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By Shannon Muchmore
Modern Healthcare, May 21, 2016

The CEO Power Panel includes 110 top leaders of hospitals, insurance companies, physician groups, trade associations and other not-for-profit advocacy groups. The second-quarter survey on policy options that the next president and Congress might address attracted 86 respondents, a 78% response rate.

Future of ACA

Do you support Congress and the next president in:

Repealing and replacing the Affordable Care Act?

2.3% – Yes
67.4% – No
29.1% – It depends on the details
1.2% – No opinion

Expanding the ACA’s subsidized private insurance plan system to achieve universal coverage?

34.9% – Yes
15.1% – No
48.8% – It depends on the details
1.2% – No opinion

Scrapping private insurance in favor of expanding an enhanced Medicare to cover the entire population (single payer)?

9.3% – Yes
61.6% – No
29.1% – It depends on the details

Other insurance issues

Allowing private insurers to sell individual and family policies across state lines under national rules that preempt state rules?

52.3% – Yes
20.9% – No
24.4% – It depends on the details
2.3% – No opinion

Expanding the use of health savings accounts to pay premiums and meet costs under high-deductible plans?

74.4% – Yes
11.6% – No
12.8% – It depends on the details
1.2% – No opinion

Creating subsidized high-risk pools to cover people with preexisting conditions?

43.0% – Yes
16.3% – No
36.1% – It depends on the details
4.7% – No opinion

Medicare

Raising Medicare eligibility to age 67?

54.7% – Yes
23.3% – No
22.1% – It depends on the details

Expanding means testing within Medicare, such as higher co-pays or reduced benefits for high-income seniors?

50.0% – Yes
18.6% – No
30.2% – It depends on the details
1.2% – No opinion

Moving to a universal Medicare Advantage system with a means-tested defined contribution (premium support) for seniors?

28.2% – Yes
20.0% – No
48.2% – It depends on the details
3.5% – No opinion

Gradually expanding Medicare to cover everyone over age 55 who doesn’t have private insurance?

21.4% – Yes
48.8% – No
28.6% – It depends on the details
1.2% – No opinion

Delivery system reform

Taking aggressive measures to curb rising prescription drug prices such as allowing imports and authorizing the CMS to negotiate prices?

70.6% – Yes
9.4% – No
20.0% – It depends on the details

Repealing delivery system reforms such as value-based payment, accountable care organizations and the use of quality measures included in the Affordable Care Act?

3.5% – Yes
83.5% – No
11.8% – It depends on the details
1.2% – No opinion

http://www.modernhealthcare.com/article/20160521/MAGAZINE/305219938/healthcare-ceos-reject-veering-sharply-from-acas-path

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Comment:

By Don McCanne, M.D.

This poll of selected “top leaders of hospitals, insurance companies, physician groups, trade associations and other not-for-profit advocacy groups” can give us a rough idea of where the executive leadership of the health care industry stands today on health care reform. A few conclusions:

* These CEOs strongly support the Affordable Care Act (ACA). That is not surprising since these vested stakeholders were part of the process that created the legislation..

* They are uncertain on whether or not the private insurance plans should be expanded to achieve universal coverage, although one-third would agree with they should be. The majority may be concerned about the potential of being required to cover care for those with greater health care needs (adverse selection) without being able to transfer risk elsewhere..

* Over 60 percent oppose replacement of private plans with a single payer enhanced Medicare for all and another 30 percent say that it depends on the details. Only 9 percent support single payer outright. This suggests that ACA was indeed designed with these stakeholders in mind, rather than for the patients..

* At least three-fourths support health savings accounts, tacitly supporting high deductible health plans that are a source of financial hardship for far too many individuals who have health care needs..

* At least half support selling insurance across state lines even though that is not practical because of problems such as building new provider networks in other states..

* Close to half support creating subsidized high-risk pools to cover people with preexisting conditions, even though the experience with state high-risk pools has been very disappointing. They are too expensive so benefits have been too meager. Besides they have been unable to cover most eligible individuals in spite of the need..

