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Money, Sex, and Religion — The Supreme Court’s ACA Sequel

By George J. Annas, J.D., M.P.H., Theodore W. Ruger, J.D., and Jennifer Prah Ruger, Ph.D., M.S.L.
The New England Journal of Medicine, July 16, 2014

The Supreme Court decision in the Hobby Lobby case is in many ways a sequel to the Court’s 2012 decision on the constitutionality of the Affordable Care Act (ACA). Like the 2012 case, the decision was decided by a 5-to-4 vote, but in the initial ACA decision, Chief Justice John Roberts acted to “save” the ACA. Not this time. To simplify, the choice facing the Court in the Hobby Lobby case was whether to favor the exercise of religion by for-profit corporations (whose owners believe contraceptives that may prevent fertilized eggs from implanting violate their religious beliefs) over the federal government’s attempt to create a uniform set of health care insurance benefits.

(This article goes on to discuss the issues in the Hobby Lobby decision, including the ACA and the Religious Freedom Restoration Act, religion and birth control, and religion and women’s health. The authors end with the following section on medical care and the ACA.)

Medical Care and the ACA

In terms of health care, the reaction of the American College of Obstetricians and Gynecologists (ACOG) to the Court’s opinion seems just about right to us: “This decision inappropriately allows employers to interfere in women’s health care decisions . . . [which] should be made by a woman and her doctor, based on the patient’s needs and her current health.” ACOG went on to underline that contraceptives and family planning are mainstream medical care and should be treated as such. In their words, “access to contraception is essential women’s health care.”

The Court’s ruling can also be viewed as a direct consequence of our fragmented health care system, in which fundamental duties are incrementally delegated and imposed on a range of public and private actors. The Court is correct on one dimension of its opinion: if universal access to contraceptives is a compelling societal interest, then the provision of such access ought to fall first and foremost on the national government and only secondarily be transferred to private parties. Our systemic reliance on health insurance that is based on private employment provokes just this sort of clash between public and private values.

Our incremental, fragmented, and incomplete health insurance system means that different Americans have different access to health care on the basis of their income, employment status, age, and sex. The decision in Hobby Lobby unravels only one more thread, perhaps, but it tugs on a quilt that is already inequitable and uneven. A central goal of the ACA was to repair some of this incremental fragmentation by universalizing certain basic health care entitlements. In ruling in favor of idiosyncratic religious claims over such universality, the Court has once again expressed its disagreement with this foundational health-policy goal.

http://www.nejm.org/doi/full/10.1056/NEJMhle1408081?query=TOC#t=article

George Annas: http://www.bu.edu/sph/profile/george-annas/

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Comment:

By Don McCanne, MD

The last paragraph says it all:

“Our incremental, fragmented, and incomplete health insurance system means that different Americans have different access to health care on the basis of their income, employment status, age, and sex. The decision in Hobby Lobby unravels only one more thread, perhaps, but it tugs on a quilt that is already inequitable and uneven. A central goal of the ACA was to repair some of this incremental fragmentation by universalizing certain basic health care entitlements. In ruling in favor of idiosyncratic religious claims over such universality, the Court has once again expressed its disagreement with this foundational health-policy goal.”

Need we say, single payer?

Fewer Doctors Enrolled in Low-Income Insurance Program Despite Surge in Patients

By Hannah Guzik
California Health Report, July 14, 2014

Nearly 25 percent fewer physicians were signed up to treat low-income patients in the state’s insurance program this spring compared to a year prior, despite the surge in patients enrolled in Medi-Cal.

The drop in providers is due to the Department of Health Care Services’ efforts to remove doctors who haven’t complied with application requirements or billed the program in a year, spokesman Anthony Cava said.

“This has not resulted in a decrease in access to care,” he said.

More than 2 million people have signed up for Medi-Cal, the state’s low-income health plan, since the program was expanded under the Affordable Care Act. In total, 10.6 million people are enrolled — a quarter of the state’s population.

An additional 600,000 people are still waiting for the state to process their applications.

About 109,000 physicians were enrolled in Medi-Cal last spring, according to the Health Care department. But by this May, that number had dropped to 82,605.

Of the doctors enrolled in May, 38,845 were primary-care providers and 43,760 were specialists.

