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PNHP’s Dr. Claudia Fegan on ‘Up with Chris Hayes’

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PNHP’s Dr. Claudia Fegan on ‘Up with Chris Hayes’

Visit NBCNews.com for breaking news, world news, and news about the economy

Dr. Claudia Fegan, past president of Physicians for a National Health Program and chief medical officer at John H. Stroger Jr. Hospital of Cook County, appeared on MSNBC’s “Up with Chris Hayes” on Nov. 24 as part of a panel that included Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services; Jacob Hacker, professor at Yale University; Joy Reid, an MSNBC regular contributor; and Josh Barro, a journalist at Bloomberg.com.

This 3-minute excerpt focuses on the planned expansion of Medicaid coverage under the Affordable Care Act, how the ACA will shift current federal DSH payments now going to safety-net hospitals to individuals enrolled in the Medicaid program, and how some enrollees may have difficulty finding providers willing to take them as patients. Later in the program, in a segment on cost control, Dr. Fegan speaks about her skepticism that the ACA will be able to control costs and, by way of contrast, notes the huge administrative savings a single-payer system would yield — enough to provide quality care to all.

The full segment is available here.

Health care advocacy group promotes 'improved Medicare for all'

The Journal (Martinsburg, W.Va.), Nov. 22, 2012

MARTINSBURG, W.Va. — Members of the Eastern Panhandle Single-Payer Action Network (EPSPAN) provided information to public employees attending the recent Public Employees Insurance Agency (PEIA) hearing in Martinsburg. EPSPAN advocates “improved Medicare for all,” a publicly funded health care system that is privately delivered.

Spokesperson Lynn Yellott described improved Medicare for all as a “system where health care dollars go to health care, not to private insurance companies. With expanded and improved Medicare for all,” she continued, “we would be able to choose any doctor, rather than be restricted by insurance company networks. We would not have insurance companies interfering with treatment. By providing preventive care, by reducing unnecessary paperwork and bureaucracy and by eliminating insurance company expenditures on high salaries for executives, campaign contributions, lobbying and marketing, we could save enough to provide medically necessary care to all in our country without increasing costs.”

EPSPAN member Steven Cotterill, whose wife is a teacher and whose family has insurance purchased through PEIA, testified at the hearing. He waved the thick stack of bills generated by his daughter’s illness which required “out-of-network” treatment. He explained that if his daughter had become ill in his country of birth, England, she would have received excellent care with no out-of-pocket expenses.

EPSPAN is a chapter of Physicians for a National Health Program and Healthcare-Now! Recently, to highlight the amount of money local jurisdictions could save if improved Medicare for all were enacted, EPSPAN analyzed the health-care-related items in the Jefferson County schools budget. The study revealed that the school system could have saved more than $2.5 million dollars in 2010 had the country adopted improved Medicare for all.

Find more information at http://wvpan.org/organizations/Eastern-Panhandle-Single-Payer-Action-Network

http://www.journal-news.net/page/content.detail/id/587439/Information-given-by-health-care-advocacy-group.html?nav=5011

Health care advocacy group promotes ‘improved Medicare for all’

The Journal (Martinsburg, W.Va.), Nov. 22, 2012

MARTINSBURG, W.Va. — Members of the Eastern Panhandle Single-Payer Action Network (EPSPAN) provided information to public employees attending the recent Public Employees Insurance Agency (PEIA) hearing in Martinsburg. EPSPAN advocates “improved Medicare for all,” a publicly funded health care system that is privately delivered.

Spokesperson Lynn Yellott described improved Medicare for all as a “system where health care dollars go to health care, not to private insurance companies. With expanded and improved Medicare for all,” she continued, “we would be able to choose any doctor, rather than be restricted by insurance company networks. We would not have insurance companies interfering with treatment. By providing preventive care, by reducing unnecessary paperwork and bureaucracy and by eliminating insurance company expenditures on high salaries for executives, campaign contributions, lobbying and marketing, we could save enough to provide medically necessary care to all in our country without increasing costs.”

EPSPAN member Steven Cotterill, whose wife is a teacher and whose family has insurance purchased through PEIA, testified at the hearing. He waved the thick stack of bills generated by his daughter’s illness which required “out-of-network” treatment. He explained that if his daughter had become ill in his country of birth, England, she would have received excellent care with no out-of-pocket expenses.

EPSPAN is a chapter of Physicians for a National Health Program and Healthcare-Now! Recently, to highlight the amount of money local jurisdictions could save if improved Medicare for all were enacted, EPSPAN analyzed the health-care-related items in the Jefferson County schools budget. The study revealed that the school system could have saved more than $2.5 million dollars in 2010 had the country adopted improved Medicare for all.