* Over half support raising Medicare eligibility age to 67, cutting back on coverage when we need to do is increase it instead..

* They would expand means-testing of Medicare, risking support of higher income individuals for the program..

* Somewhat surprisingly there is less support for Medicare vouchers for private plans (premium support), but perhaps that is due to the fact that the premium support strategy is designed to eventually reduce government payments for Medicare. After half of a century, Medicare is here to stay, and the stakeholders do recognize the need for adequate government funds to support the program..

* Only one-fifth support allowing individuals the option of enrolling in Medicare at age 55. Half are clearly opposed. They do not want to displace employer-sponsored plans presumably because they pay higher rates than does Medicare..

* By far the strongest support is for “delivery system reforms such as value-based payment, accountable care organizations and the use of quality measures included in the Affordable Care Act.” Evidence to date with these “value over volume” proposals has been disappointing, demonstrating little savings and negligible impact on quality. One possible reason they may be popular for CEOs is that their companies have learned to game the system to collect the rewards offered by these programs.

It is likely that most of these CEOs are relatively conservative politically since they predominantly support policies advanced by the “repeal and replace” Republicans, even though they do support ACA. They also strongly oppose Medicare for all single payer in spite of it being supported by a majority of Americans. Some of the policies they support would make access and affordability worse for patients, yet these policies can be self-serving for their own entities.

This survey of health industry CEOs leads me to the conclusion that the wrong people were sitting at the table when ACA was designed. For our redo, we need people at the table who represent patients rather than the health industries. A system that takes care of patients automatically takes care of legitimate stakeholders, but the reverse has not been true. It’s time to change. Single payer.

Response to Criticisms of Our Analysis of the Sanders Health Care Reform Plan

By Linda J. Blumberg, John Holahan, Lisa Clemans-Cope, Matthew Buettgens
Urban Institute, May 18, 2016

Abstract

The Sanders campaign and David Himmelstein and Steffie Woolhandler reacted with sharp criticisms to our recent report, The Sanders Single-Payer Health Care Plan: The Effect on National Health Expenditures and Federal and Private Spending. In this brief, we discuss our key assumptions in these areas of disagreement and highlight ways in which we may have actually underestimated overall costs of the Sanders proposal. By and large our assumptions are laid out thoroughly in the original paper, but here we use them to address the specific statements made by the campaign.

Conclusion

All cost estimates of new programs carry some uncertainty, but ours are based in the best empirical literature and data, methodological expertise, and a deep knowledge of the health care system. We believe we have made conservative assumptions with regard to this proposed plan, but it is possible we have somewhat overestimated administrative costs and underestimated long-term care and assorted other costs; we acknowledge this, of course. However, using reasoned analysis based upon empirical research and in-depth knowledge of the US health care system, there is no way to avoid the conclusion that the Sanders plan, while achieving universal coverage, would massively increase federal spending and require much larger tax increases than he has proposed.

http://www.urban.org/research/publication/response-criticisms-our-analysis-sanders-health-care-reform-plan

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Doubling Down on Errors: Urban Institute Defends Its Ridiculously High Single Payer Cost Estimates

By Steffie Woolhandler and David Himmelstein
The Huffington Post, May 22, 2016

Last week we posted a critique of the Urban Institute’s (UI) absurdly biased report that claimed Sen. Bernie Sanders’ proposal for single-payer health reform would cause a massive increase in health spending. Now, the report’s authors have issued a 12-page rejoinder to our criticism. But that response is riddled with distortions, misinterpretations and glaring factual errors. Moreover, they now make it clear that they didn’t even try to estimate the costs of Sanders’ (or our) single-payer proposals. Instead, they made up their own reform proposal and costed that out.

