely to increase the number of “under-insured.” In 2007, the Commonwealth Fund estimated that 14% of nonelderly adults were underinsured— defined as spending 10% or more of income (or 5% if their income was less than 200% of the poverty level) on out-of-pocket medical expenses or having deductibles of 5% or more of income[15] (although these estimates may be low).[16] The ACA aims to decrease underinsurance by insisting on a basic set of benefits (yet to be defined) for the state-run health exchanges (in the footsteps of Massachusetts that lowered its underinsurance from 7.3% of adults to 5.6% a year after the enactment of its health reform).[17] Yet, even as envisioned now, these health exchanges will impose a financial burden: if people choose the most affordable bronze plan, its “actuarial value” is only 60%, i.e. the individual will have to pay for 40% of his or her expected health costs (up to, as currently defined, $5,950 for individuals and $11,900 for families), a large burden for a poor person who gets sick or injured. Moreover, faced with rising costs, increasing enrollments in Medicaid and in state insurance exchanges, and—at least until the economy recovers— stagnating business profits and tax revenues, employers and state and federal governments will have no choice but to offer plans with increased premiums and/or reduced benefits[8, 18] (as well as, if possible, with reduced payments to providers). In 2010, the average annual premium for employer-sponsored health insurance was up to $5,049 for single coverage and $13,770 for family coverage (of which the worker contributed $899 and $3997, respectively)[8] and is surely going higher. Faced with the need to keep premiums as affordable as possible in the exchanges, it seems likely that the state directors and ACA federal administrators will be under great pressure to lessen the benefit package required of all insurers participating in the exchanges.

Fifth, access to care may increase on paper, but it is likely, especially for poor people, to decrease in practice. We need to train more physicians to prevent a growing shortage—the Association of American Medical Colleges projects that by 2020 we will have shortage of 45,000 primary care physicians and 46,000 surgeons and medical specialists[19]—and we need current physicians, especially primary care physicians, to see the newly insured patients. For this, we need to offer them sufficient reimbursement. But this is unlikely to occur—indeed, quite the opposite. For Medicaid, payments to physicians are, in states like New York, so low already that private physicians see Medicaid patients largely out of a moral commitment to care for all patients. For Medicare, payments are already less than those from private payers so that some physicians do not accept Medicare and, if Medicare rates drop further (as is threatened yearly by the provisions of the Balanced Budget Act), many more will drop it. Yet state and federal governments are talking about cutting reimbursements to providers—a likely recommendation of the Congressional committee that is to propose further cuts in federal spending to reduce the federal debt— and the ACA sets up a committee that will suggest moneysaving cuts if the Medicare budget increases too fast (as it has done repeatedly in recent years).

How to Remedy the ACA

What can we do to remedy the flaws in the ACA? I see three possibilities. First, the Obama administration can try, through administrative acts and legislation, to make small improvements in the new system and, meanwhile, to wait for better economic and political times. This is the most likely course of action, but it does little to fix the ACA’s flaws.(even if the Republicans allow any improvements). Second, the politicians could scrap the new law and institute a better system, which, as I have argued before in these pages, would be a single-payer system, equivalent to an expanded and improved Medicare for All. The radical Republicans also want, of course, to repeal the law and reduce government’s role to providing vouchers for poor people to use to purchase private health insurance (as in Ryan’s ill-received proposal for privatizing Medicare). Neither the single-payer supporters nor the radical Republicans will be able to repeal the law, both because many of its provisions are already in place and because there is no political majority for either extreme. Third, we can facilitate the changes currently taking place in Vermont and help them spread to other states. This seems currently to be the most promising approach.

Vermont’s recently passed legislation [20] creates a public plan, Green Mountain Care, “to contain costs and to provide, as a public good, comprehensive, affordable, high-quality, publicly financed health care coverage for all Vermont residents in a seamless manner regardless of income, assets, health status, or availability of other health coverage.” Thus all Vermont residents will be eligible for Green Mountain Care “regardless of whether an employer offers health insurance for which they are eligible.” Green Mountain Care will be managed by an independent board, appointed by the governor and approved by Vermont’s Senate, advised by a committee of stakeholders; the board will contract with private-sector organizations, such as Blue Cross and Blue Shield of Vermont, to administer the system. Green Mountain Care will run the health exchange required by the ACA (which will be set up to be its “foundation”); insure state and municipal employees (including teachers); absorb Medicaid, SCHIP, and Medicare as federal waivers become available; and, it is expected, be more cost-effective for private employers to join than the competing private plans. In order to avoid under-insurance, the legislation stipulates that Green Mountain Care will provide all “medically necessary health services”—including primary care, preventive care, chronic care, acute episodic care, and hospital services— and that it will pay for “at least 87 percent of the full actuarial value of the covered health services.”

The architects of the Vermont plan, led by Harvard economist William C Hsiao, needed to convince Vermont interest groups and legislators that the expansion of coverage would not result in increased overall costs. They proposed funding through a payroll tax of 14.2% on all wages, capped at the Social Security level, with exemptions for families with incomes below 200% of poverty level. Employers would pay 10.6% (versus an estimated 12% under the ACA) and employees 3.6%. They concluded that the plan would save money each year of its implementation and after 10 years would be reducing overall health care expenses by 25.3% compared to what spending would be without the reform (7.3% from reduced administrative expenses, 5% from reduced fraud and abuse, 10% from payment reform and integration of the delivery system, 2% from malpractice reform, and 1% from changed governance and claims administration). They also argued that at this point the plan would be cutting employer and household health care spending by $200 million (though employers previously not providing insurance and families earning more than 400% of the poverty level would be paying more than now), would create 3,800 jobs, and would boost the state’s economic output by $100 million.[21]

