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The Hobby Lobby case proves the necessity of single-payer healthcare

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The Hobby Lobby case proves the necessity of single-payer healthcare

By Michael Hiltzik
Los Angeles Times, July 1, 2014

Is there anything more absurd than the American way of delivering healthcare coverage? 

Most Americans receive coverage through their employers. In the wake of Monday’s Hobby Lobby decision by the Supreme Court, businesses accounting for about 52% of all privately employed workers now have the option to discriminate among their employees and among the healthcare benefits they offer, based on their owners’ religious beliefs.

The U.S. reliance on employers to provide coverage on this scale is unique among major industrialized nations. In those countries, as Jonathan Cohn observes, “the government takes on this responsibility directly, by creating its own insurance program or regulating insurers as if they were public utilities.” This is essentially a definition of single-payer healthcare.

The alternative produces ludicrous results such as the Hobby Lobby decision.

It was hoped that the Affordable Care Act, which was at the center of that decision, would begin decoupling American healthcare from the tyranny of employer sponsorship. Americans who are out of work, or whose employers can’t or won’t provide them with healthcare benefits, now can buy coverage on their own, with government financial assistance if necessary.

This was a first halting step toward single-payer, which is more the norm in the developed world and plainly the most efficient and effective way of achieving universal coverage.

But it wasn’t enough of a step: The ACA still leaves most health coverage in the hands of employers. And it strengthens the hands of private health insurers in administering coverage and setting prices and terms for the doctors and hospitals providing care. The law was one step forward toward single-payer, and about three-quarters of a step back. 

The Hobby Lobby decision underscores the patchiness of the ACA, by granting employers a huge loophole to avoid the law’s mandates — in this case, the mandate that coverage include reproductive services for women without deductibles or co-pays. At the center of the case were the evangelical Green family, owners of the Hobby Lobby retail crafts chain, and the Hahn family, Mennonites who own a wood furnishings firm. They asserted that the ACA’s birth control mandate offended their religious sensibilities; the court ruled that these sensibilities outweigh the ACA’s coverage standards.

As it happens, Justices Samuel A. Alito Jr. and Anthony M. Kennedy, in their majority and concurring opinions, respectively, implicitly acknowledged the wisdom of single-payer healthcare as a way forward.

They did so by advising the government to grant the business owners relief by establishing what is in effect a single-payer regime for the birth control methods at issue. (These are two “morning after” drugs and two forms of IUDs that the businesses term “abortifacients,” meaning they cause abortions.)

Rather than forcing the businesses to pay for those methods, the justices said, the government could follow the path it already has laid down for nonprofit religious organizations objecting to the birth control mandate. In those cases the coverage mandate and its cost are transferred from the religious employers to their insurers — but the insurers are compensated for the expense via a reduction in a healthcare tax they’re required to pay under the ACA. 

In other words, the U.S. government becomes the single payer for those groups’ employees choosing those birth control methods. Alito and Kennedy would expand this accommodation to closely held businesses whose owners assert religious scruples.

The pertinent question then becomes: Why stop there? Offer the same accommodation for all employers for all coverage, and you have a single-payer system at last.

Among its virtues, a single-payer system would eliminate the subjective uncertainties about healthcare coverage that the Hobby Lobby decision intensifies by imposing a religious standard on that coverage.

A key problem with the religious standard is the difficulty of validating someone’s “beliefs.”

The majority and dissenting opinions in Hobby Lobby both bowed to the “sincerity” of the business owners’ religious beliefs. But this was just lip service, not a conclusion drawn from empirical data.

“The Hahns and Greens and their companies sincerely believe that providing the insurance coverage … lies on the forbidden side of the line, and it is not for us to say that their religious beliefs are mistaken,” Alito wrote. But how could he possibly know?

Even assuming, for argument’s sake, that these families aren’t hypocrites in their personal lives, how are the courts to judge the sincerity of the next employer who comes forth with a “religious” objection to some aspect of the ACA, or to some other federal law?

Alito didn’t provide lower courts with a test to appraise piety. How could he? There’s no concrete definition of “religious belief,” which means there are no practical bounds to employers’ ability to pick and choose which laws they will honor.

One thing that is clear about the beliefs of the business owners in Hobby Lobby is that, regardless of whether they are sincere, they certainly are medically ignorant. 

Alito acknowledged that the families’ claim about the four contraceptives being “abortifacients” isn’t a judgment based on science or medical practice, but on “their religious beliefs.”

In scientific terms, these beliefs are nonsense. That point was made crystal clear in an amicus brief filed by 11 organizations of reproductive health professionals, including the American College of Obstetricians and Gynecologists. They advised the court that the contraceptive methods challenged by the business owners are not, in fact, abortifacients. Alito acknowledged that they’re not classified as such by the Food and Drug Administration. 

So the bottom line of the Hobby Lobby decision is that the provision of medical care to millions of American families will be contingent on feelings of their employers that may or may not be sincere, that have no practical limitations, and that have no grounding in medical science.

The only way to resolve this mess is to take employers and their “sincere beliefs” completely out of the picture — as Alito and Kennedy recommend. Remove employers and the insurance industry exits with them. What’s left is single-payer healthcare, which is the right way to deliver services that are matters of life and death. 

http://www.latimes.com/business/hiltzik/la-fi-mh-singlepayer-healthcare-20140701-column.html?utm_campaign=KHN%3A+Daily+Health+Policy+Report&utm_source=hs_email&utm_medium=email&utm_content=13360146&_hsenc=p2ANqtz-8IIOgi45vAZJq6XrZgHqiyosFxmRa2tt_MfHp_SC_4jTx811OrNhIPzGgvyQvMIPKm8h5tlCNwM-A9WetfysxgsS2w5A&_hsmi=13360146#page=1

