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Medicare for everyone

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Medicare for everyone

By Harriette Nye Seiler
The Courier-Journal (Louisville, Ky.), Letters, Nov. 20, 2014

Most Kentuckians are pleased that health care coverage has been expanded in our state, but there are questions to be considered.

Are the managed care organizations (MCOs) that oversee Medicaid providing quality treatment and follow-up — including prescribed medications for the mentally ill? MCOs profit by reducing costs and, bluntly stated, cost-cutting strategies often involve cutting care.

Persons who bought private plans (gold, silver, etc.) on the Kynect exchange last year must now re-enroll for 2015. Before buying, enrollees should read the policy carefully: Can you see your preferred doctor? How narrow is the hospital network? How high is the deductible? If you had to pay out of your own pocket for treatment, would that keep you from going for help when you have worrisome symptoms? If you have a chronic disease, check the drug formularies: Is your medication listed? Has the co-pay gone up?

As we ponder all these critical issues, the people in other advanced nations are happily going about their day because their leaders had sense enough to implement a single-payer system —- saving money for their country and for each individual. Instead of all the political and judicial machinations now going on across the U.S., let’s just tell Congress to pass HR 676. Simply improve traditional Medicare and give it to everybody!

Harriette Nye Seiler resides in Louisville.

http://www.courier-journal.com/story/opinion/readers/2014/11/20/letters-affordable-care-act/19324019/

Medicaid improving access for the homeless, but…

Early Impacts of the Medicaid Expansion for the Homeless Population

By Barbara DiPietro, Samantha Artiga and Alexandra Gates
Kaiser Family Foundation, November 13, 2014

The Affordable Care Act (ACA) Medicaid expansion offers a significant opportunity to increase coverage and improve access to care for individuals experiencing homelessness, who historically have had high uninsured rates and often have multiple, complex physical and mental health needs.

*  The Medicaid expansion has led to significant increases in coverage that are contributing to improved access to care and broader benefits for homeless individuals. Providers reported that these coverage gains have enabled patients to access many services that they could not obtain while uninsured, including some life-saving or life-changing surgeries or treatments. Participants also identified other broader benefits for homeless individuals stemming from Medicaid coverage gains. For example, providers noted improvements in individuals’ ability to work and maintain stable housing due to better management of health conditions. In addition, participants said individuals have reduced financial stress and improved access to other services and programs, including disability benefits.

*  Providers reported having access to a broader array of treatment options as a result of Medicaid coverage gains among their patients. With these increased options, providers said they are better able to provide care based on the best courses of treatment rather than based on the availability of charity or discounted resources.

*  Gains in Medicaid revenue are facilitating strategic and operational improvements focused on quality, care coordination, and information technology. In addition, administrators indicated that Medicaid revenue gains supported staff increases and led to changing staff roles to meet increased administrative and billing needs. However, participants emphasized that, even with Medicaid revenue gains, other funding sources remain vital for supporting the full range of services needed by the homeless population.

*  Participants from the non-expansion site (Florida – did not expand Medicaid) indicated that their patients remain uninsured and are continuing to face significant gaps in care that contribute to poor health outcomes. Participants also said they are facing an increasingly challenging financial situation because they are missing out on Medicaid expansion revenue gains and other funding sources are declining.

*  As homeless patients gain Medicaid coverage and are enrolled in managed care, some challenges are emerging. Participants commented that some patients are being auto-assigned to providers with whom they do not have an existing relationship and/or they may have difficulty accessing due to lack of transportation. Additionally, working within provider networks can be difficult given the complex needs of individuals, lack of transportation, and the limited experience among other providers in serving this population. Lastly, participants emphasized that prior authorization requirements and limited and/or changing drug formularies are leading to delays in care for individuals and creating substantial administrative burdens for providers.

http://kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/

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Comment:

By Don McCanne, MD

The experience of the homeless population under the Affordable Care Act (ACA) demonstrates both the benefits of reform under ACA and the flaws of ACA that call for replacement with a single payer system. ACA was better than nothing, but we can have so much more through enactment of a single payer system.

The primary ACA benefit for the homeless is that most of them in expansion states qualify for Medicaid and thus have improved access to health care without financial barriers. Some of the homeless who access health care have been noted to have an increased ability to work and to maintain stable housing. Financial stress is reduced and some have gained access to appropriate disability benefits. These benefits to the homeless are more reasons why calls for simple repeal of ACA are bad policy, devoid of compassion.

Yet the last paragraph from the excerpts above explains why Medicaid managed care is often a poor choice for the homeless (and many other lower-income individuals as well). Homeless patients often are unable to see the health care professionals who would be most accessible and appropriate for them. Transportation concerns are more likely. Essential specialized services may not be available. Managed care intrusions such as prior authorization requirements, limitations and changes in formularies, or other perverse managed care innovations may impair access to important health care services or products. Further, those states that refuse to expand Medicaid are leaving most of the homeless without any coverage and therefore reliant on often inadequately funded safety-net institutions.

There are those who believe that we should merely proceed with implementation of ACA and try to obtain legislative and administrative patches along the way. Compared to the deficiencies in our dysfunctional system, patches have only minimal beneficial impact while increasing the administrative complexity that already overburdens our system. Patches fall way too short of what we need.

We should not repeal ACA since it does provide some temporary benefit until we can implement a single payer system. But we should not let ACA implementation divert us from instituting what we really need – a single payer national health program. Not only would that benefit the homeless, it would benefit all of the rest of us as well.

Actually, health insurance premiums are rising more slowly

Health care and insurance costs are, however, still rising and need work. Let’s just make sure we consider all the facts.

