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Insurance companies are requiring higher out-of-pocket expenses to pay for complying with new rules

By Peter Frost
Chicago Tribune, Oct. 13, 2013 Adam Weldzius, a nurse practitioner, considers himself better informed than most when it comes to the inner workings of health insurance. But even he wasn’t prepared for the pocketbook hit he’ll face next year under President Barack Obama’s health care overhaul. If the 33-year-old single father wants the same level of coverage next year as what he has now with the same insurer and the same network of doctors and hospitals, his monthly premium of $233 will more than double. If he wants to keep his monthly payments in check, the Carpentersville resident is looking at an annual deductible for himself and his 7-year-old daughter of $12,700, a more than threefold increase from $3,500 today. “I believe everybody should be able to have health insurance, but at the same time, I’m being penalized. And for what?” said Weldzius, who is not offered insurance through his employer. “For someone who’s always had insurance, who’s always taken care of myself, now I have to change my plan?” Many Illinoisans buying health coverage on their own next year will face a similar dilemma spurred by the health care overhaul: pay higher monthly insurance premiums or run the risk of having to shell out thousands more in deductibles for health care if they get sick. To promote the Oct. 1 debut of the exchanges, the online marketplaces where consumers can shop and buy insurance, Obama administration and Illinois officials touted the lower-than-expected monthly premiums that would make insurance more affordable for millions of Americans. But a Tribune analysis shows that 21 of the 22 lowest-priced plans offered on the Illinois health insurance exchange for Cook County have annual deductibles of more than $4,000 for an individual and $8,000 for family coverage. Those deductibles, which represent the out-of-pocket money consumers must spend on health care before most insurance benefits kick in, are higher than what many consumers expected or may be able to stomach, benefit experts said. By comparison, people who buy health insurance through their employer have an average individual deductible of just more than $1,100, according to the Kaiser Family Foundation. Although millions of Americans will be eligible for federal assistance to help offset some of those costs, millions will not, underscoring one of the trade-offs wrought under the law’s goal to ensure most people have access to health insurance. “It’s been major sticker shock for most of my clients and prospects,” said Rich Fahn, president of the Northbrook-based insurance broker Excell Benefit Group. “I’m telling (clients) that everything they know historically about health plans has changed. They either have to pay more out-of-pocket or more premiums or both. It’s an overwhelming concern.” Plans with the least expensive monthly premiums — highlighted by state and federal officials as proof the new law will keep costs low for consumers — have deductibles as high as $6,350 for individuals and $12,700 for families, the highest levels allowed under the law. Because the federal website that runs the Illinois exchange remained largely inoperable as of late last week, the Tribune used data from websites of four of the five insurers that will offer plans in Cook County on the marketplace. One insurer, Coventry Health Care, did not have plans available on its website last week but provided data to the Tribune. Insurers say the price and cost hikes result from new benefit mandates, additional taxes levied as part of the law and a requirement that they can no longer deny coverage to people with pre-existing medical conditions. The vast majority of insurance plans for 2014 must include a list of 10 essential health benefits, some of which, like maternity care, weren’t necessarily included in all health plans a year ago. The law also includes mandatory coverage of mental health and substance-abuse treatment, prescription drugs and rehabilitative care. All preventive care, including annual physicals and routine immunizations like flu shots, must be covered at no cost. Further, insurers are required to take all applicants, regardless of whether they have pre-existing medical issues that may have locked them out of coverage in the past. And they’re prohibited from charging their oldest, sickest members any more than three times as much as their youngest, healthiest members, causing premium prices to rise for many younger people. Costs associated with those mandates are passed along to all members of a health plan. Considering those factors, “the rates are actually quite reasonable,” said Kelly Sullivan, a spokeswoman for the Illinois health insurance marketplace. Under the law, most of the estimated 15 million Americans who bought plans individually this year, like Weldzius, will have to choose new insurance coverage that meets federal guidelines. Because of the myriad changes to most plans, “it’s hard to know whether you’re really going to be able to compare like policies” from year-to-year, said Karen Pollitz, a senior fellow with the nonprofit Kaiser Family Foundation. The health care law established four broad categories of coverage — platinum, gold, silver and bronze — for which premiums vary based on the amount of out-of-pocket health care expenses consumers are required to pay. Bronze plans have the lowest monthly premiums, but they cover only 60 percent of projected medical costs. Platinum plans have higher premiums but cover 90 percent of medical costs. State officials expect most consumers to select either bronze or silver plans because monthly costs are lower. To develop the new plans that meet the federal coverage levels, insurers in Illinois took two distinct routes. Land of Lincoln Health, a new nonprofit insurer, opted to design most of its bronze and silver plans with lower annual deductibles in exchange for higher monthly premiums. All of its plans also offer a broad range of providers, though certain discounts are available for using a selection of them. “When we sat down and looked at how to design our plans, we felt it was very important for consumers to not be afraid to use their health coverage,” said Dan Yunker, Land of Lincoln’s chief executive. “We can’t have people not using their health plan because they can’t afford it when it’s time to use it.” Meanwhile, the state’s dominant insurer, Blue Cross and Blue Shield of Illinois, was able to offer plans with lower monthly premiums by crafting narrower networks of doctors, specialists and hospitals. The least expensive “Blue Choice” plans offered by Blue Cross, which carry the lowest monthly premiums in Cook County, contract with 4,100 primary care providers in the Chicago metro area. That compares with about 15,775 providers in its largest preferred provider network, according to company data. The “Blue Choice” network also includes 57 acute-care hospitals versus 213 in the larger network. People who choose to go to an out-of-network hospital or physician will foot the entire bill, in most cases, and those expenses typically are not applied toward annual deductibles. The network “was created to offer a most cost-effective and affordable network of physicians and hospitals without compromising quality,” said Steve Hamman, the insurer’s senior vice president of network management. Company data show that patient outcomes are actually slightly better in its narrower network, he said. Some plans offered by Humana Inc. and Coventry also have narrow networks. Insurers and brokers recommend people carefully study narrow-network plans to ensure their preferred doctor and hospital are included. “Y ou have to be very careful about choosing a plan with a smaller network … or there will be some big surprises,” Fahn said. Insurance brokers and health care experts also urge caution for consumers who choose plans with higher deductibles. “Yes, rates are really low, but that’s like saying, ‘Here’s a free car,’ but if it costs you $500 a month to run, it’s not really a free car,” said Dave Stumm, executive vice president at Stumm Insurance, a Chicago-based brokerage. Fahn calls the bronze plans “smoke-and-mirrors catastrophic plans,” which don’t provide benefits until and unless something bad happens — a car wreck, a major surgery or a chronic illness. For many low-income Americans, the law offers some help, though how much will vary by the individual. The vast majority of the uninsured — an estimated 80 to 90 percent, according to the Congressional Budget Office — who buy coverage on the exchanges will qualify for federal subsidies in the form of tax credits. Those who make up to 400 percent of the federal poverty level (about $46,000 for an individual and $94,200 for a family of four) will be eligible for the subsidies to help offset the cost of premiums. Further, people with incomes up to 250 percent of the federal poverty level (about $28,700 for an individual and $58,900 for a family of four) will qualify for cost-sharing subsidies that will reduce deductibles, in some cases substantially. Brokers say they worry most about people who qualify for lower subsidies or none at all. Those with more modest incomes might not have enough in savings to pay for medical expenses. They “could get slammed if they get sick,” said Pollitz, of the Kaiser Family Foundation. “They just won’t have the money. They just won’t.” A potential consequence could be that some individuals may not seek medical care beyond routine office visits when they should, dissuaded by the specter of having to pay for it out of pocket. “They’ll just live without,” Pollitz said, “kind of like they do now.”