Massachusetts Single Payer Fact Sheet

By PNHP-Massachusetts and Mass-Care

  1. 272,000 Massachusetts residents lacked health insurance in 2012, 4.1% of the population. (Source: U.S. Census Bureau) 
  2. About 300 adults die from lack of health insurance coverage annually in the state. (Ann Intern Med  2014;160:585 & AJPH 2009;99:2289).
  3. At least 530,000 Massachusetts residents under age 65 are under-insured, meaning they have coverage, but still devote a large share of income to cover costs including copayments and deductibles. Many more lack adequate coverage for long-term care or mental health services. For 618,000 with private coverage, their premiums are so high that they’re unaffordable, according to federal guidelines. (Commonwealth Fund 2014)  
  4. Massachusetts’ per capita health costs are about 30% above the national average and continue to rise.  Between 2009 and 2011 private insurance premiums in Massachusetts increased 9.7% despite a 5.1% fall in benefit levels – effectively a 14.8% cost increase. (CMS Office of the Actuary & Mass. Center for Health Info. and Analysis)
  5. Federal, state and local governments already pay about 64% of all health costs in Massachusetts, which totals about $8,500 per resident in 2014.  This figure includes health benefits for public employees and tax subsidies for private insurance, as well as government programs such as Medicare and Medicaid. That’s more than total (public + private) health spending in any other nation. (Health Affairs, 2002;21(4):88 – updated by the authors) 
  6. Surveys show strong support for single-payer.  Nationally, 56% of adults favor a “universal program like Medicare” (ABC/USA Today/Kaiser survey, 2006) and one-third of those opposed to Obamacare say its “not liberal enough” (CNN/ORC survey, May, 2013).  Among Massachusetts doctors, 60% favor single payer or public option, a policy that many conflate with single payer (Mass Medical Society  Survey, October, 2012). 
  7. Single-payer health insurance in Massachusetts could save about $12.3 billion annually on paperwork and administration (NEJM 2003;349:768-75 Updated by authors).  Separate studies commissioned by the Massachusetts Medical Society and the state legislature found that the administrative savings under single payer would be large enough to cover all of the uninsured, eliminate all co-pays and deductibles, and upgrade coverage for Medicare enrollees – without any increase in health spending.  
    1. Massachusetts’ three largest private insurers (Blue Cross, Harvard Pilgrim and Tufts) employ about 6,600 workers to administer coverage for 5 million people (Companies’ annual reports, Boston.com and Patriot Ledger).  That’s more people than work for the Center for Medicare and Medicaid Services, which administers coverage for 49 million Medicare enrollees and 51 million Medicaid enrollees.  Nationally, private insurance overhead averages 12% vs. traditional Medicare’s 2.1%.
    2. At present, Massachusetts hospitals devote on average 24.0% of total expenditures to administration, about double the percentage for hospitals in nations with single payer systems which greatly simplify billing and the documentation that private insurers require. (Himmelstein and Woolhandler analysis of 2012 Medicare cost reports, and NEJM 2003;349:768-75). Reducing hospital administration spending to the levels in Canada would save about $3.4 billion annually.
    3. The complexity of the current payment system forces doctors and clinics to spend less time on patient care and to waste money and time on billing-related documentation and paperwork.  
  8. Whatever their other merits, the ACA and the 2006 Massachusetts reform have increased administrative costs.
    1. In Massachusetts, the costs of running the Connector have added an additional 2% overhead (on top of the private insurers’ overhead) to the policies it sells.
    2. Nationally, the cost of setting up exchanges exceeded $6 billion in 2013.  That’s about $750 for each of the 8 million people who enrolled through exchanges by March 31, 2014.
    3. In contrast, the cost of getting Medicare up and running in 1966 was $867 million (in current dollars). But that figure includes the cost of administering payment for the 18.9 million Medicare enrollees, and also doesn’t subtract the $376 million in overhead that was saved on the programs Medicare displaced.  In other words, the net startup costs for Medicare were $491 million, or $26 per enrollee.  The original Medicare sign-up form is reproduced in its entirety below.  

If you would like more information, please email pnhp@bu.edu or director@masscare.org

UnitedHealth’s Premium Physician Designation Program is not about quality

UnitedHealth Premium® Designation Program

The UnitedHealth Premium® physician designation program uses evidence-based, medical society, and national industry standards to recognize physicians for providing quality and cost efficient care.

The following designation results are displayed publicly in UnitedHealthcare’s physician directories (e.g., myuhc.com) to support informed decision-making by members when making health care choices and by physicians when making referrals.

Designation information is as follows:

  • Quality & Cost Efficiency
  • Cost Efficiency & Not Enough Data to Assess Quality
  • Quality & Not Enough Data to Assess Cost Efficiency
  • Quality & Did Not Meet Cost Efficiency
  • Not Enough Data to Assess Quality & Did Not Meet Cost Efficiency
  • Not Enough Data to Assess
  • Not Evaluated
  • Did Not Meet Quality & Cost Efficiency

Innovative Benefit Plan Designs

In addition, employers may offer health benefit programs (e.g., reduced cost-sharing or tiered benefit programs) that provide benefit incentives for members to use UnitedHealth Premium Tier 1 physicians.

Members in health plans that offer tiered benefits may pay lower co-pays and co-insurance amounts for services provided by UnitedHealth Premium Tier 1 physicians.

UnitedHealth Premium Tier 1 physicians have received one of the following Premium designations:

  • Quality & Cost Efficiency
  • Cost Efficiency & Not Enough Data to Assess Quality

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=a7b0465138a17210VgnVCM1000002f10b10a____

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UnitedHealth Premium® Physician Designation Program

Summary Methodology

The UnitedHealth Premium physician designation program uses clinical information from health care claims and other sources to assist physicians in their continuous practice improvement and to help consumers make more informed and personally appropriate choices for their medical care.

Evaluation for quality compares a physician’s observed practice to the UnitedHealthcare national rate among other physicians who are responsible for the same interventions. Cost efficiency is assessed by comparing the case-mix adjusted cost of care attributed to the physician to a benchmark and applying a statistical test to determine if the difference is statistically significant.

Quality is the fundamental measurement, demonstrating our commitment to evidence-based practice. The quality designation is separate from the cost efficiency designation. Although the quality and cost efficiency evaluations are performed separately, the results are used together to determine the physician’s designation.

Physicians who meet both the quality and cost efficiency designation criteria will receive the quality and cost efficiency designation. Physicians who meet the quality designation criteria will receive the quality designation regardless of their cost efficiency evaluation. Physicians who meet the cost efficiency designation criteria will receive the cost efficiency designation if they do not have enough data to assess quality.

Quality Assessment

A physician’s quality individual outcome is determined by comparing the number of times his/her patients received recommended care with a benchmark number based on the UnitedHealthcare national rate of the same recommended care for each quality measure.

Cost Efficiency Assessment

Episode cost measurement compares a physician’s observed costs for episodes of care to a peer group’s costs for similar episodes of care, with adjustments for the patient’s severity of illness and the physician’s case mix.

For both episode cost and population cost measurement, the physician’s costs within each set are evaluated against their peer group’s costs by ordering the costs from lowest to highest cost. The costs are converted into percentiles to allow comparison across different types of cases or patients.

Physicians’ costs must be statistically significantly lower than the peer group’s physicians at the 75th percentile performance for all physicians (measured in the same specialty for the same types of episodes in the same geographic area) in order to meet the episode cost measurement criteria.

UnitedHealthcare informs members that designations are intended only as a guide when choosing a physician and should not be the sole factor in selecting a physician. As with all programs that evaluate performance based on analysis of a sample, there is a risk of error.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Unitedhealth%20Premium/UnitedHealth_Premium_Summary_Methodology_2013-2014.pdf

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Comment:

By Don McCanne, MD

The perennial promise of private health insurers is that their insurance products would bring us higher quality care at lower cost, even though there is a paucity of evidence to support such claims. UnitedHealth now claims to be serious about delivering on that promise with their new Premium Physician Designation Program. They say that “quality is the fundamental measurement.” But let’s sort through their program description to see what the truth really is.