Find more information at http://wvpan.org/organizations/Eastern-Panhandle-Single-Payer-Action-Network

http://www.journal-news.net/page/content.detail/id/587439/Information-given-by-health-care-advocacy-group.html?nav=5011

PNHP's Dr. Claudia Fegan on 'Up with Chris Hayes'

Up with Chris Hayes
MSNBC

Visit NBCNews.com for breaking news, world news, and news about the economy

Dr. Claudia Fegan, past president of Physicians for a National Health Program and chief medical officer at John H. Stroger Jr. Hospital of Cook County, appeared on MSNBC’s “Up with Chris Hayes” on Nov. 24 as part of a panel that included Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services; Jacob Hacker, professor at Yale University; Joy Reid, an MSNBC regular contributor; and Josh Barro, a journalist at Bloomberg.com.

This 3-minute excerpt focuses on the planned expansion of Medicaid coverage under the Affordable Care Act, how the ACA will shift current federal DSH payments now going to safety-net hospitals to individuals enrolled in the Medicaid program, and how some enrollees may have difficulty finding providers willing to take them as patients. Later in the program, in a segment on cost control, Dr. Fegan speaks about her skepticism that the ACA will be able to control costs and, by way of contrast, notes the huge administrative savings a single-payer system would yield — enough to provide quality care to all.

The full segment is available here.

PNHP’s Dr. Claudia Fegan on ‘Up with Chris Hayes’

Up with Chris Hayes
MSNBC

Visit NBCNews.com for breaking news, world news, and news about the economy

Dr. Claudia Fegan, past president of Physicians for a National Health Program and chief medical officer at John H. Stroger Jr. Hospital of Cook County, appeared on MSNBC’s “Up with Chris Hayes” on Nov. 24 as part of a panel that included Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services; Jacob Hacker, professor at Yale University; Joy Reid, an MSNBC regular contributor; and Josh Barro, a journalist at Bloomberg.com.

This 3-minute excerpt focuses on the planned expansion of Medicaid coverage under the Affordable Care Act, how the ACA will shift current federal DSH payments now going to safety-net hospitals to individuals enrolled in the Medicaid program, and how some enrollees may have difficulty finding providers willing to take them as patients. Later in the program, in a segment on cost control, Dr. Fegan speaks about her skepticism that the ACA will be able to control costs and, by way of contrast, notes the huge administrative savings a single-payer system would yield — enough to provide quality care to all.

The full segment is available here.

Proposed religious exemption from health insurance mandate

H.R. 6597

Rep. Judy Biggert and 57 cosponsors
November 16, 2012

SECTION 1. SHORT TITLE.

This Act may be cited as the “Equitable Access to Care and Health Act” or the “EACH Act”.

SEC. 2. ADDITIONAL RELIGIOUS EXEMPTION TO HEALTH COVERAGE MANDATE.
 
(a) IN GENERAL.—Paragraph (2) of section 5000A(d) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph:

“(C) ADDITIONAL RELIGIOUS EXEMPTION.—
 “(i) IN GENERAL.—Such term shall not include an individual for any month during a taxable year if such individual files a sworn statement, as part of the return of tax for the taxable year, that the individual was not covered under minimum essential coverage at any time during such taxable year and that the individual’s sincerely held religious beliefs would cause the individual to object to medical health care that would be covered under such coverage.
 “(ii) NULLIFIED IF RECEIPT OF MEDICAL HEALTH CARE DURING TAXABLE YEAR.-Clause (i) shall not apply to an individual for any month during a taxable year if the individual received medical health care during the taxable year.
 “(iii) MEDICAL HEALTH CARE DEFINED.—For purposes of this subparagraph, the term ‘medical health care’ means voluntary health treatment by or supervised by a medical doctor that would be covered under minimum essential coverage and—
  “(I) includes voluntary acute care treatment at hospital emergency rooms, walk-in clinics, or similar facilities, and
  “(II) excludes—
   “(aa) treatment not administered or supervised by a medical doctor, such as chiropractic treatment, dental care, midwifery, personal care assistance, or optometry,
   “(bb) physical examinations or treatment where required by law or third parties, such as a prospective employer, and
   “(cc) vaccinations.”.
 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) shall take effect as if included in the amendments made by section 1501 of the Patient Protection and Affordable Care Act.

http://thomas.loc.gov/cgi-bin/thomas

Comment:

By Don McCanne, MD

H.R. 6597, the “Equitable Access to Care and Health Act,” is a proposed amendment to the Affordable Care Act that would provide a religious exemption to an individual from a penalty for being uninsured, providing that the individual files a sworn statement, as part of the tax return, that “the individual’s sincerely held religious beliefs would cause the individual to object to medical health care that would be covered” under health plans mandated by the Affordable Care Act.