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The ACA will actually hinder efforts towards adopting a single-payer system, writes health care reform advocate.

By Margaret Flowers, M.D.
Al-Jazeera, Oct. 14, 2013

On the first day that the new health insurance exchanges went into effect as part of the new health law, the Affordable Care Act (ACA), I was caught off guard by a question asked by Bruce Dixon of the Black Agenda Report. I was prepared to detail the complexities of the ACA, but Dixon’s only question was: “What would it be like if this was the first day of a single-payer health system?” Most media outlets in the US are solely focused on the ACA – either promoting it as a positive step or calling for its repeal.  This limited debate misses the facts that a single payer health system, also called Medicare for all, would both resolve the fundamental failings of our current system and is the solution favored by most Americans.

What we are hearing in the US is fear-mongering from extreme right-wing groups, who have gone so far as to shut down our government in their attempt to remove funding for the health law, and deceptions from Democrats and their front groups about the virtues of the ACA. This is what happens when a basic issue such as health care is determined by politics instead of policy. In fact, the ACA was born in a right-wing think tank, the Heritage Foundation, and is only supported by “progressives” because it was passed by a Democratic president.

I suspect this manufactured confusion may sort itself out over time as more people discover that having health insurance in the US doesn’t guarantee access to necessary care. In the meantime, I will try to cut through the spin and hyperbole to explain why the ACA is not a step in the right direction and what health care would look like if we implemented a publicly-financed “Medicare for All.”

Here are the top three facts that need to be addressed:

* The rise of health care costs are slowing, but not because of the ACA.

* More people will have health insurance but that doesn’t mean they will have access to health care.

* The ACA further privatizes our health care system, which is the opposite of single payer.