You can consult the websites at the links above for the detailed descriptions of how determinations of quality and cost efficiency are made. Although they state that quality is the fundamental measurement, they combine that with cost efficiency measurements and then use this information to classify each physician in one of the eight categories listed above. There are really only two designations that physicians can receive: quality and cost efficiency. If the physician receives either one or both of these designations, then these honors are displayed publicly in UnitedHealth’s physician directories.

Those designations might be nice, but what the patient really wants to know is if their physician is a Tier 1 physician. In plans that offer tiered benefits – very commonplace today – plan beneficiaries pay lower co-pays and co-insurance when they use Premium Tier 1 physicians. So what determines whether on not a physician is in Tier 1?

Of the eight categories listed, only the first two will qualify the physician as Tier 1. Either the physician must receive the designations of “Quality & Cost Efficiency” or “Cost Efficiency & Not Enough Data to Assess Quality.” Although quality is the “fundamental measurement” and is determined before cost efficiency, it is important to note that the third category – “Quality & Not Enough Data to Assess Cost Efficiency” – will not qualify a physician for Tier 1. The only way to become a Tier 1 physician is to be cost efficient; quality does not count.

It is also important to understand that even if all or almost all physicians are actually cost efficient, they are compared to their peers. “Physicians’ costs must be statistically significantly lower than the peer group’s physicians at the 75th percentile performance for all physicians.” It is impossible, no matter how efficient they are, for all physicians to gain Tier 1 status.

Further, the health care market in the United States is by far the most expensive of all nations, not only because of our prices but also due to our inefficiencies, especially our profound administrative waste. Favoring prices at the lower end of a highly inflated health care market falls far short of what we need to do to improve efficiency in our health care purchasing.

Thus UnitedHealth, for Tier 1, is selecting the cheapest physicians in an overpriced and inefficient market, regardless of the quality of their care. “Higher quality at lower cost” is a fraudulent marketing slogan of the private insurance industry. We need to throw these con artists out and replace them with our own efficient, quality-driven single payer national health program. The sooner the better.

HIP Replacement 2.0, or ‘Onward with Healthcare Expansion’

By Rob Stone, M.D.
The Herald-Times (Bloomington, Ind.), June 30, 2014

Grassroots activists across the state, including Bloomington-based Hoosiers for a Commonsense Health Plan, have been working for the past 20 months to build support for the expansion of Medicaid to low-income Hoosiers under the Affordable Care Act (ACA). Our goal is now in reach. Gov. Mike Pence unveiled his new version of the Healthy Indiana Plan, dubbed HIP 2.0, and it appears that it may accomplish exactly what we have been asking for — coverage for 300,000 to 450,000 Hoosiers currently without health insurance.

The public comment period has now closed and the formal application will be submitted to Health and Human Services by the end of the month. Coverage will begin some time in 2015.

We are proud of all we have done. Working with a broad coalition, Cover Indiana, we delivered over 10,000 petition signatures to the governor on Feb. 19, just before he traveled to Washington D.C. to meet with Secretary Sebelius, along with a letter signed by bishops and other religious leaders around the state, and copies of city and county council resolutions (including Bloomington’s) calling for Medicaid expansion. We provided all that information to Secretary Sibelius too. Newspapers across the state printed our letters and op-eds. Legislators and the governor heard our message.

Listen to the language Gov. Pence is using:

“I have long believed that a society may be judged not only by how it deals with its most vulnerable, but also by how it comes alongside those often forgotten working people who are striving every day for a better life.”

“Low-income, working Hoosiers … lack access to the kind of quality health insurance that their better-off neighbors enjoy. Many Hoosiers … cannot access affordable coverage and live in uncertainty.”

“Hoosiers have long-cherished the principle that we must ‘love our neighbor as ourselves;’ that we must not ‘walk by on the opposite side of the road’ when our neighbors are hurting and in need.”

In these words, there is an implicit understanding of the failure of our current system to meet the needs of too many, and an acknowledgement that government must take a larger role in guaranteeing access to healthcare.

The governor has made many statements about market-based reforms and he claims that HIP 2.0 is anything but Medicaid expansion under the ACA. We recognize the political reality of his position, but can only praise him for the political courage he has shown. Ultra-conservatives have lambasted HIP 2.0, asserting that it “isn’t consumer driven in any meaningful sense” (The Federalist) and, “is a Medicaid expansion with some free-market window dressing.” (Forbes).

Be that as it may, if HIP 2.0 goes into effect next year as proposed, it will be the largest expansion of health insurance coverage in Indiana since the passage of Medicare and Medicaid in 1965. 

Our work is not done. Medicaid by whatever name is a flawed program, and the ACA is only a step on the way to the ultimate goal, expanded and improved Medicare for all. Everybody in; nobody out.

Robert Stone, M.D., is director of Hoosiers for a Common Sense Health Plan.

http://www.heraldtimesonline.com/news/opinion/hip-replacement-or-onward-with-healthcare-expansion/article_aaede2d9-66dc-5762-9344-62f4e00f433f.html

In support of Medicare for all

By Jack Bernard
The Florida Times-Union (Jacksonville), June 30, 2014

My party, the GOP, is running for election this year on the slogan “repeal and replace Obamacare.”

I agree, but the question is “what will be the replacement?” My answer is Medicare for all.

From a moral standpoint, due to expansion of access to health care, the Affordable Care Act is clearly better than what we had previously. The Medicaid expansion provision, which unfortunately was made voluntary by a politicized Supreme Court, does a lot to help very low-income people who cannot afford insurance premiums.

On the other hand, of the 8 million who signed up for Obamacare nationally through the exchanges, many just switched from existing “limited” insurance policies.

In Georgia (my home), 22 percent of the population (one of the highest rates nationally) was uninsured before Obamacare.

Expanding access

Even if all 8 million had been uninsured, tens of millions are still without insurance and will be for the near future. This fact is especially true in red states like ours that have inexplicably chosen to turn back federal money to expand Medicaid, a purely political decision.

Further, because the Affordable Care Act is built on the defective private insurance model, it will never be very effective or efficient.

And with no Affordable Care Act public option, insurance companies will take advantage of consumers. For example, in the Albany, Ga., area, there is only one insurance company available via the exchange, Blue Cross. Incredibly, rates there are higher than they are in Beverly Hills, Calif.

Thus, many experts believe Obamacare does little to contain costs, the “affordable” portion of the Affordable Care Act, because private insurers are at the core of the program.

As opposed to my fellow Republicans, I do not believe that politically we can just repeal it and go back to what we had.

It is also unrealistic to propose simply doing away with Medicare and Medicaid in their current form as the plan by U.S. Rep, Paul Ryan and others in the GOP propose.

Advocating for this policy will just ensure that the GOP becomes a regional party, permanently losing national elections.