On its own, the agency’s list of providers isn’t necessarily a reflection of whether Medi-Cal patients have sufficient access to doctors. The list doesn’t specify whether the doctors are accepting new patients or how many they can accept, Cava said. While some doctors on the list may have up to 2,000 Medi-Cal patients, others might see only a handful or none.

http://www.healthycal.org/archives/16231

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Comment:

By Don McCanne, MD

Medi-Cal, California’s Medicaid program, serves as an example of the consequences of using Medicaid to expand coverage for the exceptionally poor. After the backlog of applications are processed, over 11 million people will be enrolled in Medi-Cal – about 29 percent of the state’s population. At the same time, 25 percent fewer physicians will be listed as Medi-Cal providers (a result of culling, not voluntary disenrollment). Further, many of the physicians enrolled already limit or exclude Medi-Cal patients from their practices. We should learn soon what impact this will have on access, and the news will not be good.

California has the additional problem that it has the lowest per patient Medicaid funding, with an additional 10 percent reduction in payment rates – a Great Recession cut which Gov. Brown refuses to restore. Think of the options that physicians have when they are being paid significantly less than their overhead expenses for taking care of these patients. None of their options are very good.

The latest CBO projections (April 2014) indicate that nationally 48 million people will be enrolled in Medicaid and CHIP – 13 million more than would have been enrolled had the Affordable Care Act (ACA) not been enacted. The number of uninsured will be 31 million – a number that includes those who would have been eligible for Medicaid had their governors not refused to expand Medicaid in their states. As if access for Medicaid patients were not bad enough, access for the uninsured will be much worse.

As has been said here before, building on the current system, as ACA did, is the most expensive and one of the least effective models of achieving reform goals. The least expensive comprehensive model, and one that achieves the desired goals, is single payer.

Although progressives are tooting their horns about how well ACA is working, the Medicaid program is only one example of how miserably short we have fallen in our efforts to achieve a premier performing system. Put away the horns and get to work.

A Business Case for Universal Healthcare: Improving Economic Growth and Reducing Unemployment by Providing Access for All

By David Sterret, Ashley Bender, David Palmer
American University, Health Law & Policy Brief, Spring 2014

From the Introduction

This report will illustrate that the United States economy is currently hampered in numerous ways by having an inefficient, inequitable healthcare system. The research on which we relied was completed before the full implementation of the Patient Protection and Affordable Care Act (ACA). However, we expect that even if the law works as intended, it will not resolve the problems that we raise because the law largely preserves our employment-based healthcare system. In Part I, we discuss specific harms to the economy inflicted by our system’s reliance on employers to provide healthcare benefits. Part II examines how the United States economy compares through the lens of several indices, including some published by conservatives. These comparisons illustrate that most countries with more vibrant economies than the United States have government- directed, universal healthcare systems.

II. Implementing a Universal Care System Would Improve American Competitiveness Internationally

A. The United States Trails Many of Its Competitors by Various Economic Measures
B. How the Employer-Funded United States Healthcare System Harms Businesses
C. Why a Universal Care System Would Lessen Burdens on Businesses

No universal care systems, including pure single-payer systems, are a free lunch for businesses. In one way or another, often through a payroll tax, businesses end up providing at least some of the money to finance the system.

There are several reasons to believe that a universal care system would mitigate this impact on businesses. Primarily, such a system would cause future costs to be lower, or at least stem the trend of cost-increases far exceeding inflation. Secondly, businesses’ overall share of healthcare bills would likely be lower. Finally, a universal care system would distribute costs far more equitably among businesses.

Conclusion

If the United States were to implement a system to ensure universal care, American companies would no longer face a disadvantage in competing with businesses from countries, such as Canada, that provide national healthcare systems. Additionally, healthcare would cease to be a large factor guiding individuals’ career decisions. A national, universal care system would level the playing field among domestic businesses, and eradicate the free-rider problem. For all of the above reasons, economic growth would likely improve, which would yield additional self-perpetuating benefits.