White House spokesperson Jay Carney stated numerous times recently that the slowing of the rise of health care spending in the United States is a result of the Affordable Care Act. In fact, the slowing of total health care spending actually began after the economic crisis of 2008, which was prior to the ACA being signed into law in 2010. As I wrote earlier this year, the slowing of health care spending was due to self-rationing. As more of the cost of health care is shifted onto the individual, we see less utilization of health services.

For example, a recent report found that low-income workers with health plans that required high out-of-pocket payments in Massachusetts did not go to the emergency department for serious medical conditions because of the costs. They had 25 to 30 percent fewer visits, whereas high income workers with similar plans did not reduce their visits. A health survey from 2012 found significant increases in the number of people who did not get care because of the cost (80 million total), who had difficulty paying medical bills (75 million) and who went into bankruptcy as a result (4 million over 2 years).

It is not likely that the ACA will have a positive effect on health care spending, by which I mean making health care more affordable. As economist Dean Baker writes, we will continue to pay high prices for medications, medical devices and physicians. Although there are proven methods to control health care costs such as simplified administration, global budgets and negotiating bulk prices, none of them were included in the ACA. In fact, the ACA increases our already enormous administrative costs by adding new levels of administration to our health system.

While it is true that because of the ACA more people will have health insurance in the US, what is not discussed is that tens of millions of people will still be without health insurance of any kind. There are 48 million people without insurance and that number is expected to fall to 31 million in 2019. Although historically in the US, estimates of new coverage are always overblown. At the state level, similar new programs that were predicted to lead to universal coverage fell far short of their goals and ultimately failed completely. Even though, because of the ACA, young adults up to the age of 26 can stay on their parent’s health plans, this has had only a tepid effect. The percentage of 19 to 26 year olds without insurance has fallen from 48 to 41.

Health insurance does not equate to health care

In the US, having health insurance does not guarantee access to necessary health care. The ACA will increase the number of people who have inadequate insurance which requires high out-of-pocket costs and does not cover all necessary services. This trend towards underinsurance has been growing steadily over the past decade so that currently about one-third of employer-based health insurance and half of individual plans are high-deductible plans. It is expected that in 2014, 44 percent of major US companies will only offer high-deductible health plans.

The ACA has significantly lowered the bar for what is considered to be adequate health insurance coverage. On the new health insurance exchanges, plans are offered based on four tiers. The Platinum plans will pay for 90 percent of covered care and Bronze plans, the lowest tier, will pay for 60 percent of covered services. It is important to distinguish that these levels are only for covered services because people don’t usually understand that they will have to pay for uncovered services and out-of-network services. Unfortunately, the use of out-of-network services is often involuntary and occurs without being known at the time of care, especially in emergency situations.

Subsidies are being offered to help people purchase insurance. These exist on a sliding scale for people who earn 133 to 400 percent of the Federal Poverty Level (FPL). If an uninsured person earns below 133 percent of the FPL and lives in one of the 26 states that did not expand their Medicaid programs, that person is likely to be out of luck. And the subsidies only apply to the Silver plans, which cover 70 percent, or to higher level plans. Because t he subsidies are believed to be inadequate, it is expected that many people will choose the least expensive Silver or Bronze plans.

Subsidies can only be used to purchase plans in the state or federal exchanges. Employees will not qualify for subsidies to purchase insurance offered by their employer; but if what their employer offers costs above a certain percentage of their income, they can purchase insurance on the exchange and possibly receive a subsidy. Some employers will stop offering insurance and will instead provide what is called premium support, or funds that can be used for buying insurance. And some employers will decrease their employee’s hours below the 30-hour per week threshold that relieves them from the mandate to provide insurance or pay a penalty. These actions will push more people into the exchanges.

Pre-existing caveats

Insurance companies have a long history in the US of skirting regulations that interfere with profits. So, while insurers can’t exclude sick people, they can avoid areas where there are sick people. For example, several of the large insurance companies are selling plans on only a small number of exchanges, preferring to sell plans mostly to businesses instead. And companies that sell plans on the exchanges are restricting their networks. They avoid hospitals that care for complicated patients and keep the number of doctors in their plans low, making it more likely that people will have to go out of network and pay more of the costs of care.

And while companies can’t charge more to people with health problems as individuals, they can charge up to three times more based on age and can charge more in geographic areas where the population has more health problems or the costs of care are higher. It is expected that if a company finds they can’t make enough profit in a particular area, they can just pull their plans from that area. These are some of the most obvious ways that insurers will game the system. The largest insurance companies assisted with writing the law and then with the regulations that accompanied it, so we will see what other tactics they employ as time goes on.