As a proven fiscal conservative, I generally do not like high taxes, especially when public money is going to the wrong places and programs.

Reducing costs

So why do I want to see more government involvement in our health insurance system via Medicare expansion to everyone? Because as opposed to many government programs, Medicare works well. Based on their experience, taxpayers (especially senior citizens like me), like Medicare.

And it is efficient, cutting out marketing and overhead expenses. Medicare has overhead expenses of only 3 percent compared to 20 percent-plus for private insurance companies.

Adding a younger and healthier cohort will automatically lower overall Medicare utilization per patient.

Another factor is the strength that being a single payer gives you in the marketplace. This has proven to be true in Canada, which spends much less than we do per capita and has better outcomes.

Obama, by nature a cautious moderate, made a major mistake in abandoning his previous support for Medicare for all. I believe that he should reverse course and establish a presidential commission to determine the exact benefits and costs of converting our current non-system to single-payer.

Before his retirement, Jack Bernard was a senior health care executive with several national firms as well as the former director of health planning for the state of Georgia.

http://members.jacksonville.com/business/columnists/2014-06-30/story/guest-column-support-medicare-all

Supreme Court decision: Whose religious freedom?

Opinion of the Court

Supreme Court of the United States, June 30, 2014

BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. v. HOBBY LOBBY STORES, INC., ET AL.

and

CONESTOGA WOOD SPECIALTIES CORPORATION ET AL., PETITIONERS 13–356 v. SYLVIA BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL.

Justice Alito delivered the opinion of the Court.

We must decide in these cases whether the Religious Freedom Restoration Act of 1993 (RFRA), 107 Stat. 1488, 42 U. S. C. §2000bb et seq., permits the United States Department of Health and Human Services (HHS) to demand that three closely held corporations provide health-insurance coverage for methods of contraception that violate the sincerely held religious beliefs of the companies’ owners.

In holding that the HHS mandate is unlawful, we reject HHS’s argument that the owners of the companies forfeited all RFRA protection when they decided to organize their businesses as corporations rather than sole proprietorships or general partnerships. The plain terms of RFRA make it perfectly clear that Congress did not discriminate in this way against men and women who wish to run their businesses as for-profit corporations in the manner required by their religious beliefs.

Since RFRA applies in these cases, we must decide whether the challenged HHS regulations substantially burden the exercise of religion, and we hold that they do.

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Ginsburg, J., dissenting

Importantly, the decisions whether to claim benefits under the plans are made not by Hobby Lobby or Conestoga, but by the covered employees and dependents, in consultation with their health care providers. Should an employee of Hobby Lobby or Conestoga share the religious beliefs of the Greens and Hahns, she is of course under no compulsion to use the contraceptives in question. But “[n]o individual decision by an employee and her physician — be it to use contraception, treat an infection, or have a hip replaced — is in any meaningful sense [her employer’s] decision or action.” Grote v. Sebelius, 708 F. 3d 850, 865 (CA7 2013) (Rovner, J., dissenting). It is doubtful that Congress, when it specified that burdens must be “substantia[l],” had in mind a linkage thus interrupted by independent decisionmakers (the woman and her health counselor) standing between the challenged government action and the religious exercise claimed to be infringed. Any decision to use contraceptives made by a woman covered under Hobby Lobby’s or Conestoga’s plan will not be propelled by the Government, it will be the woman’s autonomous choice, informed by the physician she consults.

http://www.supremecourt.gov/opinions/13pdf/13-354_olp1.pdf

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Comment:

By Don McCanne, MD

Allowing an employer to deny coverage of family planning services for employees, strictly on the basis of the employer’s own religion, is yet one more flaw in our highly dysfunctional system of health care financing – a system that is being perpetuated by the Affordable Care Act. If we had a single payer national health program, the employer would not be involved.

As Justice Ginsburg stated in her dissent, a woman’s use of family planning services should be “the woman’s autonomous choice, informed by the physician she consults.” If religious beliefs enter into that decision, it should be the religious beliefs of the individual and not anyone else.

Vermont and its educators lead the way on single payer

By Mary Ellen Flannery
NEA Today, June 27, 2014

The same state that led the nation on same-sex marriage is now tackling another social justice issue: health care coverage for all of its residents.

Led by Gov. Peter Shumlin, with the strong support of VT-NEA and its leaders, the state of Vermont is moving effectively toward becoming the first in the U.S. with a universal, publicly funded healthcare system. Also known as “single payer,” a universal system promises to contain the out-of-control costs of health care while delivering high-quality, comprehensive, and affordable care to all Vermonters, no matter their family income, employment status or background.

“Many people may have been surprised and a little curious (to hear) Vermont-NEA was backing the move toward universal, publicly funded health care,” wrote VT-NEA President Martha Allen this spring. “After all, the thinking goes, members of the state’s largest union already have comprehensive and affordable health insurance, so why on earth would they support Vermont’s efforts to become the first U.S. state to go down this road?

“The answer, of course, is that the creation of Green Mountain Care is good for Vermonters.”

Proponents of universal health care in Vermont, including many doctors and small business owners, began decades ago to pursue a unified health care system. In 2011, they won a key victory: Passage of Act 48, a state law requiring creation of a “universal and unified” health care system for the “public good” of all Vermont residents. Called “Green Mountain Care,” the new program must, by law, cover residents “in a seamless manner regardless of income, assets, health status, or availability of other health coverage.” It also must work to contain costs, provide patients with choices, and preserve and enhance primary care in Vermont’s communities.

“There’s no reason that anybody in Vermont, regardless of who they are, where they work, or what their health status is, should be without comprehensive, affordable health care,” said Mark Hage, VT-NEA’s health-policy expert. “We’ve been a leading player here to expand access to public health care  for Vermonters. This has always been important to us as a union. We believe it’s the right thing to do.”

If all goes well with the General Assembly’s next task—finding the money to pay for roughly $2 billion program— Vermonters will be enjoying Green Mountain Care in 2017, the first year that states may be permitted to enact a single-payer system under the federal Affordable Care Act (ACA). At that point, it could be a model for other states interested in following its lead.

“Vermont is a very progressive state,” said Ida Hellender, of the Physicians for a National Health Program. But the essential ingredients of Vermont’s health care system can be found anywhere: “They have doctors, they have hospitals, they have the same kinds of bodies that the rest of us do…”

Opportunity knocks

NEA has long believed that “affordable comprehensive health care … is the right of every resident,” and that belief has been codified among the NEA resolutions adopted by the NEA Representative Assembly (RA) each summer. NEA also has resolved to support a single-payer system for the United States, and to support the reform efforts that will move the U.S. closer to that goal. That includes technical and financial support for the current efforts in Vermont.