Vermont’s goal in setting up Green Moun
tain Care was to “provide health benefits through a single payment system.” But the state could not do this immediately, and it is not certain that it will be able to reach its goal. The state must, in accordance with federal statutes, allow individuals or businesses to purchase private health insurance if they want, inside or outside of the exchange (as long as the private plans meet the requirements of the ACA); the assumption is that individuals and businesses will find it in their interests to switch to Green Mountain Care. The state must seek federal waivers to bring Medicare, Medicaid, and SCHIP into Green Mountain Care; these will not be available until 2017 unless Congress passes a law to allow states more flexibility earlier than 2017, and such passage will depend on federal politics and, in particular, on the results of the 2012 and 2014 elections. The Vermont legislature still has to decide on a financing mechanism. But, in spite of these uncertainties, the Vermont law is a momentous first step that shows other states how they too can create the embryo of a single payer system from within the ACA.[21]

County administrators should be excited by the ability of a Green Mountain Care and, moreover, of a complete single-payer system to reduce county taxes, to take over the health insurance of county employees and retirees, to provide health care to all county residents, and even to increase employment. It is time to take action—to support similar health reforms in your states and to lobby Congress for the waivers needed to make these state reforms successful.

References

1. Kaiser Family Foundation. Focus on health reform. Summary of new health reform law, March 26, 2010. Available at http://www.kff.org/healthreform/ upload/8061.pdf. Accessed on July 18, 2011.

2. U.S. Census Bureau. Income, poverty, and health insurance coverage in the United States, 2009. U.S. Government Printing Office, issued September 2010. Available at http://www.census.gov/ prod/2010pubs/p60-238.pdf. Accessed on July 17, 2011.

3. Buettgens M, Garrett B, Holahan J. Americans under the Affordable Care Act. Urban Institute, Robert Wood Johnson Fund, December 2010. Available at http:// www.rwjf.org/files/research/71555.pdf. Accessed on July 9, 2011.

4. Sommers BD, Rosenbaum S. Issues in health reform: how changes in eligibility may move millions back and forth between Medicaid and insurance exchanges. Health Aff 2011;30:228–236.

5. NY Times, July 26, 2011.

6. Kaiser Family Foundation. Health reform implementation timeline. Available at http://healthreform.kff.org/timeline. aspx. Accessed on August 4, 2011.
7. Oberlander J. Beyond repeal—the future of health care reform. N Engl J Med 2010;363:2277–2279.

8. Kaiser Family Foundation. Employer health benefits: 2010 summary of findings. Available at http://ehbs.kff.org. Accessed on July 28, 2011.

9. Newport F. U.S. still split on whether gov’t should ensure healthcare. Gallup Poll, Nov 18, 2010. Available at http://www.gallup.com/poll/144839/Split-Whether- Gov-Ensure-Healthcare.aspx. Accessed on August 4, 2011.

10. Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US physicians practices versus Canadians: Spending nearly four times as much money interacting with payers. Health Aff 2011. Available at http://content.healthaffairs. org/content/early/2011/08/03/ hlthaff.2010.0893.full.pdf+html. Accessed on August 4, 2011.

11. Okma KGH, Marmor TR, Oberlander J. Managed competition for Medicare? Sobering lessons from the Netherlands. N Engl J Med 2011;365:287–289. Available at http://healthpolicyandreform.nejm.org/?p=14712#more-14712. Accessed on July 27, 2011.

12. Oberlander J. Throwing darts: Americans’ elusive search for health care cost control. J Health Politics, Policy and Law, June 2011.

13. Schoen C, Guterman S, Shih A, Lau J, Kasimow S, Gauthier A, Davis K. Bending the curve: options for achieving savings and improving value in U.S. health spending, The Commonwealth Fund, December 18, 2007. Available at http://www.commonwealthfund. org/Content/Publications/Fund-Reports/2007/Dec/Bending-the- Curve–Options-for-Achieving-Savings-and- Improving-Value-in-U-S–Health-Spending. aspx. Accessed on July 30, 2011.

14. Keehan SP, Sisko, AM, Truffer DJ, Poisal JA, Cuckler GA, Madison AJ, Lizonitz JM, Smith SD. National health spending projections through 2020: economic recovery and reform drive faster spending growth. Health Aff 2011;8. Available at http://content.healthaffairs. org/content/early/2011/07/27/ hlthaff.2011.0662.full.pdf+html. Accessed on July 30, 2011.

15. Schoen C, Collins SR, Kriss JL, Doty MM. How many are underinsured? Trends among U.S. adults, 2003 and 2007. Health Aff Web Exclusive, June 10, 2008:w298–w309

16. Abraham JM, DeLeire T, Royalty AB. Moral hazard matters: Measuring relative rates of underinsurance using threshold measures. Health Serv Res 2010;45:806–824.

17. Long SK. The impact of health reform on underinsurance in Massachusetts: Do the insured have adequate protection? The Urban Institute, October 2008.

18. Towers Watson. Shaping health care strategy in a post-reform environment. 16th annual Towers Watson/National Business Group on Health employer survey on purchasing value in health care, 2011. Available at http://www.towerswatson.com/ assets/pdf/3946/TowersWatson-NBGH- 2011-NA-2010-18560-v8.pdf. Accessed on July 27, 2011.

19. Association of American Medical College. Physician shortages to worsen without increases in residency training. Available at https://www.aamc.org/download/150584/ data/physician_shortages_factsheet.pdf. Accessed on August 4, 2011.

20. Vermont legislature, H202, 2011. Available at http://www.leg.state.vt.us/ docs/2012/BILLS/PASSED/H-202.pdf. Accessed on July 30, 2011. 21. Hsaio WC, Knight AD, Kappel S, Done N. What other states can learn from Vermont’s bold experiment embracing a single-payer health care financing system. Health Aff 2011;30:1232–1241.