The new health system is complex by design because that inhibits transparency and accountability. Imagine what we would be seeing right now if instead of the ACA, we had passed HR 676, also known as Expanded and Improved Medicare for All. This would have created a single publicly funded non-profit universal and comprehensive national health insurance. Overnight, everyone living in the US would be eligible for care without financial barriers. Any person who showed up to a health facility for care would be admitted because they would be automatically enrolled. Every person would have the right to receive the care they need rather than the care they can afford.

Some people believe that the ACA is a step towards a Medicare for all health system, but it actually takes us towards greater privatization of our health system which is the opposite direction. Over a trillion dollars of public funds will go directly to private insurance companies to subsidize the purchase of inadequate health plans. Nothing was done to stem the tide of large health corporations that are acquiring and consolidating health facilities. And since the ACA was passed in 2010, our public insurances, Medicaid and Medicare, have become more privatized. Private Managed Care organizations are taking over Medicaid plans. And Medicare Advantage plans, private insurance plans that are more expensive than traditional Medicare, were supposed to be curtailed by the ACA but have actually grown by more than 30 percent.

We have not changed the fundamental problem with the health care system in the US: that health care is treated as a commodity to be bought on the market rather than as a good that all people need. In fact, the dominant message in the mass media is that the ACA has created a health insurance marketplace as if this is a good thing for patients. The United States is the only industrialized nation that uses a market-based health system and it has clearly failed. The US spends the most by far on health care and has low life expectancies and poor health outcomes to show for it. I often say that if our health system was a medical experiment, it would have to be stopped for ethical reasons.

Perhaps television comedian Jon Stewart summed it up the best when he recently said, “I don’t understand the idea of staying with a market-based solution for a problem where people can’t be smart consumers. There are too many externalities in health care that I honestly don’t understand, why businesses would jump at the chance to decouple health insurance from their responsibility, and why the government wouldn’t jump at the chance to create a single-payer that simplifies this whole gobbledygook and creates the program that I think America deserves.”

Only a single payer, Medicare for all health system will begin to correct the many problems with the health care system in the United States. Grassroots groups across the country continue to organize support for Medicare for all. And just as similar groups did in Canada and Mexico, we believe that one day we will succeed as well. We aspire to join the ranks of civilized countries who understand that a healthy population makes a better society and is best achieved through national health insurance.

Margaret Flowers, MD, served as Congressional Fellow for Physicians for a National Health Program and is on the board of Healthcare-Now. She is co-director of It’s Our Economy and co-host of Clearing the FOG Radio Show.

http://www.aljazeera.com/indepth/opinion/2013/10/beyond-spin-some-facts-about-affordable-care-act-2013101483653308300.html