By Dimitri Drekonja, M.D.
Star Tribune (Minneapolis), Nov. 20, 2014

In “Gruber’s gaffes show why MNsure was sure to fail” (Nov. 20), Sen. David Hann, R-Eden Prairie, asked for “every well-intentioned voice to be heard” and urged that we “take a hard look at the facts.” Good advice, which I’ll try to follow.

Hann cites the Kaiser Family Foundation as his source that health insurance premiums are increasing by 20 percent in the last year. On the face of it, this seems noncontroversial. Kaiser is a well-respected nonpartisan organization that many rely on as a source of high-quality analysis of health policy, and an annual increase of 20 percent seems high.

However, I happened to be catching up on my journal reading last night, and a recent issue of the Journal of the American Medical Association (JAMA) had an update on health insurance costs, provided by Kaiser. For those wanting to see it, it is freely available at the JAMA website (http://jama.jamanetwork.com/article.aspx?articleid=1930824).

The report tracked increases in health insurance premiums over three five-year periods (1999-2004, 2004-2009 and 2009-2014). For the last five years, the increase in premiums agrees with Hann’s number: 26 percent. However, what Hann chose to leave out is that from 1999-2004, premiums rose 72 percent, and from 2004-2009, the increase was 34 percent.

So over the last 15 years, the lowest increases in health insurance costs came during the period in which the Affordable Care Act (ACA) began to be implemented.

This is one of the good things about the ACA — costs have not risen as fast as during the pre-ACA period. The other good thing is that more people have health insurance.

However, there are indeed problems with the ACA. An improvement from the pre-ACA days was easy — costs were rising rapidly and the number of uninsured was far too high. The downsides are that we still have millions of people uninsured and that the cost of insurance still is rising faster than both overall inflation and workers’ earnings (from 2009-2014, when premiums rose by 26 percent, overall inflation and workers earnings both rose 11 percent). This pattern is ultimately unsustainable.

Responding to Hann’s call for facts, here is another: the United States spends close to 20 percent of its gross domestic national product on health care; the next closest countries are France, Germany, Switzerland and Canada — all hovering just below 12 percent and all of which are able to provide universal health care coverage for their citizens.

If Hann is indeed interested in these facts and wanting “every idea to be considered,” here is a suggestion: Just down the road is the University of Minnesota, an institution with the resources and expertise to study different ways of providing health care for all Minnesotans. Give researchers the task of assessing the pros and cons of various ways to pay for health care. They could consider a single-payer system like Canada’s; a system that includes private insurers, like Germany’s; the current status quo with the ACA, or some proposal put forward by Hann and his colleagues (if he has such a plan, I am unaware of it).

Let each proposal undergo rigorous analysis by experts in the field, and share the results publicly.

Studying what someone (like Prof. Jonathan Gruber) said three years ago about how a piece of legislation passed is not terribly high on my priority list; studying how to achieve a cost-effective way to provide health care to all Minnesotans is.

Hopefully, this is a goal shared by Hann, and he will indeed look at all the facts.

Dimitri Drekonja is a staff physician, infectious diseases, with the Minneapolis VA Health Care System, an assistant professor of medicine at the University of Minnesota Medical School and a board member of the Minnesota chapter of Physicians for a National Health Program. The views expressed here are solely his own.

http://www.startribune.com/opinion/commentaries/283424521.html

Medicare for all would be affordable

By Stan Gutelius, M.D.
Auburn (N.Y.) Citizen, Letters, Nov. 20, 2014

Good news! Now that we are in that time of year when you should be comparing your medical insurance policy with other possible policies, I can offer you the one you have been looking for.

It is offered by a company that has been in business for 49 years. Once you have it, it is yours forever. It is not related to your employment or the state of your health. It pays for 80 percent of the covered services. (That’s the GOLD level). You can’t go “out of network” because there are no networks. You can see any physician or go to any hospital you desire.

The premium is $104.90 per month. The deductible for physician’s visits is $147 per year. The hospital deductible is $1,260 for the first 60 days.

Signup is simple. You don’t need to go to an Exchange. Just present your birth certificate dated prior to November 17, 1949 and you’re in. What’s that? You don’t have such a birth certificate? Oops! Sorry. I can’t sign you up for this policy.

Why can’t I sign you up? That’s a very good question to ask your elected representatives in Washington. They are responsible for the disaster we refer to as the “Affordable Care Act.” Everyone in the country should have access to the policy I describe above. No need for networks, exchanges, or sky high out of pocket expenses.

What? Oh, sorry. I forgot to mention that the “company” is the U.S. government and the policy is Medicare. You might like to suggest to your congressional representatives that “Medicare-for–All” would be a really good idea.

Dr. Stan Gutelius resides in Auburn.

http://auburnpub.com/news/opinion/mailbag/letter-medicare-for-all-would-be-affordable/article_8ceb6431-bddc-523c-b004-4b0d0f7faa33.html

How ACA fuels corporatization of American health care

By Philip Caper, M.D.
Bangor (Maine) Daily News, Nov. 20, 2014

A new Harvard study has found that Americans’ trust in the medical profession has dropped dramatically in recent years and lags behind that in many other wealthy countries. At the same time, doctors are becoming increasingly unhappy with our profession. In his new memoir, “ Doctored,” Dr. Sandeep Jauhar eloquently explains why: More and more doctors are coming to view our profession as just another job.

We now have a situation where patients are losing confidence in their doctors, while doctors are losing confidence in our ability to do the right thing for our patients. We have a health care system becoming more hostile to doctors and patients and more friendly to health care corporations.