There is an argument that the taxes to finance such a system would constrain business. This claim is seriously undercut by examples from around the world. For instance, Hong Kong, viewed by many as a “beacon of capitalism,” has universal healthcare. So does Denmark, which has higher levels of entrepreneurship than the United States. What is becoming increasingly clear now is that the current employer-sponsored healthcare system in the United States does hurt business.

http://jts.hbp.com/pdf/design/135358_AU_HLP_3.pdf

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Comment:

By Don McCanne, MD

The majority of Americans obtain their insurance through their employment. Business has a vital concern in the financing of health care. This report adds to the plethora of evidence that business owners would be better off if they were relieved of their responsibilities of providing health benefit programs for their employees. So why is there not an outcry to switch to a proven financing system that would serve their employees well? Is it ideology?

The Affordable Care Act (ACA) calls for a financial penalty for larger employers who do not provide health care coverage for their employees. Could that be the reason? No, the resistance to change existed before ACA was enacted. Further, there are now so many experts in the policy community across the political spectrum who are calling for repeal of the penalty that it is likely that it will be eliminated anyway.

If so, what are employers likely to do? We are already seeing much interest in private health insurance exchanges. If ACA requirements on employers were lifted, they may be willing to provide their employees with a voucher to purchase plans in the private exchanges. Since that converts the benefit into a defined contribution, that would pass on to their employees the burden of future health care inflation.

Another possibility is that they might want to give their employees raises and then let them select their own plans in the state-based ACA exchanges. That would remove the employer entirely from the responsibility of supporting a health benefit program.

A concern that employers might have is that health care costs are now too high and income inequality has increased to the level such that health care benefits must be progressively financed if people are to receive the care they should have. Employers could be concerned that their tax burden may be increased to pay for the higher subsidies that will be needed for premiums and cost-sharing in the exchange programs. Not knowing what that tax burden might be could cause some reluctance to change from a system that at least they understand.

Most employers are well aware of the inefficiencies and high costs of our private insurance-based system. Would employers be ready to embrace a more efficient government-financed and government-administered single payer system? This may be their greatest fear because the financing would no doubt be through explicit progressive tax policies. Most proposals would reduce total health spending for 95 percent of us, but would increase it for those in the top 5 percent of income. 

Although some in the business community might be opposed simply because of ideology, for most it’s the money. We’ve learned the lessons that Thomas Piketty has for us, but we can’t apply them until we are willing to exercise democracy by changing the politics. That push for change will not come from the business community.

Why Improving Access to Health Care Does Not Save Money

By Aaron E. Carroll
The New York Times, July 14, 2014

One of the most important facts about health care overhaul, and one that is often overlooked, is that all changes to the health care system involve trade-offs among access, quality and cost. You can improve one of these – maybe two – but it will almost always result in some other aspect getting worse.

You can make the health care system achieve better outcomes. But that will usually cost more or require some change in access. You can make it cheaper, but access or quality may take a hit. And you can expand access, but that will increase cost or result in some change in quality.

More people being able to get care was the point of the A.C.A. It’s possible that overall health care spending may remain flat or even decrease because of other changes to the health care system, or economic factors outside the system entirely. But with respect to emergency care, prevention and procedures, we should expect that increasing access will lead to more spending, not less.

It’s understandable that supporters of the law want it to increase access, increase quality and decrease spending all at the same time, but that’s very unlikely. Trade-offs occur; we need to be honest, and prepared, for what’s likely to happen.

Comment:

By Don McCanne, MD

The supposedly inevitable trade-offs between access, quality and cost ignore one important intervention regarding cost. The health care financing system in the United States is unique in its profound, costly administrative waste due to the highly inefficient, fragmented financing through a multitude private insurers and public programs (and no programs at all for the uninsured).

Merely changing to a universal single payer program or a national health service model dramatically reduces costs without having a negative impact on access and quality. The future trajectory of cost increases would be shifted downward – achieving that elusive bending of the cost curve. That is one way other nations provide truly universal health care at a per capita cost averaging only half of that of the United States.

In fact, the monopsonistic purchasing of a public program can actually improve quality by obtaining greater value in health care purchasing.

Some of the savings that would accrue by changing to a universal program such as an improved Medicare for all would be redirected to much needed improvements in access.

The important bottom line is that we really can achieve improved access, improved quality, and lower costs by structural reform of our highly dysfunctional financing system – a system that was only expanded by the Affordable Care Act.

Race Is On to Profit From Rise of Urgent Care

By Julie Creswell
The New York Times, July 9, 2014

NORWALK, Conn. — For more than eight hours a day, seven days a week, 52 weeks a year, an assortment of ailments is on display at the tidy medical clinic on Main Avenue here. But all of the patients have one thing in common: No one is being treated at a traditional doctor’s office or emergency room.