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By the Editorial Board
Inside Tucson Business, Oct. 11, 2013 The nasty fight over Obamacare that has shutdown our country and threatens to destroy the world if the U.S. defaults on its loans is seen as a liberals vs. conservatives battle. Liberals see it as compromise legislation that finally found a way to bring millions of uninsured Americans under a health insurance umbrella through expanded indigent health care rolls and mandated insurance purchases by businesses and individuals. Conservatives, who used to be pro-business Republicans, see Obamacare as a hideous government takeover of the national health system. It’s neither. It’s a sloppy wet kiss to the U.S. health insurance industry. Which could be seen as pro-business, assuming you’re in the health insurance business or own stock in one. It also has the potential to be pro-business in that it could unintendedly relieve American businesses of the burden of subsidizing their workers’ health insurance. The Affordable Care Act is so complicated it was bound to be beleaguered by the law of unintended consequences. One of the most prominent has been the 30-hour rule, in which companies with more than 50 workers must offer any employee working more than 30 hours a week subsidized health insurance. That has prompted some employers, mostly small franchisers who hire mostly part-time workers, to cut maximum employee hours to 29 to avoid the mandate. But while that has been cause for a lot “I told you so” shouting on conservative media, it hasn’t proved to be very prevalent. While there are anecdotal incidents of a few hundred companies saying they’ll cut worker hours, it’s a drop in the bucket in the massive American workplace. Moreover, a survey of American employers last month by an international human resources foundation found that 69 percent of companies planned to continue to offer their employees health insurance subsidies after the federal-run health insurance exchanges open next year. So clearly, some companies will continue to offer a subsidy. Which creates another law of unintended consequences. If the company offers the employee the subsidy, and the subsidy is less than 9.5 percent of the employee’s household income, the employee is mandated by the ACA to purchase the insurance through the employer even if the employee could buy cheaper insurance through the exchange. That’s perverse and unfair. But, the employer could help out their employee by ceasing to offer insurance subsidies at all, forcing the employee to purchase insurance through the exchange and likely receiving a federal taxpayer subsidy in the process, making their insurance costs even cheaper. That’s what has some fiscal conservatives whipped into a lather. Once employers and employees figure out how to beat the shell game, they will. And the taxes the ACA imposes are insufficient to cover the full cost of 100 million or more Americans qualifying for a federal subsidy for health insurance. But that’s no different than that unfunded Medicare Part D drug coverage passed under the Bush Administration, which itself was a sloppy kiss to the pharmaceutical industry. It didn’t destroy the country, it just made it poorer. Obamacare will do the same thing, it won’t destroy the country, it will just make it poorer. But it could make business more profitable. The largest cost of business is labor and one of the largest labor costs is health care insurance. American businesses should not be in the business of helping their employees buy health care. That should be the responsibility of the employee. After all, employers don’t help pay for their employees’ housing or food. The only reason employers do it is because everyone else does it. You had to do it to be competitive because competitors could better recruit and retain employees if they offered health care insurance and you didn’t. But now, it might be more competitive to stop offering health care since an employer wouldn’t be throwing their employees into the ravages of the uninsured wilderness – Obamacare would be there to catch them. But even if that would be good for business, it wouldn’t necessarily be good for the country, or health care. One of the great failings of Obamacare is that it doesn’t solve the primary problem, which too many people believe to be the millions of uninsured. The primary problem with American health care is the runaway costs that are crushing the country. The reasons for those double-digit cost increases year after year are legion: Expensive diagnostic systems and tests; reflexive and defensive medicine caused by unconstrained malpractice claims; fee-for-service medicine in which a doctor doesn’t get paid unless he or she “does” something to the patient, like order a test; distorted health insurance markets caused by massive tax subsidies (paying premiums with pre-tax income); and the rise of medical specialization in which patients have to see specific doctors for specific problems, among other reasons. There is a solution out there that could be good for the country, good for Americans and good for American business. And that’s single payer insurance. That’s right, Medicare. If everyone in the country received Medicare, everyone in the country becomes responsible for their own health care consumption. It’s not a panacea, to be sure. One of the risks of nationalizing health insurance is the urge to then nationalize health care provision. The fear is that if Americans view their health care as “free,” paid for by the government, they’ll get as much as they want, or worse, more than they need. And in fact, health care providers would encourage them to do so because it would mean money in their pockets. Nationalized health care provision is then seen as the counter to that. But Medicare has been able to function for more than 50 years without having to resort to nationalized health care by a regime of strict payment controls and regulations. Another drawback is we would have to add to Medicare what it currently doesn’t have, a tax to pay for it. All of that would be hard to do. Perhaps impossible in the current political climate. But there is no question it would be a boon to American business. Employer health insurance subsidies cost American employers nearly $1 trillion a year. Some of the savings would be eaten up by a new Medicare tax, but that tax would be spread among all Americans meaning employers would still see significant savings just in the absent subsidy alone. But there would be additional, ancillary savings. Most American businesses, on top of paying the insurance subsidy, spend hundreds of billions of dollars a year just managing their employees’ health insurance plans. Whole armies of human resources and benefits employees are needed to manage health care plans. American hospitals and doctors’ offices spend billions on staff and technology to keep track of all the insurance plans patients have, filling out forms and fighting with insurance companies to get paid. All of that goes away with single payer. Those savings would more than offset the tax to pay for it. Obamacare could save American employers billions. Medicare for all could save it more than a $1 trillion. That’s a lot of potential profit. And isn’t that what it’s all about? http://www.insidetucsonbusiness.com/opinion/editorials/medicare-for-all-would-be-good-for-business/article_d74b674a-31f6-11e3-b381-001a4bcf887a.html

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The right hates the new healthcare law because they think its reach will be universal. The problem is the opposite.

By Adam Gaffney, M.D.
Salon, Oct. 10, 2013

The battle for universal healthcare is not over. This is not because of the reason you might suspect – that Republicans will obstinately endeavor to obstruct Obamacare in every way they can (though that seems to be the case). Instead, even after the smoke clears from the government shutdown (presumably with the law intact), the battle over universal healthcare will still not be over, but for a more fundamental reason: Obamacare, whatever its advantages (and despite the right’s worst fears), does not create a system of universal healthcare.

Now first, to be clear, this is not to say that Obama’s Affordable Care Act won’t help many people. The uninsured who become eligible for coverage through the expansion of Medicaid, for example, will of course be better off – assuming they don’t live in one of the 20 or more states that have callously elected to deny them this potentially lifesaving opportunity. Additionally, many uninsured who were previously unable to afford private health insurance may now be able to do so, for instance through the new income-based premium subsidies. And most of us will benefit from many of the law’s insurance reforms, like the one that prevents insurers’ from denying us coverage because we are sick.