There are few things about Vermont that make it a likely pioneer of universal, publicly funded health care. For one thing, with a population of about 625,000, it’s small. (By contrast, its neighbor Massachusetts has 6.6 million residents.) “It’s possible to actually talk to almost every Vermonter about the benefits of Green Mountain Care,” said Peter Sterling, director of Vermont Leads, a nonprofit organization that advocates for universal, publicly funded healthcare. (To sign Vermont Leads’ petition for universal, publicly funded health care for all, or to contribute financially to its advocacy efforts, visit its website.)

For another thing, Sterling pointed out, Vermont already has very popular and very successful state-funded healthcare systems. Its program for kids who live in poverty, “Dr. Dynasaur,” has provided excellent care for 25 years (without deductibles or co-pays), helping to make Vermont’s children “the healthiest kids in the nation,” according to data collected by the U.S. Centers for Disease Control and Prevention. Additionally,  another state-funded, comprehensive program called Catamount Health, which existed for several years until the start of Vermont’s ACA-mandated “state exchange,” covered Vermont working families who weren’t  Medicaid-eligible.

But 47,000 Vermonters still lacked health insurance at last count, and many tens of thousands more have private insurance but can’t actually afford to use it—and it’s only getting worse for them. Nearly 90,000 Vermonters now pay for their insurance through Vermont Health Connect, an ACA-mandated “state exchange” or online marketplace, and its prices are expected to soar next year. Blue Cross Blue Shield of Vermont, which sells nearly two-thirds of the policies on the state exchange, has asked state regulators for a 9.8 percent increase; its “silver plan” would go from $425 a month to $471.

Vermont and its residents spend almost $5 billion each year on health care costs, up from $2 billion in 2000. Per person, they spent $7,876 in 2010, up from $3,776 in 2000, according to the Green Mountain Care Board.

“I hear from a lot of people who can’t afford the out-of-pocket costs. Nurses tell me that they give their patients dollars, so that they can afford their prescription drugs. If somebody has a $20 co-pay to see their mental-health specialist, they’re just not going to go,” said Sterling. “Vermont is not a wealthy state. A lot of providers are saying that their non-Medicaid eligible patients, lower-middle income people, can’t get the recommended care because they can’t afford the costs.”

Even VT-NEA members aren’t immune from these cost increases. While their collectively bargained contracts often provide affordable, high quality health benefits (in many cases, they have deferred salary increases to keep those benefits), it’s becoming harder to retain these high-quality benefits with premium co-pays that are affordable. Cost pressures, of course, are also hurting retired members.  .

Moreover, while most Vermont teachers and educational support professionals are insured through the Vermont Education Health Initiative, a unique health care trust run by VT-NEA and the Vermont School Boards Insurance Trust, eventually certain provisions in the ACA, and in state law, will hasten the dissolution of that trust, compelling almost all of those educators to join the state exchange.

“It won’t happen overnight, but it will happen,” said VT-NEA’s Hage. At that point, what’s already clear should become obvious to all VT-NEA members: The state needs a unified, universal health care system that its residents can actually afford and enjoy. And when that happens, VT-NEA will make sure its members, active and retired, do not suffer in the transition to a universal system.

“Vermont-NEA’s members have been at the forefront of social justice issues for more than a century, and have done great work to ensure that working people and their families are treated fairly, compensated justly and allowed to live with dignity,” said Allen. “We pledge to continue that great tradition and will not waver in our commitment to making sure Green Mountain Care brings comprehensive, affordable benefits for all of us.”

Vermont and its Educators Lead the Way on Single Payer

Student Board Member Position

Description:

Student representatives serving on the Board of Directors of PNHP (board) are physicians-in-training in compliance with PNHP’s constitution and bylaws.

The student representative works in a small group of 1 – 5 other students with the voting power of one total on the board. When filling vacant positions, the current student board members make every effort to achieve geographic representation of the student membership of PNHP.

The student representatives work on two levels. First, they represent the interests of physicians-in-training and health professional students on the board. Per the PNHP bylaws, “The Board shall have the general direction, management, and control of all the property, business, and affairs of the Organization. It shall determine the duties, beyond those affixed by these By-Laws, of all officers and agents of the Organization. In addition, the Board shall establish policies, issues, and strategies for Organizational activities.”

Second, the student representatives work together closely as a small group to develop and implement national programs for SNaHP (Students for a National Health Program). The representatives are expected to serve on a planning committee for and attend the annual SNaHP Summit (usually in February or March), plan student programming at the PNHP Annual Meeting and Leadership Training, and provide leadership and guidance as needed for the SNaHP Leadership Teams and national actions.

Eligibility:

Student representatives on the board member must be a physician-in-training (i.e. medical or osteopathic student), per PNHP’s bylaws. Ideal candidates will have substantial experience in PNHP and/or SNaHP locally or nationally. Forward-thinking, creative students who are eager to suggest and implement new ideas are encouraged to submit statements of interest. Students of color, women, LGBTQ, and of diverse class backgrounds are also particularly encouraged to apply.

Time Commitment:

Student board members are required to attend at least one in-person meeting with the full PNHP board of directors the day following the PNHP Annual meeting in mid-November, in addition to at least one additional in-person or phone meeting, as called by the President of PNHP. These PNHP board calls may occur as frequently as every other month.

Additionally, student board members work as a small-group through email communication and conference calls on an as-needed basis. These calls typically increase in frequency during planning months for the Annual Meeting and SNaHP Summit. Student board representatives should be prepared to rapid-respond to some email requests within 24-36 hours.

To Apply:

Send CV or resume and a brief statement of interest in the board representative role (no more than 250 words) to Emily Henkels at e.henkels@pnhp.org by Wednesday, June 7 at 11:59pm CST. Positions will be filled by July 7, 2017

Problem with defaulting to automatic plan renewal in exchanges

Department of Health and Human Services, June 19, 2014

This proposed rule would specify additional options for annual eligibility redeterminations and renewal and re-enrollment notice requirements for qualified health plans offered through the Exchange, beginning with annual redeterminations for coverage for plan year 2015.

In paragraph (j)(1), we propose that if an enrollee remains eligible for enrollment in a QHP through the Exchange upon annual redetermination, and the product under which the QHP in which he or she was enrolled remains available for renewal, consistent with 45 CFR §147.106, such enrollee will have his or her enrollment in a QHP under the product renewed unless he or she terminates coverage, including termination of coverage in connection with voluntarily selecting a different QHP, in accordance with §155.430. In this situation, we propose that the QHP in which the enrollee will be renewed will be selected according to the following order of priority: first, in the same plan as the enrollee’s current QHP, unless the current QHP is not available; second, if the enrollee’s current QHP is not available, the enrollee’s coverage will be renewed in a plan at the same metal level as the enrollee’s current QHP; third, if the enrollee’s current QHP is not available and the enrollee’s product no longer includes a plan at the same metal level as the enrollee’s current QHP, the enrollee’s coverage will be renewed in a plan that is one metal level higher or lower than the enrollee’s current QHP; and fourth, if the enrollee’s current QHP is not available and the enrollee’s product no longer includes a plan that is at the same metal level as, or one metal level higher or lower than the enrollee’s current QHP, the enrollee’s coverage will be renewed in any other plan offered under the product in which the enrollee’s current QHP is offered in which the enrollee is eligible to enroll.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/508_CMS-9941-P-OFRv-6-26-14.pdf

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Exchange Plan Renewals: Many Consumers Face Sizeable Premium Increases in 2015 Unless They Switch Plans

By Elizabeth Carpenter
Avalere, June 26, 2014

Under the Affordable Care Act, federal premium assistance is tied to the second lowest cost silver plan (“benchmark plan”) in a given region.  Subsidized exchange enrollees who select a more expensive plan must pay the difference—dollar for dollar—between the benchmark plan premium and their selection.  In six of nine states analyzed by Avalere, the 2014 benchmark silver plan will lose benchmark status in 2015. Further, in seven of the nine states, the lowest cost silver plan will also change in 2015. 