Instead, they have turned to one of the fastest-growing segments of American health care: urgent care, a common category of walk-in clinics with uncommon interest from Wall Street. Once derided as “Doc in a Box” medicine, urgent care has mushroomed into an estimated $14.5 billion business, as investors try to profit from the shifting landscape in health care.

But what is happening here is also playing out across the nation, as private equity investment firms, sensing opportunity, invest billions in urgent care and related businesses. Since 2008, these investors have sunk $2.3 billion into urgent care clinics. Commercial insurance companies, regional health systems and local hospitals are also looking to buy urgent care practices or form business relationships with them.

The business model is simple: Treat many patients as quickly as possible. Urgent care is a low-margin, high-volume proposition.

Urgent care clinics also have a crucial business advantage over traditional hospital emergency rooms in that they can cherry-pick patients. Most of these centers do not accept Medicaid and turn away the uninsured unless they pay upfront. Hospital E.R.s, by contrast, are legally obligated to treat everyone.

Already, the race is on to build large chains with powerful, national brands — a McDonald’s or a Gap of health care. Wall Street money is driving the growth, but so are other forces. Millions of newly insured Americans are seeking care. Others are frustrated by long waits at E.R.s, or by having to conform to regular doctor’s hours.

The insurance giant Humana paid nearly $800 million in 2010 to buy Concentra, the nation’s largest group of urgent care centers, with about 300 currently. Two years later, Dignity Health, a San Francisco-based health system, acquired U.S. HealthWorks, a group that today has 176 centers.

Even hospitals are embracing the trend. Florida Hospital in Orlando, for example, has opened 24 Centra Care urgent care clinics.

But some of the most aggressive buyers have been private equity firms, according to data from a research firm, PitchBook.

In 2010, General Atlantic, a private equity firm, and Sequoia Capital, a giant in venture capital, acquired a stake in MedExpress Urgent Care, which operated 47 clinics in four states. today, MedExpress has 130 clinics in 10 states.

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Comment:

By Don McCanne, MD

The growing popularity of urgent care centers is understandable. Patients can receive timely care with shorter waits, at a cost well below that of hospital emergency departments. These centers are working well for patients, for the health professionals who staff them, and for… yes, passive investors who have learned how to divert to their own coffers some of the $3 trillion that we are spending on health care.

That’s the thing about capitalism. When there is an opening that can provide a significant return on invested dollars, capitalists jump in, while socialists stand back and observe, especially since the machinery of government grinds very slowly.

In the case of urgent care centers, what approaches will provide the best return for the capitalists? Above all, locate them in wealthy communities. Do not ever consider placing them in communities with high poverty levels, even though the medical need may be great. Cherry pick your patients. You can turn away Medicaid and cashless uninsured patients and give them instructions on how to get to the nearest hospital emergency department, which is required by law to accept them. But cater to the insurance companies that are quite willing to pay your higher fees as long as they are lower that emergency department fees. In fact, maybe the insurers will even be willing to pay a premium to buy you out.

The record is in on for-profit health care facilities. Business principles trump patient service principles every time. Make the most money on insured patients that the market will bear, but avoid losses on uninsured and welfare patients by turning them away. 

About those socialists who are standing back and observing, what are they to do? How do they move urgent care services into communities with high poverty? They know that the private investors want no part of that. What about primary care practices? Isn’t it unrealistic to expect physician offices to be staffed 24 hours a day? What about community health centers? On their tight budgets, can they provide 24hour/7day urgent care services? What about emergency departments of hospitals? Of course, they are already serving that function, but at very high fees that are used to support other money-losing services of the hospital – not to mention long delays at times other health care facilities are closed.

Under a single payer system, facilities would be established through central planning based on the health care needs of the community, not on what would be the most profitable. Passive investors would not be involved and thus would play no role in those decisions, as they shouldn’t. 

Private sector investors move in rapidly at any opportunity, structuring their investments to get the most dollars they can from us while neglecting those without dollars. Government bureaucrats move much more slowly, but at least they get it right, making sure that health care is available for people when they need it. Single payer is what we need.