These trends are collateral damage caused by another trend: our increasingly corporatized, commodified and commercialized U.S. health care “industry” that is being put into hyper drive by the Affordable Care Act. The ACA is accelerating an ongoing wave of hospital consolidations and acquisition of doctors’ practices by large corporations, such as Eastern Maine Healthcare Systems and MaineHealth.

As we continue down this road, doctors see our clinical autonomy disappearing as more and more of us become corporate employees subject to pressure to meet corporate financial goals that often differ from what is best for our patients. Patients sense that pressure as they are rushed through exams and are subject to more tests and procedures, some of them of questionable clinical value. They can almost hear the cash registers ringing as they move through their doctors’ offices, as more wealth is transferred from patients to those selling health care goods and services.

Why is American medicine, once the crown jewel of American professionalism and a proud and respected calling, becoming just another commercial enterprise? In his 2010 book “ Hijacked,” Dr. John Geyman, chairman emeritus of the department of family practice at the University of Washington, explains how during the year-long Congressional debate leading up to enactment of the ACA, the interests of the public, including doctors and patients, were subverted to those of large health care corporations.

The highjacking of health care reform is paying off handsomely. Robert Pear of the New York Times recently described how the federal government and the commercial health insurance industry have morphed into one big fan club for the ACA. He quotes the libertarian Cato Institute’s Michael Cannon explaining that since the ACA’s enactment, “Insurers and the government have developed a symbiotic relationship, nurtured by tens of billions of dollars that flow from the federal Treasury to insurers each year.”

Pear goes on to report that, “Since Mr. Obama signed the law, share prices for four of the major insurance companies — Aetna, Cigna, Humana and UnitedHealth — have more than doubled, while the Standard & Poor’s 500-stock index has increased about 70 percent.”

Pharmaceutical companies also have done very well. The ACA contains no authority for the government to negotiate pharmaceutical prices but continues the federal prohibition on the importation by U.S. residents of lower priced prescription drugs from many foreign countries.

This situation won’t change anytime soon. Congress is gridlocked. What is widely recognized as a drafting error in the ACA — which, in saner times, could have been fixed quickly without attracting much attention — is now headed to the Supreme Court.

Of course, health care is just one of many examples in which the welfare of corporations has been put ahead of the interests of the public, but it may be the poster child. Health care is now more than a sixth of our economy, and human lives and dollars are at stake.

Corporate stranglehold of our public policy traces back to the increasingly corrupt way our political campaigns are financed. The recent midterm elections were a stark reminder of that, setting record levels for corporate spending, even on local races, and saturating voters with negative, intrusive and often obnoxious messages.

What’s at stake is the future of health care and many other issues that will determine what kind of a country our children will live in. That future depends on how active and informed the public is willing to become in electing public officials who place the welfare of their constituents ahead of the wishes of their corporate contributors.

The results of the recent elections are not encouraging. But what’s becoming clearer is that our struggle is not between Democrats and Republicans, liberals and conservatives, or occupiers and tea partiers. It is between real American people and corporations.

I, for one, intend to continue pointing that out. That’s where our attention should be focused.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com or through his website at philcaper.net.

http://bangordailynews.com/2014/11/20/health/blogs-and-columns/how-aca-fuels-corporatization-of-american-health-care/print/

International comparison of patients over 65 – impact of Medicare

International Survey Of Older Adults Finds Shortcomings In Access, Coordination, And Patient-Centered Care

By Robin Osborn, Donald Moulds, David Squires, Michelle M. Doty and Chloe Anderson
Health Affairs, November 2014 (online)

Abstract

Industrialized nations face the common challenge of caring for aging populations, with rising rates of chronic disease and disability. Our 2014 computer-assisted telephone survey of the health and care experiences among 15,617 adults age sixty-five or older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States has found that US older adults were sicker than their counterparts abroad. Out-of-pocket expenses posed greater problems in the United States than elsewhere. Accessing primary care and avoiding the emergency department tended to be more difficult in the United States, Canada, and Sweden than in other surveyed countries. One-fifth or more of older adults reported receiving uncoordinated care in all countries except France. US respondents were among the most likely to have discussed health-promoting behaviors with a clinician, to have a chronic care plan tailored to their daily life, and to have engaged in end-of-life care planning. Finally, in half of the countries, one-fifth or more of chronically ill adults were caregivers themselves.

Comparative US Performance And Challenges Going Forward

Despite having Medicare coverage, older US adults remained much more likely to face financial barriers to care than their counterparts in other developed countries. This may be surprising, as other studies have found that Medicare offers more stable and protective insurance than other forms of coverage in the United States, including employer-sponsored private coverage. However, it is still clearly less protective than the universal coverage offered in the health systems of other countries surveyed. This finding likely reflects limitations in Medicare coverage, including substantial deductibles and copayments, especially for pharmaceuticals, which are often more expensive in the United States than elsewhere. The absence of limitations on catastrophic expenses and long-term care coverage likely play a role as well.

Financial barriers aside, elderly Americans also face comparatively poor access to primary care and after-hours care, relatively high dependence on the ED, and large gaps in care coordination. Yet the survey also captures areas where the experience of US older adults is favorable. Both comparatively and objectively, Americans reported good access to specialists. The US health care system also performed relatively well when it came to hospital discharge planning and on the more patient-centered measures of health promotion, self-management support for chronically ill patients, and support for end-of-life planning.