“Most enrollees in 2014 chose a plan based on the monthly premium. However, the lowest cost plans in 2014 may no longer be low cost in 2015,” said Elizabeth Carpenter, director at Avalere Health. “Before consumers renew their 2014 plan, they should consider the tradeoff between continuity of care and lower monthly premiums.”

“Two-thirds of people enrolling in silver plans are choosing one of the two lowest cost silver options,” said Caroline Pearson, vice president at Avalere. “The competitive landscape for plans is changing in 2015. However, the premium subsidies are tied to the benchmark plan and a percentage of income. Consumers have to pay the difference if they enroll in a plan more expensive than the benchmark.  Those receiving federal premium subsidies may need to switch plans in 2015 to avoid paying more than the limits established by the ACA, and the impact will be more profound for lower-income consumers.”

http://www.avalerehealth.net/expertise/managed-care/insights/exchange-plan-renewals-many-consumers-face-sizeable-premium-increases-in-20

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Comment:

By Don McCanne, MD

Acknowledging the complexity of the administration of the exchanges under the Affordable Care Act, HHS has decided to simplify the process by making renewal of plan enrollment automatic unless the enrollee decides on a different option. It is estimated that about 95 percent of enrollees will qualify for automatic renewal, and undoubtedly many will passively accept this hassle-free option. That may not be a wise choice.

The Avalere report indicates that the benchmark silver tier plan – the plan with the second lowest premium in the silver tier – will change in many of the exchanges since premium bids are changing for most plans. Since the enrollee is responsible for the full balance of the premium above the benchmark plan, net premiums for the enrollees could increase significantly unless the person opted to change to next year’s benchmark plan or a plan close to it.

As Avalere director Elizabeth Carpenter states, “(consumers) should consider the tradeoff between continuity of care and lower monthly premiums.” This means that those current enrollees who do not passively accept higher premiums will be forced to choose between higher premiums or a change in their narrow provider networks, the latter likely resulting in disruption of continuity of care.

Further, according to the HHS rule, the individual could be transferred to a different metal tier, thereby losing eligibility for the subsidies for cost sharing, though that would likely occur only in exchanges that have few choices.

Even something as simple as “automatic renewal” becomes complex when you try to rely on market dynamics to satisfy private insurers. Imagine if at renewal time you didn’t have to make a decision on what premiums you could afford, or on what provider networks you would choose when none of them quite fit, or where you might fall based on subsidy eligibility redetermination.

Imagine instead if the concept of renewal did not even exist – you were simply automatically enrolled for life. We really do need to replace this boondoggle with a single payer national health program – quality health care for everyone at a price we can afford.

UnitedHealthCare disadvantages Medicare Advantage

By the editorial board
St. Louis Post-Dispatch, June 24, 2014

One of the major flaws in the Patient Protection and Affordable Care Act is also one of the reasons it was able to pass: It accommodated, and in some ways enhanced, the role of for-profit insurance companies.

Last week, the Post-Dispatch’s Tara Kulash reported that thousands of Missouri seniors and hundreds of its doctors had learned that they’d be paying a high price for this accommodation. The patients are among the 95,000 Missourians who purchased a Medicare Advantage plan from UnitedHealthCare (2013 profits: $10 billion). Many of the doctors appear to be practicing in suburban or rural areas in such fields as dermatology, ophthalmology, gastroenterology and orthopedic surgery.

The company, the nation’s largest seller of Medicare Advantage plans, is reducing the number of doctors in its approved-provider network. It appears to be trying to steer patients into large hospital-affiliated physician groups, where there are economies of scale. By Sept. 1, eight months into the coverage year, patients will have to find new doctors.

Had there been the political will to enact a single-payer national healthcare system, this sort of problem could have been avoided.

Certain conflicts were inevitable with the ACA, one of them being the insurance companies’ desire to make as much money as possible and the government’s desire to cover as many people as possible at the lowest possible cost.

One of the ways the ACA does this is by gradually reducing its subsidies to Medicare Advantage Plans, which are purchased by about 30 percent of Medicare-eligible seniors. These 15.7 million Medicare Advantage policyholders get broader benefits and lower co-pays than the 20 percent paid by traditional Medicare patients. Indeed, those 20 percent copays help pay for the lower costs of Medicare Advantage.

But unlike basic Medicare, which is a fee-for-service plan that allows patients to see any participating doctor they want, Medicare Advantage plans are like HMOs: They specify the doctors, hospitals and other providers that patients can visit.

To offset declining federal reimbursements — or to boost profits, or both — some of the companies that sell Medicaid Advantage plans have decided to shrink the number of doctors in their provider networks.

UnitedHealthCare began cutting its provider network in Missouri and other states this spring. The second round of cuts announced last week will affect between 5 and 7 percent of the 10,000 physicians currently in UnitedHealthCare’s Missouri network.

UnitedHealthCare hasn’t offered a reason for its decisions. It owes a full explanation to doctors, patients and the public that is paying the Medicare bills.

The natural speculation is that UnitedHealthCare is hiding behind the ACA to boost its profits. In a letter to UnitedHealthCare CEO Stephen Hemsley (2010-2013 total compensation: $212 million) last spring, Thomas L. Holloway, executive vice president of the Missouri Medical Association, suggested the company is “cherry-picking … targeting the sickest, most costly patients and summarily terminating the physicians.”