Anthem Blue Cross faces another suit over Obamacare doctor networks

By Chad Terhune
Los Angeles Times, July 9, 2014

Amid growing scrutiny statewide, insurance giant Anthem Blue Cross faces another consumer lawsuit over its use of narrow networks in Obamacare coverage.

A group of Anthem policyholders sued California’s largest for-profit health insurer Tuesday in state court, accusing the company of misrepresenting the size of its physician networks and the insurance benefits provided.

A similar suit seeking class-action status was filed June 20 against Anthem, a unit of WellPoint Inc., The Times has reported.

In response to the two lawsuits, Anthem said “materials at the time of enrollment and in members’ explanation of benefits have clearly stated that the plan was an EPO plan which may not have out of network benefits.”

The company added that Blue Cross Blue Shield Assn. rules required the PPO designation on EPO member cards because coverage for emergencies is available in other states.

In May, two San Francisco residents sued Blue Shield in state court, accusing the company of misrepresenting that their policies would cover the full network.

Separately, California regulators are investigating whether Anthem and Blue Shield of California violated state law in connection with inaccurate provider lists and making it difficult for patients to obtain timely care.

To hold down premiums under the health law, Anthem and Blue Shield cut the number of doctors and hospitals available to patients in the state’s new health insurance market.

These exclusive-provider organization, or EPO, health plans have been particularly troublesome for some consumers who were accustomed to having more conventional preferred-provider organization, or PPO, policies.

One of the major differences is that patients with an EPO plan typically have little or no coverage if they see an out-of-network medical provider and they are often responsible for the full charges.

“EPOs will continue to play a role,” said exchange spokeswoman Anne Gonzales. “But we’re going to have to do a better job educating people about how these networks work. We recognize the EPO model can be confusing.”

Some supporters of the Affordable Care Act say the smaller size of the provider networks isn’t the problem so much as clear information about what doctors and hospitals are available.

“The problem has been the transparency and reliability of the networks,” said Micah Weinberg, a health-policy analyst at the Bay Area Council, an employer-backed group.

“That’s the problem that we need to fix. If we focus on narrowness we will be focusing on the wrong thing,” Weinberg added.

http://www.latimes.com/business/healthcare/la-fi-anthem-narrow-networks-lawsuit-20140709-story.html

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Comment:

By Don McCanne, MD

Micah Weinberg, a health-policy analyst at the Bay Area Council, an employer-backed group, says, “The problem (with exclusive provider organizations – EPOs) has been the transparency and reliability of the networks. That’s the problem that we need to fix. If we focus on narrowness we will be focusing on the wrong thing.” Really? Narrow networks are not the problem?

There is a general rule that when you are confronted with a problem you should provide a solution that corrects the problem at its origin rather than providing a solution that requires compliance by everyone else involved. In the case of EPOs it would have been far better to simply eliminate them and address cost issues by more effective policies rather than to try to get each individual to understand EPOs and comply with the restrictions on which health care providers will be covered – compliance which is sometimes impossible to achieve.

Once private insurers began using networks of contracted physicians and hospitals, compliance has been a problem for many reasons. The network lists are difficult to access. They undergo continual revisions. Frequently not all physicians providing coordinated health care services are contracted with the insurer. EPOs tend to use narrower networks to leverage more favorable contracts with those who do participate which further limits patients’ access and coverage. The individual’s selection of health plans often changes for a variety of reasons, and the networks change accordingly. This often disrupts continuity of care.

The only rationale for EPOs is for the insurer to negotiate lower prices. It is a terribly inefficient and disruptive way to do that. A far more effective way of pricing health care services appropriately would be to establish a single payer system. There would be no networks involved.

Much the same applies to PPOs. They differ from EPOs primarily in that they may cover a very modest portion of the charges outside of their networks, but they do not protect the patient from prices that are higher than the insurers’ usual contracted rates. By the rule that a problem should be corrected at its source, PPOs should be eliminated as well.

In fact, single payer advocates know that this applies to all private insurance plans. They should be eliminated and replaced with a single, publicly-financed and publicly-administered health program. You have eliminated the problem at its origin – the private insurers – and have replaced it with a program in which patient compliance is totally automatic – a single payer national health program.

Inadequate State, Federal Payment Rates Forcing Hospital Closure, Officials Say

By David Gore
California Healthline, July 5, 2014

Doctors Medical Center in San Pablo, about 10 miles north of Oakland, is slated to shut its doors at the end of July, unless some kind of deal can be worked out to keep it operating.