Finally, the US elderly population is sicker than the comparable population in other surveyed nations, reporting a much higher incidence of chronic disease. This higher disease burden will pose critical challenges for US policy makers in years to come. The United States already significantly outspends all of the other countries in the survey—often by a two-to-one margin—despite having the youngest population. Although the growth in health care costs has slowed in recent years in all of these countries, these considerations suggest that the United States will face growing cost pressures. It will be hard to maintain the current low-growth trajectory unless the United States successfully implements delivery and payment system reforms that reduce the cost of care and finds a way to narrow the health gap between itself and other countries.

http://content.healthaffairs.org/content/early/2014/11/13/hlthaff.2014.0947.abstract

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Richard Gottfried, Chair, Committee on Health, New York State Assembly, made the following observation: “The lesson:  Living 65 years with American insurance companies leaves you sicker. Then, transitioning to American social insurance gives you quicker access to specialists.”

(Personal communication, 11/19/14)

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U.S. Seniors’ Health Poorest, Global Survey Shows

By Steven Reinberg
HealthDay, November 19, 2014

Dr. Steffie Woolhandler, co-founder of Physicians for a National Health Program, said American seniors are sicker because of the inadequate care they received before they turned 65.

“The health care system for the under-65 population is full of gaps, and lots of people fall through the cracks,” she said.

Woolhandler, who is also a professor of health at CUNY School of Public Health at Hunter College in New York City, added that Medicare is also leaving many Americans underinsured and that the Affordable Care Act will not make a major difference.

“We need to be providing much more comprehensive coverage to everyone, including lower co-pays and deductibles,” she suggested.

http://consumer.healthday.com/senior-citizen-information-31/senior-citizen-news-778/u-s-seniors-health-poorest-global-survey-shows-693917.html

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Comment:

By Don McCanne, MD

This international comparison of health care in older adults in eleven nations is the latest in the series sponsored by the Commonwealth Fund. For the United States, it is unique in that it compares only patients over 65 in our public Medicare program with older patients in other nations that already have universal health care systems.

Perhaps the most remarkable finding for the United States is that patients enter the Medicare program sicker than older patients in other nations, but, once there, they have better access to health care than those younger than 65. But even our Medicare program leaves our elderly exposed to greater financial barriers to care than do the systems of other nations.

This study once again shows what the United States needs is obvious. We need to improve Medicare so that it provides better coverage, and then we need to expand it to cover everyone.

Disdainful Economists, Hubristic Jurists, and Fanatical Republicans: A Recipe for Single-Payer Health Care?

By Neil H. Buchanan
Verdict, Justicia.com, Nov. 20, 2014

The two most recent attempts to reform the American health care system, in the early 1990s and early in this decade, were notable for what the would-be reformers refused even to consider: single-payer health care. Although nearly every major nation in the world uses a version of the single-payer system—and, as I will discuss below, even though the U.S. itself has had great success with a partial single-payer plan—both the Clinton and Obama Administrations ruled out universal single-payer reform even as one of the possible options.

Self-styled realists claimed in both instances that the political obstacles blocking adoption of a single-payer plan were insurmountable—so why even try? Defenders of President Obama’s approach noted that his advisors were worried that proposing anything like single-payer would brand the Administration as being too extreme, and that this would lead to huge losses in Congress for the Administration, and perhaps even the loss of Democratic majorities in both the House and Senate. We all know how that worked out for the Democrats, as former Speaker of the House Nancy Pelosi and soon-to-be Minority Leader Harry Reid sit dazed in their smaller offices.

Even that explanation, however, assumes that the Clinton and Obama Administrations were reluctantly trimming their sails, settling for less than they truly wanted. That could be true, I suppose, but there is an even stronger case—based on the totality of the economic policies that both presidents have enthusiastically embraced—that neither president was ever all that interested in seriously challenging the status quo.

The Affordable Care Act (ACA) is actually working rather well, given that it is by design a wasteful system that continues to pump profits into the bank accounts of unnecessary intermediaries. On the substance of what is included in the ACA—no more denials of coverage for preexisting medical conditions, more choices for many consumers, affordable coverage even for people who move between jobs, and millions of previously uninsured people now receiving coverage—Americans genuinely like the law. Even rising Senate Majority Leader Mitch McConnell, in what by the end was a very easy reelection campaign, refused to admit that he would take away the Kentucky version of the ACA, even as he promised to try to repeal the whole law nationwide.

No matter whether it is a marriage of convenience or a matter of deeper ideological commitments, the Obama Administration now finds itself in the position of having the health insurance industry as its greatest (only?) ally. Indeed, it seems that the rest of the political world is aligned to bring an end to “Obamacare.” An economist who advised the Administration has become the unintentional star of videos in which he disparaged voters’ intelligence. The Supreme Court is poised potentially to drive a stake into the heart of the ACA. And the rabid anti-Obama activists in the Republican Party continue to push for the ACA’s repeal.

The interesting question is what comes next, if the ACA fails or is killed. Republicans have never provided a meaningful alternative, and they dare not repeal the more popular parts of the law (including, in addition to the features noted above, the inclusion of children through age 26 on their parents’ policies). Moreover, the more Republicans attack the government for its supposed incompetence in running the ACA, the more we could reach the paradoxical moment where the public rallies behind the ultimate government solution that is single-payer health care.

How to Understand the Now-Infamous Remarks of One Unfortunate Economist: Both Liberal and Conservative Economists Think They Are Smarter Than Everyone Else

Much of the anti-ACA political landscape is by now utterly familiar. We have seen years of posturing by Republicans at all levels of government, dozens of pointless votes in the U.S. House of Representatives to repeal the law, and a razor-thin loss for repeal advocates in the Supreme Court in 2012. All of this makes the ACA a sore spot, and a focus of rage, for the Republican base. Even so, little new has come along to change the political landscape, until this week.