Our critique identified three main problems with the UI’s projection that implementing single payer would boost total health spending by $519 billion in 2017. First, UI ignored about 75 percent of the administrative savings that single-payer reform would achieve. Second, it substantially underestimated single payer’s savings on prescription drugs. And finally, it posited an absurdly large increase in the utilization of health care under single payer, far more than could possibly be provided by the current supply of doctors and hospitals.

Below, we briefly discuss the UI’s response to those criticisms, and the facts of the matter.

1. Administrative savings, Part 1: The original UI report projected that single payer could cut insurance overhead from the current 9.5 percent of health spending ($341 billion) to 6 percent ($215 billion). As they now admit, they were modeling a compromised single-payer system, in which private managed care insurers like UnitedHealthcare would continue to play a major role, as they do in the Medicare Advantage program. (Neither we nor Sanders have suggested such a continued role for private insurers.) We pointed out that Canada’s single-payer system runs for 1.8 percent overhead (a figure they impugn, but which is taken directly from Canada’s official health statistics), and is similar to the overhead in the traditional Medicare program. Reducing our insurance overhead to the Canadian level would mean cutting it to “only” $65 billion. There’s no reason to believe we can’t be as efficient as Canada if we, like Canada, proscribe participation by private insurers.

The UI rejoinder argues that “it would be inadvisable to cut administrative costs so much that important functions could not be carried out effectively under a new system. Such functions include rate setting for many different providers of different types facing different costs across the country; quality control over care provision; development, review, and revision of regulations; oversight for fraudulent activity; provider oversight and enforcement of standards; bill payment to providers; consumer services; and more.” Of course traditional Medicare (and Canada) are already doing all of those things, and the UI response gives no reason why $65 billion can’t do the job.

2. Administrative savings, Part 2: The original UI estimate projected that single-payer reform wouldn’t realize any savings on the vast amounts hospitals and doctors currently spend on billing and paperwork. Yet, Sanders’ (and our) proposals would enormously simplify this billing and paperwork. We noted that reliable studies published in the most respected medical and policy journals have documented these provider administrative savings, and that numerous single-payer estimates by the Congressional Budget Office, the Government Accountability Office and private consultants have all assumed that these savings would occur.

In response, our UI colleagues continue to project zero administrative savings for providers, but say: “We agree that administrative costs would fall, but we do not agree they would be close to zero as HW [Himmelstein and Woolhandler] assert.” Actually, we never asserted any such thing. We wrote that “U.S. hospitals spend one-quarter of their total budgets on billing and administration, more than twice as much as hospitals spend in single-payer systems like Canada’s or Scotland’s. Similarly, U.S. physicians, who must bill hundreds of different insurance plans with varying payment and coverage rules, spend two to three times as much as our Canadian colleagues on billing.” Our estimate that cutting U.S. providers’ administrative costs to Canadian levels would save about $2.57 trillion over 10 years was based on this well-established (and peer-reviewed) data.

3. Drug prices: The latest UI piece restated their conviction that a U.S. single-payer system could get only half the discounts that single-payer systems in other nations have gotten from drug companies (and would actually raise drug prices for patients currently on Medicaid). They continue to offer no reason why the discounts would be so small. Moreover, they now claim that Himmelstein and Woolhandler “argue incorrectly that we ignored savings from paying less for prescription drugs.” In fact we didn’t ignore their estimated savings, but said they should be two-fold higher than the 25 percent they projected.

4. Utilization of care, Part 1: The original UI report estimated that single-payer reform would cause a $519 billion increase in health spending in 2017, even accounting for some savings on administration and drugs. But we noted that there just aren’t enough hospital beds or doctors to meet the huge surge in visits and hospitalizations they predict. To back up our claim we cited data from Canada (when its single-payer reform was implemented) and the U.S. (when Medicare and Medicaid were implemented). These data document that no, or very modest increases in society-wide use of care, occurred, and that instead care shifted from the rich and healthy to the sick and poor.