There are many contributing factors to the financial death spiral at Doctors Medical Center, according to said Eric Zell, chair of the West Contra Costa Healthcare District board of directors, which oversees Doctors Medical Center. But there is one fundamental and underlying reason it cannot remain economically viable:

“It’s the Medi-Cal and Medicare reimbursement rates,” Zell said. “The rates are just too low.”

Zell added, “The payer mix is 80% Medicare/Medi-Cal and about 10% uninsured. There’s only about 10% private pay, and that’s not enough to keep us going.”

According to hospital officials, Doctors Medical Center is paid 60 cents for every dollar it spends to treat each Medi-Cal patient and just 90 cents on the dollar for every Medicare patient.

When you’re looking at 100 patients a day and you lose money on 90 of them, the losses mount quickly, according to John Gioia, a longtime district supervisor on the Contra Costa Board of Supervisors.

Most medical facilities have a payer mix with a much higher percentage of people with commercial health insurance to mitigate the losses of their Medi-Cal, Medicare and uninsured patients, Gioia said.

And when you have such a large population of people living at poverty level, that also means the residents of western Contra Costa County don’t have much money to try to underwrite the hospital.

Doctors Medical Center is one of the few remaining stand-alone small district hospitals left in the state, Gioia said. “There have been many places like this, hospitals like this in similar circumstances,” he said. “Many have closed, dozens of them in California.”

“This hospital represents a larger problem and issue,” Gioia said, referring to the access issue that would emerge in the west county if Doctors does shut down. “This represents a larger problem and issue,” he said. “Is there a model that’s more sustainable?”

“I think this is a failure of our health care system,” (state Sen. Loni) Hancock said. “We need to have a single payer health system.”

But at its root, Hancock said, it shouldn’t be up to hospitals in the area to pick up the slack for low Medi-Cal and Medicare rates.

“Look, it’s a great health care system for employed, insured people,” Hancock said. “But this is not a health care system for people who are poor.”

http://www.californiahealthline.org/insight/2014/inadequate-state-fed-payment-rates-forcing-hospital-closure-officials-say

Doctors Medical Center is owned and operated by the West Contra Costa Healthcare District.

Home

Doctors Medical Center Has an Emergency

If it doesn’t get financial help in the next few months, it will close its doors permanently. More than 40,000 people use Doctors Medical Center for emergency room services every year. If you have a heart attack or stroke, or you are in an accident, the ER at DMC is often the first stop for an ambulance. Without it, an ambulance trip could take up to an additional hour. That time could mean the difference between life and death.

http://www.savedmc.org

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Comment:

By Don McCanne, MD

It does not take much intellect to understand that hospitals should be located where they are needed and that they should be financed by a system that would ensure that adequate funds would be available to pay for appropriate health care services for the community. Based on our current methods of hospital planning and financing, it may be intellect that is in short supply.

Today a hospital that is located in a community with high levels of poverty is dependent on income from Medicare and Medicaid. In California these programs, especially Medicaid (Medi-Cal), pay rates below costs of providing that care. Insolvency is inevitable. This is directly related to our dysfunctional, fragmented system of financing health care through a multitude of private insurers, public programs, and no programs at all.

With the private sector making decisions on hospital planning, areas with assurance of revenues will be selected – usually areas with a high percentage of privately insured patients plus Medicare patients with higher regionally adjusted payment rates. The private planners do not select areas with high poverty rates and high numbers of uninsured and Medicaid beneficiaries. Private planning decisions are based on money, not on local need.

Under a well designed single payer system, capital spending is budgeted separately. Hospitals are built in areas of need. The hospital operations are financed through global budgets, just as with our fire and police departments. Public financing obviates the need to consider wealth when establishing the location of health facilities.

If Doctors Medical Center is closed down, the billionaire who is passing through town and is critically injured in an accident may die if his ambulance has to drive past a padlocked emergency department and continue for another hour to a different facility. No amount of money will buy your way to the front of that queue.

We need to adopt a system that will provide both appropriate planning and appropriate financing. Our current fragmented system can’t do that.

California State Senator Loni Hancock is right. “This is a failure of our health care system. We need to have a single payer health system.”