And at the same time, have no doubt: The various Republican alternatives for American healthcare would be disastrous. Consider the most recent GOP healthcare proposal H.R. 3121, which would gut state insurance regulations, eliminate popular ACA reforms like the ban on “preexisting conditions,” end the Medicaid expansion, and provide tax benefits that would preferentially benefit the wealthy, among other unhelpful proposals that would do nothing to help the uninsured. Conservative “consumer-driven” healthcare dreams, more generally, would in truth be nightmares, radically furthering the transformation of healthcare into yet another commodity, bought by “consumers” in proportion to their means, not provided to patients on the basis of their needs.

Yet these facts don’t change the fundamental fact that the ACA will not create what so many of us want, what the right so fervently fears, and – most important – what so many people really need: true universal healthcare. Why?

First, on a basic level, the ACA is not universal healthcare because though it will reduce uninsurance, it won’t provide universal coverage. According to the Congressional Budget Office’s May 2013 estimates, even by 2020 some 30 million Americans will be left uninsured under the ACA, a number that can only be partially attributed to intransigent Republican state governments that have blocked the expansion of Medicaid in their states.

But even putting aside those 30 million people, the ACA is insufficient because it will not deliver what most of us think of as universal healthcare: a system of equitable and comprehensive care for all, with full protection against the cost of illness. Indeed, on the contrary, underway already is a “quiet revolution” in American healthcare, in the words of Dr. Drew Altman of the Kaiser Foundation, that moves us “from more comprehensive to less comprehensive” health insurance, with patients paying more and more out of pocket every time they get sick. Ironically, even with the ACA going into full effect, “the vision of insurance that they’ve [conservatives] always favored,” as Altman told the New York Times, “with more skin in the game, is the one that’s coming to dominate in the marketplace.”

The data clearly show, for instance, that with each passing year, more and more of the insured are already paying higher and higher deductibles, co-pays, and co-insurance whenever they actually need to use their expensive insurance (despite unsurprising evidence that rising out-of-pocket expenses can deter people from seeking needed medical care). In another disturbing trend, major employers – including Walgreens, Sears and Darden restaurants – seem to be moving away from “fixed benefit” health insurance to “fixed contribution” plans, in which employees receive a lump sum to buy a healthcare plan, with no guarantee that these contributions will keep up with the cost of health insurance in future years. It should be noted that this “quiet revolution” toward higher out-of-pocket expenses and more limited benefits is not of the ACA’s making. At the same time, however, the ACA will do little to reverse it (and, in the case of the new excise tax on “Cadillac” healthcare plans, may even exacerbate it).

Meanwhile, for those not insured by their employer and who buy health insurance on the state exchanges that opened on Oct. 1, “underinsurance” may very well become the norm. The plans on the exchanges will be offered in tiers, with the lowest level – the Bronze plan – only required to have an actuarial value of 60 percent (that is to say, the percent of your average annual healthcare expenses that insurance actually pays for), with out-of-pocket annual expenses (after your premium is paid) reaching as high as $12,700 a year for families (depending on income). Moreover, to keep premiums in check, many of these plans will have significantly limited networks of doctors and hospitals, bringing back memories of 1990s managed care. In Missouri, for instance, the Anthem BlueCross BlueShield Plans sold on the exchange will exclude one of the state’s top hospital systems, thereby denying access to the state’s primary academic medical center and its prominent children’s hospital.

Finally, the ACA most likely won’t significantly bend the overall cost curve of healthcare, mainly because it will more or less leave our existing, fragmented and inefficient system in place. According to the most recent projections, for instance, once the economy recovers, the rate of growth of national health expenditures is expected to rebound to about 6 percent annually. This is better than in some previous years, and in an expanding economy in which growth was being distributed throughout the pay scale, might be entirely acceptable. But insofar as these rising costs continue to be passed on to the average working person – while at the same time gains in economic gro wth continue to accrue solely to the most affluent among us – these rising expenses will simply translate into tighter and tighter household budgets, and therefore even more inequality.

So while what the right says about Obamacare is generally wrong, paranoid or both, and though their own proposals would clearly make things much worse, we can’t pretend that Obamacare will create universal healthcare in the sense that most of us imagine it. We won’t have, that is to say, truly comprehensive healthcare for all, with free choice of doctor and hospital, and without a “sickness tax” in the form of out-of-pocket expenses every time we become ill.

What would a system of true universal healthcare look like?  The most feasible and best-studied system for the United States is a form of national health insurance called “single payer,” in which care would be provided by the same mixture of private and public hospitals and physicians that is already in place, but in which a single entity – the government – insures everyone in the country. Medicare is one example of an existing single-payer system, but under a national single-payer system, everyone – not only the elderly – would be covered. Uninsurance would thereby be finally, and entirely, eliminated.