Now, the MIT economist Jonathan Gruber is at the center of a controversy over arrogant and disdainful remarks that he made at some policy/academic forums over the last few years. In particular, Gruber referred blithely to the “stupidity of the American voter” in explaining why he thought the law was written in less-than-clear ways.

Even a political opposition that was not as extreme as today’s Republican party would understandably respond to such comments with glee. Professor Gruber sounds, after all, more than “a bit dickish,” as Jon Stewart put it on his late-night show recently. If the Obama people relied on Gruber, as they clearly did, in setting up the law, then the President’s opponents would be crazy not to make political hay.

The problem is that people are misunderstanding what was at work in Professor Gruber’s comments. Republicans and their allies want to paint this as a case of “liberal condescension,” where the supposedly smug do-gooders in the Obama Administration are caught showing that they have no respect for “real Americans.” But that is most definitely not what was happening.

I am an economist, and I have spent large amounts of time with other economists. The one unimpeachable fact about economists of all political stripes is that they think that non-economists are stupid. (Indeed, one of the reasons that I now teach in a law school is that I found this mindset among economists to be so unfortunate—and unwarranted.) Economists are trained to think that only they can see through the silly nonsense of politicians, lawyers, pundits, and regular people—people who are too dense to understand that wage increases are not necessarily “real” (because they might be offset by inflation), or who fail to notice that a subsidy is the same thing as a tax reduction, or any of a number of other “simple” issues that economists deal with all the time.

Importantly, this disdain for the public is nonpartisan and not at all ideological. In fact, the Economics Department at the University of Chicago, which is famously conservative in its approach to economics, takes pride in its supposed ability to set the world straight and correct people’s dimwitted misunderstandings. One Chicago-School economist once referred to his colleagues’ approach as an “acid bath,” bringing the harsh reality of brutal logic to bear against the confused and sentimental ramblings of the great unwashed masses.

Professor Gruber, therefore, was simply caught saying to his colleagues what economists say to each other all the time: If everyone in the world were as smart as we are, we wouldn’t have to deal with their nonsense; but because they are easily confused, we can use our superior intelligence to take advantage of their shortcomings and dupe them into doing the smart thing. I have heard virtually the same words coming out of the mouths of conservative economists and liberal economists alike, many times.

Even so, and even though nothing that Professor Gruber said actually bears on the substantive content of the ACA, the new narrative is that the Obama Administration was somehow uniquely Machiavellian in its manipulation of the American people. That is not true, but there are plenty of false accusations against this president that Republicans have refused to abandon.

The net result of this new mess, therefore, is that the Republicans will be able to repeat relentlessly the claim that the ACA is a nefarious trick that was foisted on an unsuspecting public. The general suspicion that “we can’t trust Washington” will have inadvertently been enhanced by one economist being recorded saying what all of his colleagues believe.

The Supreme Court and the New Challenge to the ACA

As Professor Michael Dorf explained in his Verdict column yesterday, the Supreme Court has agreed to hear a new challenge to the ACA, King v. Burwell. There, the Court could decide that the subsidies for low-income Americans that allow them to buy insurance under the new health law must be limited to the dozen or so states that have set up their own insurance exchanges. That would leave the citizens of the majority of states without subsidies, because they are currently buying their insurance through exchanges established on the states’ behalf by the federal government.

The merits of that challenge are not the issue in this column, but I have to say that I find the central claim in King to be extraordinarily weak. Even so, a motivated group of conservative justices could decide to engage in naked partisan politics in that case, which would (among other things) allow Chief Justice Roberts to rehabilitate himself in conservatives’ eyes, after his vote to uphold the ACA in the 2012 NFIB v. Sebelius case.

If the Court strikes down the subsidies in the affected states, what would happen next? The so-called “death spiral,” in which the insurance pools in those states would include fewer healthy people, causing rates to rise and push out even more healthy people, is better thought of as a near-death experience. The exchanges would not be “really most sincerely dead” (in the immortal words of the munchkin coroner in The Wizard of Oz), because there would still be a core group of relatively ill people who are just barely able to buy the now-much-more-expensive insurance, and for whom even expensive insurance is better than nothing.

As the New York Times columnist Josh Barro has written, this unfortunate limbo perfectly describes the pre-ACA world in which New York State’s residents lived for years. It was a bad state of affairs, and no one liked it, but it limped along until the ACA radically improved the situation.

The point here, however, is that conservatives’ preferred result in the King case would lead to a new reality in which two-thirds of the country is stuck with especially dysfunctional private insurance markets. The public might well look back fondly on the days when health insurance was briefly affordable under the ACA.

Of course, even now Republicans are doing everything possible to convince the world that the ACA is impossibly broken. Last week, the Obama Administration announced that health insurance premiums would rise in 2015, in some cases by as much as 20%. Although unfortunate, this outcome (if, indeed, it turns out to be true) was quite common before the ACA came into effect. The reason that there was political support for reform in 2009 and 2010, after all, is that the old health care system was broken, and people knew it.

At this point, the Republicans cannot resist any opportunity to attack the ACA. A news article describing the new cost estimates included an Administration official claiming, correctly, that “the Affordable Care Act is working.” The next sentence in the article, however, says that “Republicans quickly pounced on the data as evidence of the opposite.” Their message: Get rid of the ACA, because we cannot trust a new bureaucracy to get things right.