In response, the UI rejoinder says: “Contrary to HW’s [Himmelstein and Woolhandler’s] claim in their article, health care use and spending for the elderly population did increase substantially once the Medicare program was implemented in 1965.” Here (as in their claim about our statement on providers’ administrative costs) they have misquoted us. We wrote that “between 1964 (before Medicare) and 1966 (the year when Medicare was fully functioning) there was absolutely no increase in the total number of doctor visits,” and that “the same thing happened in hospitals.” While we are well aware that utilization by the elderly and the poor went up after Medicare and Medicaid were implemented, the point is that there was a compensatory, slight reduction in utilization by other Americans, reflecting the limitations imposed by the existing supply of hospital beds and doctors (most of whom were already working full time).

Here’s the actual data on the number of doctor visits per person (not just the elderly) before and after Medicare/Medicaid:

(Table in original article – link below)

And here’s the actual data on the total number of hospitalizations:

(Table in orignal article – link below)

In sum, we were correct in stating that the overall utilization of care showed no surge.

5. Utilization of care, Part 2: We noted in our critique that the lack of a surge in overall utilization in Canada, or with the start-up of Medicare/Medicaid, reflected a shift of care, with the newly insured poor and sick patients getting more of the care they needed, and the healthy and wealthy getting less elective and unnecessary care.

The UI rejoinder disputes that such a shift could occur. “HW [Himmelstein and Woolhandler] indicate that use would increase for the newly insured but would decrease by a similar amount for those already covered as physicians cease unnecessary services for those otherwise covered and perform additional necessary care for those otherwise uninsured. This assumption is faulty for two major reasons. First, no uniform definition of what is necessary and unnecessary exists in medical care; if such a definition existed, insurers would stop paying for all unnecessary care under our current health system. Second, there is absolutely no reason to believe that higher-income, currently insured individuals would lower their use of care under provider supply constraints.”

Their puzzlement displays a lack of familiarity with the considerable literature on variability in the utilization of care between different areas in the U.S., as well as the actual practice of medicine. John Wennberg and colleagues long ago observed that the number of surgical operations in a community showed only modest correlation with needs of the population, but was strongly correlated (r=.64) with the supply of surgeons.

As any doctor knows, doctors play a large role in regulating the amount of care they deliver. If we have no free appointment slots for the next month we’re likely to put off seeing our healthy patients a bit longer. Gastroenterologists often perform unnecessary screening colonoscopies. That’s not something many patients would demand. Indeed, the Aday paper referenced (to support a different point) in the UI rejoinder makes exactly our point: “After Medicare and Medicaid were introduced, providers may have begun to ration the number of visits by the ‘well-to-do’ to accommodate the influx of low-income patients with newly acquired purchasing power and a backlog of unmet need.”

In sum, there’s considerable evidence that doctor routinely adjust the utilization of care by their patients, and that when many additional people gain coverage, doctors shift care to this newly insured group, and compensate by reducing unneeded care for the wealthy and healthy.

6. What system was the UI analyzing? The UI researchers claimed to be estimating the budgetary impact of Sen. Sanders’ proposal. Yet now they tell us, “To be politically acceptable, compromises would have to be made, and those compromises are reflected in our assumptions.” In other words, their estimates are not actually based on the reform that Sanders (or we) have recommended. Instead they assume that the insurance and drug companies are too powerful to really rein in.

Overall, the UI response misrepresents key elements of our critique, and fails to address the erroneous assumptions that underlay their original analysis. Single-payer systems elsewhere provide more and better care at a lower price than we pay. The administrative bloat of our market-driven payment system accounts for much of the difference. While we recognize that a transition to a true single-payer system faces stiff political headwinds, it’s medically and economically feasible. And as Sen. Sanders has shown, political climates can be changed.

Drs. Woolhandler and Himmelstein are internists in the South Bronx, professors at the City University of New York School of Public Health at Hunter College, and lecturers in medicine at Harvard Medical School. The opinions expressed do not necessarily reflect those institutions’.

http://www.huffingtonpost.com/steffie-woolhandler/urban-institute-errors-single-payer-costs_b_10100836.html

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Comment:

By Don McCanne, M.D.