From a quality perspective, the evidence suggests that universal systems perform better – not worse, as is frequently alleged.  A January 2013 report from the National Research Council, for instance, showed that the U.S. has essentially the worst health outcomes among 16 wealthy “peer nations,” despite spending about twice as much on healthcare.

Such a system would have other advantages as well. For instance, it would drastically reduce our massive and rising expenditure on healthcare administration, which in 1999 accounted for an estimated 31 percent of all healthcare spending in the U.S., as opposed to a mere 7 percent in Canada.  This difference is the predictable result of our highly complex and fragmented system of billing and insurance, which is particularly a problem of the private health insurance industry, which has such additional costs as product design, marketing and profits. Indeed, as much as 85 percent of excess spending on “health administration and insurance” is attributable to the private health insurance system. How, exactly, the health insurance industry contributes to actual healthcare – putting aside its extracting role as unnecessary middleman – remains among the great mysteries of the modern age.

The potential windfall from simplifying this mess could therefore be enormous. According to one recent study, a single-payer system could save the federal government about $592 billion a year. These savings could be used to pay for the cost of eliminating both uninsurance and underinsurance, with everyone receiving comprehensive healthcare without onerous co-pays and deductibles every time they got sick.

Such a system might sound like a dream for some, but it’s not only a dream worth fighting for, but also one that can – with time and determination – be won. The fight for universal healthcare, it is clear, is still far from over: A new stage of that fight, in fact, has only just begun.

Adam Gaffney is a physician and writer in Massachusetts.

http://www.salon.com/2013/10/10/republicans_biggest_misunderstanding_about_obamacare/

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By Amy Goodman
Truthdig, October 9, 2013 “We apologize for the inconvenience. The Marketplace is currently undergoing regularly scheduled maintenance and will be back up Monday 10/7/3013.” You read it right, 3013. That was the message on the homepage of the New York state health insurance exchange website this past weekend. Yes, the Affordable Care Act (ACA), popularly known as Obamacare, is going through difficult birth pains, as the marketplace websites went live only to crash. The government is not giving out numbers, but informed observers speculate that very few people have succeeded in signing up for any of the plans so far. The ACA rollout occurred as Republicans shut down the government in their attempt to defund Obamacare. But their strategy backfired. Had there been no shutdown, all of the attention would have been on the disastrous rollout. The fundamental issue, at the core of the health-care dispute, is typically ignored and goes unreported: The for-profit health-insurance industry in the United States is profoundly inefficient and costly, and a sane and sustainable alternative exists—single-payer, otherwise known as expanded and improved Medicare for all. Just change the age of eligibility from 65 to zero. “When Medicare was rolled out in 1966, it was rolled out in six months using index cards,” Dr. Steffie Woolhandler told me Monday. “So if you have a simple system, you do not have to have all this expense and all this complexity and work.” Woolhandler is professor of public health at CUNY-Hunter College and a primary-care physician. She is a visiting professor at Harvard Medical School and the co-founder of Physicians for a National Health Program, or PNHP. PNHP is an organization with 17,000 physicians as members, advocating for a single-payer health-care system in the U.S. What is single-payer? Critics denounce it as “socialized medicine,” while ignoring that single-payer is already immensely popular in the U.S., as Medicare. A 2011 Harris poll found that Medicare enjoyed 88 percent support from American adults, followed closely by Social Security. Woolhandler explained that with a Medicare-for-all system, “you would get a card the day you’re born, and you’d keep it your entire life. It would entitle you to medical care, all needed medical care, without co-payments, without deductibles. And because it’s such a simple system, like Social Security, there would be very low administrative expenses. We would save about $400 billion [per year].” Dr. Woolhandler went on, rather than “thousands of different plans, tons of different co-payments, deductibles and restrictions—one single-payer plan, which is what we need for all Americans to give the Americans really the choice they want … not the choice between insurance company A or insurance company B. They want the choice of any doctor or hospital, like you get with traditional Medicare.” Monthly premiums in most cases are expected to decrease with Obamacare’s health-exchange systems, which will enhance the transparency and ease of comparison for people shopping for a health-insurance policy. If and when the technical problems are eliminated from the online health insurance exchanges, and people can easily shop, there will likely be a huge number of people buying policies for the first time. The ACA offers important advances, which even single-payer advocates acknowledge: subsidies for low-income applicants will make insurance affordable for the first time. Medicaid expansion also will bring many poor people into the umbrella of coverage. Young people can stay on their parents’ insurance until the age of 26. People with so-called pre-existing conditions can no longer be denied insurance.