The Centers for Medicare Services, which administers the program, should review such decisions. The ACA won’t work if companies can go back to dumping their sickest patients. The AARP, which teams with UnitedHealthCare on a popular Medicare Advantage policy, should reconsider that partnership. And during this fall’s enrollment period, patients might want to shop elsewhere.

http://www.stltoday.com/news/opinion/columns/the-platform/editorial-unitedhealthcare-disadvantages-medicare-advantage/article_48fb3a8c-4f42-5d9c-9c41-5cff618a247c.html

June 2014 Meeting Minutes

Granite State PNHP
Agenda, June 12, 2014
1.   Around the state: what is new?
2.    NH Single Payer legislation
a.    Drafting
3.    Educational efforts
a.    Speakers Bureau
b.    Powerpoints
c.    Movie
4.    Membership
a.    List-serv
b.    Recruiting
5.    Collaboration
a.    Students
b.    Maine colleagues

Marianne Savarese,  Health Care for Homeless, Manchester, RN  (by phone)
Chip Deming, retired Internist, Hanover (by phone)
Susan Zlotnick-Hale, Family Physician, Tilton VA
Donald Kollisch, Family Physician, WRJ VA
David Ecklein, lay member, engineer
Cosy Santiago, retired Child Psychiatrist Rumney,
John Swartz, lay member, engineer
Camilla Jones, retired Developmental Pediatrician
Susanne Smith, Rep from Hebron, Holderness
John Lloyd,  FP, Penacook NH
Richard “Dick” McNamara, Rep from Peterborough
Ahmed Kutty, retired Cardiologist, Peterborough

Around the State reports

  •  
    • Ahmed: we need a grass-roots effort and coordination with leadership
    • Dick:  History of Single-Payer in the state
      • SB 71 – Business profits tax à study committee à killed in the house
      • HB 133 (2003) – Single Payer Study à Commerce à killed in Committee and house
      • HB 88 (2007) – Single Payer Study à passed Committee à “laid on the table” in the House
    • John Lloyd –
    • Susanne – There is an MD in the House, Tom Sherman, well-respected, and one of the forces behind Medicaid expansion; he could be
    • Camilla – NHMS Survey (from UNH) – reported in the NNMS bulletin
    • John Swartz – looking forward to Community TV
    • Susan – in her visits at the VA, does a lot of education about health policy
    • Chip –
    • Cosy – talking with individuals.
    • David – blogs on the Internet (after edits from Cosy)
    • Don –
      • NH Progressive Summit – Richard Kirsch
        • 40-50 years
        • Medicare on the exchange
      • Vermont
  • Legislation
    • Susan:  VERY important for there to be a strong showing of supporters at Bill hearings. 
      • Get reporters to a well-attended hearing.
      • Don’t down-grade to a “Study Group”
      • This bill should come in this year, a budget year, because it is a “money” bill
      • Important to have support from both Senate and House
    • Camilla: we must push home the idea that SP will save money
    • Susan: Legislative Budget Accounting Office – a non-partisan group – will address all of the financial models for each bill
    • John S: the bill could include some of the ideas for fiscal impact
    • Ahmed: HR676 offers some model of fiscal implications, using language of credits, deductions, and premiums rather than the word “tax”
    • Dick: Tyler from the NH Insurance Office can help with the fiscals

            Action Steps: 

  •  
    • Don to send around the .ppt from Tyler about fiscal
    • Don to send out the NH draft bill
    • Writing Group: Ahmed, Cosy,   (who else: ?Marc, Rob, Gary)
      • Meeting
      • Resources

    Don to recruit a third and “charge” the group

  •  
    • “Our” reps can help craft it and help select a primary sponsor
  • Educational Efforts
    • Camilla: there is a 3rd draft of the NH Slide Set with slides improved based on suggestions from our last meeting – 37 slides
      • Camilla will send this to Don
    • David: consider using Google Docs for working documents
    • Don: consider having final documents available on the PNHP web-site
    • Camilla: when slide set is done, then ask all of our members to go out and give talks
    • Ahmed: the 25 minute versions of The Health Care Movie could be good for a small-group presentation.  The 67-minute version would be excellent for an already-committed group; it includes a lot of the history of Single-Payer efforts.
    • Susan: I’ll look into Red River Theater (Concord) presenting the film
    • Ahmed: we can urge our members to make a presentation at their hospital’s Grand Rounds
    • John L: watch Escape Fire
  • Membership
    • Camilla: the ListServ has activated a few members
    • Camilla: put on the ListServ “if you know colleagues who are interested, they can be involved even if they aren’t members of PNHP” – Cosy/David will post it
    • Ahmed: when we are ready, send out a solicitation to NHMS members
    • Camilla: WFEA AM radio station – “On Call with the NHMS” -Scott Colby interviews people on Wednesdays from 9-10am
    • Dick: there are a lot of other radio/TV show hosts
    • John/Camilla:
    • John: Todd Buckman of NHPR is on the contact  list  for PNHP Press Release
  • Collaboration
    • Don: will reach out to PHR to let them know that we have speakers available to address Health Care as a Human Right
    • Don: may reach out to our colleagues in Maine and Massachusetts, as well as Vermont

Transition to defined contributions is underway

Shifting toward Defined Contributions — Predicting the Effects

By Kevin A. Schulman, M.D., Barak D. Richman, J.D., Ph.D., and Regina E. Herzlinger, D.B.A.
The New England Journal of Medicine, June 26, 2014

When Representative Paul Ryan (R-WI) attracted national attention by joining Senator Ron Wyden (D-OR) in proposing a sweeping privatization of Medicare, he was variously vilified and praised for suggesting that Medicare should be converted from a defined-benefit program to a defined-contribution program. Although there has been little congressional action to advance the Wyden–Ryan plan, defined-contribution programs are becoming increasingly prevalent in employer-sponsored health insurance and may ultimately bring about substantial changes in U.S. health care.

A defined-benefit program provides specific benefits to enrollees when those benefits are needed. For example, a defined-benefit pension program provides payments of specified amounts to retirees. Defined-benefit health insurance, such as Medicare and most private plans, pays for specific health care services when eligible beneficiaries demand such services. In contrast, a defined-contribution program — like most typical 401(k) retirement plans — provides certain financial support to beneficiaries before any benefits are consumed, and beneficiaries then spend those funds to meet their eventual expenses. In defined-contribution pension plans, only the financial contribution is defined, and the extracted benefits are determined by the payment and investment preferences of the beneficiary.

Economists have posited that defined-contribution health insurance plans offer two key benefits. First, enrollees in such plans receive more choice than they would in the one-size-fits-all plans typically offered by employers. They can thus consider the quality of plans and express their preferences for various features of benefits packages, such as open or limited provider networks and low or high deductibles. Second, defined-contribution plans can give employers greater certainty about costs, insulating them from unpredictable health care inflation. Such plans might also curb or reverse the trend toward employees’ passively shouldering the growing costs of employer-based defined-benefits plans. (Between 2003 and 2013, employer spending increased by 77%, while employees’ costs increased by 89%.1) In a competitive labor market, with the transparency of a defined-contribution plan, employers would have to compensate employees through higher wages for any shifting of additional health care costs, although increased compensation might only need to match employees’ perceptions of the value of the lost benefits.