The media continue to cite the flawed Urban Institute analysis of the costs of single payer while ignoring the actual facts as presented by David Himmelstein and Steffie Woolhandler. Yet the Urban Institute authors twice have felt compelled to answer the Himmelstein/Woolhandler criticism of their analysis. Woolhandler and Himmelstein respond here to Urban’s doubling down of errors in their second response.

The fundamental fact remains: “Single-payer systems elsewhere provide more and better care at a lower price than we pay.” The $3 trillion we are already spending on health care is enough to finance a comprehensive single-payer system here in the United States.

Shifting more health care spending to the federal budget is not a flaw of single payer, as Urban implies, but actually a benefit because it makes the funding more equitable and efficient.

We need to hold the media to the truth – the full truth.

Survey of Non-Group Health Insurance Enrollees, Wave 3

By Liz Hamel, Jamie Firth, Larry Levitt, Gary Claxton, and Mollyann Brodie
Kaiser Family Foundation, May 20, 2016

This survey is the third in a series that seeks to shed light on the experiences and opinions of those purchasing their own health insurance in the non-group market.

A somewhat higher share of non-group enrollees now report being in plans with high deductibles than did so in 2015. In the current survey, about half (49 percent) of those with ACA-compliant non-group coverage say their plan has an annual individual deductible of at least $1,500 or a family deductible of at least $3,000, up from just over a third (36 percent) last year. Those with Marketplace plans are somewhat less likely to report having a high deductible (46 percent, compared with 61 percent of those in ACA-compliant non-Marketplace plans), likely because many Marketplace enrollees qualify for cost-sharing subsidies that lower their deductible.

Health plan ratings and satisfaction with coverage

Similar to the trend in overall plan ratings, the current survey finds those with ACA-compliant non-group plans are less likely than in previous years to say their coverage is an “excellent” or “good” value for what they pay for it. Just over half (54 percent) now rate the value of their coverage as “only fair” or “poor” (up from 42 percent in 2015 and 39 percent in 2014). Those with employer-sponsored coverage, who generally pay a lower portion of their premium, are more likely than those with non-group coverage to see their plan as at least a “good” value for the money, but the share of this group saying the value is “only fair” or “poor” has also increased, from 28 percent in 2014 to 40 percent in 2016.

A majority of enrollees also say they are satisfied with their plan’s premium (54 percent of all those in ACA-compliant plans and 59 percent of those in Marketplace plans), and about half say the same about their deductible (50 percent of ACA-compliant enrollees and 51 percent of Marketplace enrollees). However, satisfaction with premiums and deductibles has declined since 2014. Nearly half now say they are dissatisfied with their plan’s annual deductible (47 percent among all those ACA-compliant plans and 46 percent in Marketplace plans), and four in ten are dissatisfied with their monthly premium (43 percent and 40 percent, respectively).

Each of these trends toward more negative ratings of non-group coverage may be related to the fact that more enrollees now report being in high-deductible plans (as noted above, 49 percent of those with ACA-compliant plans now have a high-deductible plan, up from 36 percent in 2015). The latest survey finds that those with high-deductible plans give their coverage lower ratings overall and are less likely than their counterparts in lower-deductible plans to say they are satisfied not only with their deductible, but also with their copays and premiums.

Financial protection of health insurance

About half (51 percent) of non-group enrollees with ACA-compliant plans say they feel well-protected by their health insurance; however, the share saying they feel vulnerable to high medical bills has risen over the past two years, from 36 percent in 2014 to 45 percent in the current survey. Again, it’s notable that while those with employer coverage are more likely than non-group enrollees with ACA-compliant plans to say they feel well-protected, this group has also seen a similar increase in the share saying they feel vulnerable (from 26 percent in 2014 to 36 percent today).