While the ACA was deemed constitutional by the Supreme Court, the opinion gave states the option to opt out of the Medicaid expansion, which 26 states with Republican governors have done. A New York Times analysis of census data showed that up to 8 million poor people, mostly African-Americans and single mothers, and mostly in the Deep South, will be stranded without insurance, too poor to qualify for ACA subsidies, but stuck in a state that rejected Medicaid expansion. So, while partisan bickering (between members of Congress who have among the best health and benefits packages in the U.S.) has shut down the government, the populace of the United States is still straitjacketed into a system of expensive, for-profit health insurance. We pay twice as much per capita as other industrialized countries, and have poorer health and lower life expectancy. The economic logic of single-payer is inescapable. Whether Obamacare is a pathway to get there is uncertain. As Dr. Woolhandler summed up, “It’s only a road to single-payer if we fight for single-payer.” Denis Moynihan contributed research to this column. Amy Goodman is the host of “Democracy Now!,” a daily international TV/radio news hour airing on more than 1,000 stations in North America. She is the co-author of “The Silenced Majority,” a New York Times best-seller.

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By Garrett Adams, M.D., M.P.H. The following text reflects the prepared remarks given to a session of the Healthcare-NOW strategy meeting in Nashville, Tenn., on Oct. 5. Dr. Adams, a pediatrician, is immediate past president of Physicians for a National Health Program. The United States has the greatest wealth gap of all industrialized countries and the gap is surging. We also have the worst health and societal outcomes. As Richard Wilkinson and Kate Pickett demonstrate in their book titled “The Spirit Level, Why Greater Equality Makes Societies Stronger,” income inequality is divisive and socially corrosive. As income inequality increases, the range of social problems increases. The Reverend Dr. Martin Luther King Jr. once said, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.” A national, publicly financed single-payer health plan would be the best thing that could ever happen to this country. In one fell swoop on at least one level – health – everyone becomes the same. We not only improve the nation’s health status, we seriously commit ourselves to a true democracy with liberty and justice for all, and we build the better society that more equality can bring. What exactly is single payer? “The Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance” (JAMA, August 2003) and Congressman John Conyers’ House Resolution 676, the Expanded and Improved Medicare for All Care Act, are the road maps to single payer. The message is that single payer replaces the health insurance industry and substitutes cost-efficient central planning for market-based health care profiteering. The term “single payer” means that one fund, administered by a nonprofit government agency accountable to the public, would make payment for all medical services. Period. Is single payer politically feasible? Yes. When asked if they would support “a universal health insurance program in which everyone is covered under a program like Medicare, run by the government and financed by taxpayers,” two-thirds of Americans say they would. Tell me a politician that wouldn’t be thrilled to have that level of approval. That’s political feasibility. In 2007, 5,000 physicians randomly selected from the AMA Masterfile were asked, “In principle, do you support or oppose government legislation to establish national health insurance?” Fifty-nine percent said yes. In some specialties, 83 percent supported national health insurance. Why the disconnect between popular opinion and congressional voting? Corporate power and campaign financing. We must shine a spotlight on the profiteering of the medical-industrial complex. Single payer is politically feasible; but it has been blocked by medical profiteers. Is single payer financially feasible? Yes. Professor Gerald Friedman recently showed that if H.R. 676 were in force in 2014, the U.S. could save an estimated $592 billion by slashing the administrative waste associated with the private insurance industry ($476 billion) and reducing pharmaceutical prices to European levels ($116 billion). The savings would be enough to cover all the uninsured and upgrade benefits for everyone else. “No other plan can achieve this magnitude of savings on health care,” he said. What do we do now? We advocate and educate for single payer, so that when the Affordable Care Act crumbles, people understand there is a solution. While the ACA has positive points, it is fatally flawed because of its inability to control costs and profiteering. Paradoxically, because of the ACA, single payer now has more and more recognition in the general public. We should take advantage of this inflection point in single-payer awareness. As my dear friend and courageous single-payer activist the Rev. David Bos said, “We need to keep our eyes on the prize.” Healthcare-NOW is the original single-payer coalition, founded by Marilyn Clement from the civil rights movement and Dr. Quentin Young of PNHP as the “Campaign for a National Health Program.” Importantly, the original coalition also included an African American leader of Pastors for Peace – repeat: an African American leader of Pastors for Peace. Well over 900 groups have endorsed H.R. 676. One especially useful group today has a very informative listserv is One Payer States. Public Citizen gives invaluable support. In addition to the many statewide coalitions, a national coalition called the “Leadership Conference for Guaranteed Health Care” functioned quite well in the run-up to the 2010 reform. That coalition included PNHP, Healthcare-NOW, National Nurses United/California Nurses Association, Progressive Democrats of America, the Labor Campaign for Single Payer Healthcare, and the All Unions Committee for Single-Payer Health Care – H.R. 676. Minority groups suffer the most from health inequities and disparities. These disparities are the worst in Southern states. We particularly need to take the single-payer message to them. This movement will not succeed without the enthusiastic support of everyone, white, Black, Asian and Latino.

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