Single-Payer Could Become a Very Real Possibility After All

If Republicans convince the public that the ACA is broken, then there will be a need for an alternative. As I noted above, however, they have offered nothing to replace the ACA. At best, they will return us to the status quo ante, but more likely, they will end up with a system in which the private health care markets are even worse than they were before. Moreover, state-by-state differences will become more pronounced, and businesses will find that their support of Republicans has made conducting business nationwide much more expensive.

If Americans are convinced that the government cannot run the ACA, would they ever believe that the government can do anything right? Strangely, the answer is yes. Once the Republicans and their allies on the Supreme Court—with an inadvertent assist from Professor Gruber—have convinced the public that the government cannot be trusted, while dooming Americans to an even worse private health care market, people will be looking for an alternative that is simple, clear, and tested.

We have such a system, and it is called Medicare. Even the older voters who skew toward the Tea Party love Medicare. (Famously, some of them apparently do not even realize that Medicare is a government-run program.) It is a single-payer system, and it has been working here in the United States for half a century. It is true that the way we formally finance the Medicare program is currently out of balance, but that is entirely fixable. Moreover, because the program has such low administrative costs, its total cost would be much lower than the private insurance system that it would replace.

I am not going to bet the house that the U.S. will adopt “Medicare For All” any time soon. I am certain, however, that the current road down which the Republicans and the Supreme Court are driving the country does not necessarily lead to their version of a utopia. Health care will always require a large amount of government involvement, as even the pre-ACA system showed. At some point, Americans might decide that enough is enough, and every citizen will finally be able to enjoy a tried-and-true program that works.

Neil H. Buchanan, a Justia columnist, is an economist and legal scholar, a Professor of Law at The George Washington University, and a Senior Fellow at the Taxation Law and Policy Research Institute, Monash University (Melbourne, Australia). He blogs at DorfonLaw.org, and he is the author of “The Debt Ceiling Disasters: How the Republicans Created an Unnecessary Constitutional Crisis and How the Democrats Can Fight Back.”

http://verdict.justia.com/2014/11/20/disdainful-economists-hubristic-jurists-fanatical-republicans#sthash.hyfA2tWh.dpuf

U.S. Seniors’ Health Poorest, Global Survey Shows

Commonwealth Fund report reveals stark comparison to 10 industrialized countries with universal health coverage

By Steven Reinberg
HealthDay News, Nov. 19, 2014

Seniors in America have more chronic health problems and take more medications than seniors in 10 other industrialized countries do, according to a new global survey.

The United States also stood out among the 11 nations surveyed by The Commonwealth Fund for having more seniors struggling to get and afford the health care they need.

Eighty-seven percent of U.S. adults who are 65 and older suffer from at least one chronic illness, and 68 percent have at least two illnesses, which were the highest rates found, the survey showed. Also, 53 percent of older Americans take at least four medications, another record high, and 21 percent spend at least $2,000 in yearly out-of-pocket health care costs, which was second only to Switzerland.

“The retirement of baby boomers means pressure on Medicare will intensify,” Dr. David Blumenthal, president of The Commonwealth Fund, said during a news briefing Tuesday to announce the study findings, which were published online Nov. 19 in the journal Health Affairs.

Despite the moderating of health care costs in recent years, Blumenthal added, “Costs are still going up too fast to be sustainable over the long term, and this will be exacerbated by increasing numbers of elderly individuals.”

The study’s lead author and Commonwealth Fund vice president, Robin Osborn, noted at the news briefing: “Those over 65 in the U.S. will almost double from 2005 to 2030. These sicker adults will likely put a strain on the health care system [which] will need to transform to meet the challenges of an aging population.”

For the survey, the researchers collected responses from more than 15,000 older adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States.

Most all of the other countries have some form of universal health insurance, and American seniors have Medicare, but Osborn said striking differences emerged in the survey:

  • Although the U.S. senior group was the youngest of all the countries in the report, they were also among the sickest: 25 percent of older Americans saw at least four doctors in the past year, second only to Germany at 39 percent.
  • In addition, more Americans (19 percent) said they skipped essential health care because they could not afford it, and 11 percent said they had trouble paying their medical bills. In France, only 3 percent of seniors said they skipped health care because of cost, and in Norway only 1 percent said they had trouble paying medical bills.
  • In terms of out-of-pocket costs, only the Swiss spent more than Americans. In the United States, 21 percent spent $2,000 or more a year, compared with 22 percent in Switzerland and 2 percent in the United Kingdom. In France, on the other hand, virtually no one spent out-of-pocket costs.
  • Only 57 percent of U.S. seniors said they were able to see their doctor the same or the next day when they were sick, compared with 83 percent in France and New Zealand, and 81 percent in Germany.
  • Americans use of emergency rooms was one of the highest, at 39 percent. Thirty-five percent of these visits were for conditions their doctors could have dealt with had they been available, the researchers found.
  • When a specialist was needed, 86 percent of U.S. seniors and 82 percent of seniors in Switzerland were able to see one within four weeks — the highest rates in the survey. Seniors in Canada (46 percent), Norway (46 percent) and Sweden (50 percent) were the least likely to get appointments that quickly.
  • U.S. seniors, like seniors in the other countries, appear to suffer from poorly coordinated care or gaps in communication between doctors: 35 percent of U.S. seniors reported having such problems, as did 41 percent in Germany and 37 percent in Norway. In France, only 7 percent said they had these problems. But, the survey showed, American seniors also had better doctor/patient relationships than seniors in many other countries. 

An expert who was not involved with the study had a simple explanation for the key findings on American senior illnesses.