Half (50 percent) of those with ACA-compliant plans say it is difficult for them to afford the out-of-pocket health care costs not covered by insurance, and a similar share (46 percent) say it’s difficult to afford their monthly premiums (nearly identical to the 45 percent who said so in 2014). A similar percentage (51 percent) says it is difficult for them to afford paying off debt, while a much larger share (71 percent) reports difficulty saving money for retirement, education, and other purposes. Ranking lower in terms of difficulty, a third (33 percent) say they find it difficult to afford basic necessities like food, housing, and utilities.

Not surprisingly, those whose plans have higher deductibles are more likely than those with lower deductibles to say it is difficult for them to afford their out-of-pocket health care costs (58 percent versus 43 percent). This is despite the fact that those with high-deductible plans report higher incomes on average than those whose plans have lower deductibles.

Plan utilization and reported problems

Among those who’ve had ACA-compliant non-group coverage for at least a year, many report having problems with their plans. Most commonly, just over a third (36 percent) say their plan paid less than they expected for a bill, about a quarter (26 percent) say their plan wouldn’t cover or required a very expensive copay for a drug prescribed by their doctor, one in five (21 percent) say they were surprised to find their plan wouldn’t pay anything for care they thought was covered, and a similar share (20 percent) say that a particular doctor they wanted to see wasn’t covered by their plan.

Those who are heavier utilizers of health insurance are more likely than their counterparts to report some of these problems, including their plan paying less than they expected for a bill (47 percent versus 31 percent), their plan not covering a prescription or requiring a very expensive copay (37 percent versus 20 percent). Heavy utilizers are also more likely to report problems paying medical bills in the past 12 months (31 percent versus 16 percent).

In addition to problems with their plans, one in five (20 percent) of those who’ve had ACA-compliant coverage for at least a year say there was a time in the last 12 months when they or another family member covered by their plan needed medical care but did not get it because of the cost. Nearly as many (16 percent) say there was a time in the past year when they did not fill a prescription because of the cost.

Opinions of the Affordable Care Act among those with non-group coverage

As in previous waves of the survey, and as is true among the general population, overall views of the Affordable Care Act among those with non-group coverage are largely divided, with 46 percent saying they have a favorable view of the law and 48 percent unfavorable. Even among this population – whose views one might expect to be divided more on the basis of experience – the biggest differences in opinion are along partisan lines, with 75 percent of Democrats having a favorable view of the law, 79 percent of Republicans expressing an unfavorable view, and independents divided (40 percent favorable, 44 percent unfavorable).

Similar to last year, the largest divide in how people feel the law has impacted them is partisan, with Democrats overwhelmingly feeling they’ve benefited and Republicans overwhelmingly feeling they’ve been negatively affected.

From the Discussion

The share of enrollees who see their plan as a good value has been declining, reflecting growing dissatisfaction with premiums and cost-sharing. Some enrollees who have had their plan for a year or more report expensive drug copays, as well as surprise medical bills and other unexpected expenses they thought their plan covered.

http://kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-3/

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Comment:

By Don McCanne, M.D.

Today’s report confirms the growing dissatisfaction with higher premiums and greater cost-sharing of not only ACA-compliant non-group plans but also employer-sponsored group plans as well. The share saying that they feel vulnerable to high medical bills has increased to 45 percent for non-group enrollees and 36 percent for those with employer coverage.

One of the most important functions of health insurance is to provide financial security in the face on medical need. In spite of the Affordable Care Act, that security is deteriorating.

The burden of insurance premiums could be greatly reduced by financing the system through equitable taxes based on the ability to pay. The burden of cost sharing could be greatly reduced by adopting a philosophy of pre-paid health care which has worked well in certain integrated health systems and in the health financing systems of many other nations.

Instead of erecting financial barriers to care, cost containment can be achieved through patient-friendly policies characteristic of a well designed single payer system. Let’s change direction.