One largely overlooked attraction of defined-benefit plans is related to the political economy of firms. Because the tax exemption for employer-provided health insurance often hides what employers pay for employees’ health insurance, many employees demand costly plans without realizing that the employer’s contribution ultimately reduces their own take-home pay. A defined-contribution plan, in contrast, makes insurance premiums more transparent, thereby inducing employees to demand more affordable health plans because they are aware of the full amount they pay. For example, when human resources consultancy Aon Hewitt helped companies implement insurance plans under a defined-contribution system in 2013, 42% of employees purchased less expensive plans, 32% purchased coverage similar to what they had previously had, and only 26% bought more expensive coverage.

The intellectual appeal of the Wyden–Ryan plan rested on this logic. Its supporters argued that because the risk of higher-than-expected health care inflation would be shifted onto Medicare enrollees, who would be empowered to exercise consumer choice, the market dynamics would change. On one hand, there would be greater cost consciousness behind consumer demand; on the other hand, supply would reflect greater competition for consumers’ premium dollars.

If Medicare reforms do not adequately address the excessive costs of health care, converting the program to a defined-contribution plan could leave many seniors uninsured or exposed to unaffordable health care bills, thereby undermining one of the fundamentals of the Medicare program — protection against financial risk — while leaving providers with major revenue shortfalls.

Although Medicare seems unlikely to be transformed into a defined-contribution program in the immediate future, the private insurance market is shifting toward defined contributions. Many large companies — including IBM, Duke Energy, and Time Warner — are now pursuing defined-contribution strategies for their retirees; others, including Walgreens, are doing so for current workers. Some companies have designed private insurance exchanges through which workers and retirees can purchase insurance plans, and others may encourage retirees to purchase insurance through private exchanges or the public exchanges established under the Affordable Care Act. A recent survey suggests that 58% of employers have confidence in private exchanges as a viable alternative to the plans they currently offer employees and that “employers are intrigued by the potential of private exchanges to control cost increases, reduce administrative burdens and provide greater value.”

Some observers have expressed legitimate concerns that employers could limit their payments for health benefits by increasing wages by amounts less than those of employees’ medical costs. In theory, a competitive labor market would ensure that total employee compensation remained at competitive levels, thereby preventing employers from using defined-contribution mechanisms in this way. But competitive labor markets require compensation to reflect productivity. In rigid sectors of the economy, defined-contribution strategies could burden employees disproportionately with the weight of medical inflation.

Yet the appeal of defined-contribution plans — whether as part of Medicare reform or in the form of changing benefits for retirees and workers — remains potent. Defined-contribution strategies reveal to employees and health insurance customers any cost increases that exceed the growth of wages, and individuals purchasing insurance on exchanges have shown a growing preference for lower-priced plans that increase cost sharing for health expenditures. In 2013, for example, Aon Hewitt found that the proportion of employees who selected high-deductible plans (most of which included a contribution to a health savings account) increased from 12% to 39%, while enrollment in preferred provider organizations decreased from 70% to 47%.

Defining the contributions to health care expenditures before containing health care costs might be placing the cart before the horse. On the other hand, making such inflation visible and painful to consumers is one tool for bringing costs under control.

Whether or not providers and consumers are ready, defined-contribution benefit plans are growing in popularity. They will unquestionably have both short- and long-term consequences for providers. They will bring greater transparency to health care costs and health care inflation, and they will probably give insurance purchasers greater motivation to attend to insurance prices, stimulating the provision of lower-cost insurance.

Because insurance premiums are ultimately the primary source of revenue for providers, cost consciousness among consumers will impose new fiscal constraints on providers. For some highly leveraged providers — especially those who expanded costly infrastructures that relied on lucrative fee-for-service revenue models — even small changes in the private health insurance market could have substantial financial effects. In this world, providers’ future success will depend on their ability to sustain themselves on a flattening allowance.

Over the long term, greater consumer sensitivity to insurance premiums will affect all providers. It is a truism that the growth of health care costs — or, phrased differently, the growth of provider resources — will be bounded by the growth of health care revenue. A dramatic shift in the revenue available to providers will impose strong cost pressure. And such pressure, in turn, can be seen as a new opportunity for developing more cost-efficient delivery mechanisms.

http://www.nejm.org/doi/full/10.1056/NEJMp1314391

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Comment:

By Don McCanne, MD

This article from the prestigious New England Journal of Medicine should alarm anyone who cares about ensuring that everyone has access to health care. We are now seeing a rapid conversion of health care financing from defined benefit (paying for appropriate health care) to defined contribution (paying a specific dollar amount while placing upon the beneficiary the responsibility of using those funds to find affordable care, if possible). This places the burden of health care inflation most heavily on those who have the greatest health care needs when these individuals and families are already over-burdened with our deficient system of health care financing.

Look at the explanation that these authors give as to why defined contribution is a superior method of financing health care:

  • Patients would not be stuck with a one-size-fits-all plan of comprehensive benefits that covers their essential care but rather would be allowed to forgo crucial health care services that they could not afford (permitting them to accept suffering, disability and even death as a small price to pay for not selecting a plan that they couldn’t afford).
  • They would have the right to plans that exclude from provider networks physicians and hospitals that they might need in the future but would not be able to afford.
  • They would have the right to enroll in plans with high deductibles that have been proven to impair access and create greater personal financial hardships.
  • They can rest assured that their employers will be insulated against future increases in health care costs, while graciously accepting for themselves the costs of unpredictable health care inflation.
  • They can personally experience the ongoing deterioration in labor markets as employers decline to provide as wage increases the savings in the costs of their health benefit programs – a valuable lesson in the differences between market ideology and the actual application of market dynamics.
  • They need not understand the value of their lost benefits (i.e., “increased compensation might only need to match employees’ perceptions of the value of the lost benefits” – the fools know not what they are deprived of).
  • With greater transparency in premiums under defined contribution, employees would be in a position to demand only the lower premium plans that they could afford, even though that can be disastrous should health status change for the worse. (Employees choose low premium plans not because they want less coverage but rather because they cannot afford the higher premiums of more comprehensive plans.)
  • Employees can be reassured by the fact that their “employers are intrigued by the potential of private exchanges to control cost increases, reduce administrative burdens and provide greater value” – for the employers that is. There is nothing like a work environment that takes good care of the employers.

Perhaps there is a limit to what the employee/patient/beneficiary/consumer may support in this transition to defined contribution financing of health care. According to these authors, “Defining the contributions to health care expenditures before containing health care costs might be placing the cart before the horse. On the other hand, making such inflation visible and painful to consumers is one tool for bringing costs under control.”

Ah ha! We need to switch to defined contribution financing because it will make health care inflation “visible and painful to consumers.” Clearly there had to be more advantages than just those listed above. There ain’t no gain if there ain’t no pain.

Regina Herzlinger is an icon in the consumer-directed policy community. They are winning the battle, and the people are losing. If you like the policies listed above, you don’t need to do anything. Regina and her friends will take care of it for you.

For the rest of you, get over the lousy satire and go out and fight the battle for health care justice for all.