Dr. Steffie Woolhandler, co-founder of Physicians for a National Health Program, said American seniors are sicker because of the inadequate care they received before they turned 65.

“The health care system for the under-65 population is full of gaps, and lots of people fall through the cracks,” she said.

Woolhandler, who is also a professor of health at CUNY School of Public Health at Hunter College in New York City, added that Medicare is also leaving many Americans underinsured and that the Affordable Care Act will not make a major difference.

“We need to be providing much more comprehensive coverage to everyone, including lower co-pays and deductibles,” she suggested.

SOURCES: Steffie Woolhandler, M.D., professor, CUNY School of Public Health, Hunter College, New York City, and co-founder, Physicians for a National Health Program; Nov. 18, 2014, news conference with: David Blumenthal, M.D., president, and Robin Osborn, vice president and director, International Program in Health Policy and Practice Innovations, both Commonwealth Fund; Nov. 19, 2014, Health Affairs, online

http://consumer.healthday.com/senior-citizen-information-31/senior-citizen-news-778/u-s-seniors-health-poorest-global-survey-shows-693917.html?related=true&utm_expid=38353063-2.r5ETjFV6SrG5_xobVbsyDw.1

Need government to meet people’s needs

By Tom Ellis
The Daily Gazette (Schenectady, N.Y.), Letters, Nov. 7, 2014

In her Oct. 30 column, “GE breaks its promise to retirees,” Sara Foss commented on General Electric’s sudden alteration of its long-established health care program for GE retirees, many of who are quite elderly and who thought GE had promised benefits that are now about to be dropped. She also noted that today, few private-sector workers can expect to have lifetime employee-sponsored health insurance.

We do not have to live like this. Either New York state or the federal government could establish an Expanded and Improved Medicare For All program that would largely eliminate the need for private health insurance. Many of the world’s developed nations have such systems; their residents visit physicians and pick up medications and never see or worry about a bill.

These plans cover every necessary medical cost, from pre-natal to death, regardless of age, marriage, health, citizenship, or employment status. In the United States, they could be financed via payroll taxes or a combination of payroll and income or stock transaction taxes.

Why do federal and state elected officials refuse to do for the United States what so many other nations do well? Are they incompetent, callous or corrupted by health insurance and pharmaceutical corporations who bribe them with “campaign contributions?” It seems as if a majority of our elected state and federal officials desire to keep us in a state of perpetual insecurity — even in old age — worried about outliving our money and not being able to pay our medical costs.

Not only are corporations ditching health insurance for their retirees, but they are also discontinuing defined benefit pensions. To ensure adequate lifetime income for all New Yorkers, the state government could enact a New York state Social Security system, modeled on the federal system, and make participation voluntary or mandatory. Some revenues collected but not yet needed for pensions could be invested in maintaining and installing water, sewers, roads, railroads, bridges, tunnels, mass transit, libraries, and other public infrastructure, creating millions of good jobs and improving our quality of life. New York has a good pension system for public-sector workers; it should establish one for other workers.

Imagine how prosperous New York would be if all New Yorkers had access to lifetime, high-quality health care and sufficient old-age income. New York used to be the leader in the U.S., and the U.S. used to lead the world. We need to replace elected officials who preach the false gospel of perpetual austerity with those who have a positive vision of what government can do. We can make government work to meet our needs. Northern Europeans do it; so can we.

Tom Ellis resides in Albany.

http://www.dailygazette.com/news/2014/nov/07/1107_print/?print

Replace ACA with Medicare for all Americans

By Richard A. Damon, M.D.
The Billings (Mont.) Gazette, Letters, Nov. 16, 2014

Now that both houses of Congress are controlled by the party that has tried to dismantle the Affordable Care Act by selective changes 54 times, what happens to the health care law?

The House has voted to repeal the Affordable Care Act in its entirety six times since enactment. Fifty-four House votes ranged from refunding to delaying measures and other fixing of the law. The 1099 tax reporting requirement was repealed and the CLASS Act (for long-term care) was dropped. Funding was reduced for the Prevention and Public Health Fund.

Does the ACA meet the affordability, accessibility and cost-control goals of health care reform? Objectively, we find it is a gallimaufry of millions of people struggling with insurance illiteracy. Patients find unexpected out-of-pocket charges. Prospective provider organization enrollees find they pay a percentage of the bill. Few patients understand cost-sharing, provider networks, unrecognized co-payments, deductibles and co-insurance.

The 2013 AIR Health Insurance Literacy Survey shows many Americans are unprepared to make informed choices. Patients want access, lower costs and better outcomes from reform. Unfortunately, the ACA misses all three.

The ACA leaves 10 to 30 million Americans under-insured, at risk of bankruptcy or death. Thirty million are left totally uninsured. Health care ends when income ends.

CBO estimates $100 billion annual decrease in government spending with $100 billion increase in total health care spending. That means patients and employers will annually pay $200 billion more than they pay now. Physicians want easy billing and prompt payment, which hasn’t existed for decades. Employers want health care costs to be predicable and consistent.

Replacement should be simple; pass “Expanded and Improved Medicare for All,” HR 676, Conyers’ legislative bill.

Dr. Richard A. Damon resides in Bozeman.

http://billingsgazette.com/news/opinion/mailbag/replace-aca-with-medicare-for-all-americans/article_25674872-4d27-52d5-b22d-830636d93e4b.html#ixzz3JXnxEuIg

Implementing a Universal Healthcare System Costs Less, Provides Better Care

The U.S. spends more money on administrative costs than anywhere in the world, according to a recent article in Health Affairs

By Samuel Metz, M.D.
The Lund Report (Portland, Ore.), Nov. 11, 2014

Honoring a rather unpleasant tradition, the September issue of Health Affairs published yet another peer-reviewed study confirming that administrative costs in the U.S. healthcare system are the highest in the world. These administrative costs do not improve patient care. They pay for more administrators.

Each American physician requires 10 administrators to stay in business. Why does American healthcare require twice as many administrators as any other healthcare system?

Because these additional administrators perform a function totally unnecessary in other countries: They restrict access to healthcare and limit benefits of patients who do gain access.

If restricting access and limiting benefits produced a healthier population at lower cost, then Americans could be proud of our massive number of administrators. But the U.S. does not have a healthier population and our healthcare is not inexpensive. In fact, our public health is the worst in the developed world, and our healthcare system is the most expensive of any nation on the planet.

Some blame government bureaucracies for these excessive administrative costs. But let’s not be hasty. Per patient, private insurance overhead exceeds that of Medicare, Medicaid, and the VA – combined. We may have doubts about our government to spend money in other areas, but when it comes to reducing the administrative costs of health care, government programs are ten times as efficient as private insurance.

Restricting access and limiting care is an expensive process, consuming more money than we would spend simply providing unrestricted access and treating all treatable diseases. How do we know? Because every healthcare system in the world that implements universal care without limiting benefits ultimately provides better care to more people for less money.

Where does our private insurance model lead us astray? The primary goal of insurance companies, like all other businesses, is to make more money than they spend. But an insurance company cannot stay solvent selling comprehensive policies at affordable prices to people who will get sick. So insurance companies spend a lot of money to avoid populations that include sick people, to shift costs to patients, to limit benefits, and to exclude physicians who care for patients with expensive diseases (e.g., AIDS, cancer). After all, who will buy a policy that lets you go broke before you get better?

How much money do insurance companies consume in their (so far successful) efforts to avoid selling policies to sick people and limiting their care? A conservative estimate is $400 billion annually (that’s $5 billion annually in Oregon).

How much would the US spend if we simply provided comprehensive care to everyone? About $300 billion ($3.3 billion in Oregon).

The math produces an inescapable conclusion. If Oregon diverted all the money we currently spend to restrict access and limit benefits and instead invested directly in healthcare, we could provide comprehensive care to everyone and save ourselves $1.7 billion.

There is no mystery. A statewide healthcare program that diverted all the money we currently spend on insurance premiums and out-of-pocket payments into a single agency that paid for comprehensive healthcare for everyone would cost less than we spend now. Not only that, but all Oregonians would enjoy healthcare when they need it, no matter what their employment status might be. We just need to stop paying money to restrict access and limit care.

It’s obvious that the barriers to healthcare cost more than providing healthcare. If we commit to universal healthcare in Oregon, we can not only save money but get better care.

Dr. Samuel Metz is a private practice anesthesiologist who lives and works in Portland.  He is a member of Physicians for a National Health Program and a founding member of Mad As Hell Doctors, both of which are organizations that advocate for universal health care in Oregon and nationally. He is collaborating with State Sen. Michael Dembrow on finding private funding for the HB 3260 study of financing universal health care in Oregon. He can be reached at S@SamuelMetz.com.

https://www.thelundreport.org/content/implementing-universal-healthcare-system-costs-less-provides-better-care

Million dollar baby: Canadians handed $1M bill after woman gives birth in U.S.

By Marlene Leung
CTV News (Canada), November 19, 2014

A dream vacation has turned into a financial nightmare for one Saskatchewan couple, after a mom-to-be gave birth while on holiday in Hawaii.

Jennifer Huculak and her husband have been saddled with a medical bill of nearly $1 million after she gave birth to her daughter in the U.S.

Huculak was six months pregnant when she flew to Hawaii for a holiday with her husband in October 2013. Before her trip, she bought Blue Cross insurance and received approval from her doctor.

But two days into her trip, Huculak’s water broke and she spent the next six weeks on bed rest in a Hawaiian hospital. Her daughter was born nine weeks early and spent two months in intensive care.

While she’s grateful that her 11-month-old daughter is now healthy, Huculak and her husband were left with a $950,000 medical bill.

“It makes you sick to your stomach,” she told CTV Saskatoon. “Who can pay a million-dollar medical bill? Who can afford that?”

Blue Cross is refusing to pay any of the amount, arguing that Huculak had a pre-existing condition.

In a letter to Huculak, the company noted the following: “Ms. Huculak was diagnosed and treated for a high-risk pregnancy in the six months prior to departure. As Ms. Huculak is currently hospitalized and being treated for this high-risk pregnancy, any expenses incurred are not eligible under the terms of your policy.”

But Huculak says that she did not have a high-risk pregnancy, she had a bladder infection which led to bleeding.

“The specialist in Hawaii said that these things just happen. There’s nothing that causes them,” she said.

Her specialist at home in Saskatchewan has written to Blue Cross, saying that the bladder infection did not lead to Huculak’s early labour. But her coverage was still denied.

Huculak is angry because she said the Blue Cross pamphlet had no fine print explaining any rules for pre-existing conditions.

She said the family is now trying to decide if they should fight Blue Cross, declare bankruptcy, or wait and see what happens.

Meanwhile, she hopes that other travellers will learn from their ordeal. “It’s a very sad situation to be in and people need to be aware that insurance companies will deny you if they have anything they can go on,” she said.

http://www.ctvnews.ca/canada/million-dollar-baby-canadians-handed-1m-bill-after-woman-gives-birth-in-u-s-1.2107020#ixzz3JYTb8ksJ