If any medical care were obtained, that would nullify the exemption, and penalties for being uninsured would apply. Theoretically, that would separate those whose religious beliefs regarding abstaining from health care were sincere, from those who would submit a sworn statement merely to avoid the penalty while remaining uninsured. In actuality, even with such religious beliefs, individuals might find it difficult to refuse care in some instances such as major trauma.

If you check the list of cosponsors, you will see that this act does have very broad bipartisan support. It seems like a reasonable amendment, though it still doesn’t protect the rest of us from the costs of care that the person might receive when the medical imperative is greater than the religious conviction.

Is there a better way of doing this? Of course. Include everyone in a single national health program. Do not fund it based on medical need, but fund it through equitable, progressive tax policies. Under such a system, anyone can decline medical care for whatever reason, religious or otherwise (except if the person’s disorder constitutes a genuine threat to public health).

Should a person be required to pay taxes into a universal health care system? I can answer that by stating, as a pacifist, I vehemently object to paying taxes to fight wars. Yet I cannot be allowed the option of withholding my allocated tax assessment assigned to our nation’s military ventures. Nor can anyone be allowed to opt out of paying taxes for any public service that, through our democratic process, we decide to provide for the public good. That includes health care.

Dr. Martin Donohoe’s New Book Cites Major Advances in Public Health

His website, Phsj.org, has gotten 575,000 hits since its inception in 2007, and focuses on public health and social justice issues

By Raymond Rendleman
The Lund Report (Portland, Ore.), Nov. 23, 2012

When you Google “public health and social justice,” the first thing that comes up is Portland Dr. Martin Donohoe’s expansive website.

Now Donohoe, 49, is turning his go-to resource into a book that also compiles the major advances in the public health field, but in a handy best-of format of a mere 656 pages for $85.

Although throughout the book there are suggestions for change, this content is often a “real downer,” he acknowledged, so he included an optimistic section about achieving social justice in healthcare through education and activism. Stephen Bezruchka promotes public understanding of population health, Carolyn Raffensperger and Peter Montague offer ideas for a common agenda to eliminate health disparities and provide universal healthcare, and Robert Weissman sees mechanisms to defeat corporate power.

Donohoe’s own methods for combating corporate control include advocating for publically financed political campaigns, increased funding for education, a national single-payer comprehensive health plan and a reconfiguration of tax systems to discourage companies’ toxic waste generation.

“You can make a huge difference simply by addressing the social factors that relate to illness, but that requires a social and governmental commitment,” Donohoe said. “The first step is factual awareness of the social factors, and as a society we have to prioritize what’s important to us based on ethical standards of fairness. In the U.S., government is very efficient in providing healthcare, although it’s excessively demonized.”

On a broader scale, he’d like to see people work toward a cleaner planet by working with environmental groups, and groups providing standards of housing that contribute to social and environmental health.

“You’ll be much more efficient working with groups than working by yourself,” he said.

While the book is being marketed for colleges and universities, it’s accessible to lay audiences. His hope is that the first volume is successful enough to merit a volume two that would also hopefully “nudge students in the direction of hopefully doing some type of service during their careers.”

He’s also raising money to develop a national program to train healthcare activists. His long term vision is to develop an annual, weeklong colloquium for medical students and residents interested in obtaining the information, skills and professional contacts to help them become social justice advocates and leaders. In a “highly competitive,” two-year program, academic experts and leaders from nonprofit organizations would impart basic knowledge surrounding major progressive social justice issues. People can contact him for more information about his national program concept at martindonohoe@phsj.org.

“It’s a passion to use what I’ve learned in my medical training and put it to the betterment of humanity,” he said. “The gift that I have to give is my teaching, and my real goal is to re-forge that schism between medicine and the humanities of public health professionals that occurred in the early 20th century.”

Healing this schism will occur through once again emphasizing public health principles in the training of health professionals. Groups such as Physicians for a National Health Program already provide some of this advocacy, but there’s no formal program in which progressive healthcare professionals join together to provide comprehensive education and training. Donohoe likes the 25-year-old group because he sees data-driven volunteer members looking at costs and outcomes of healthcare models, who truly care for their patients.

“Physicians for a National Health Program is committed to a very specific goal that I also like, which is providing single-payer healthcare for everyone from cradle to grave on a national level,” he said.

Origins of Concept

Phsj.org has gotten 575,000 hits since inception in 2007, nearly 20,000 a month, for its thousand of links and hundreds of original articles, slide shows, syllabi and other documents relevant to topics in public health and social justice.

For the past five years, Donohoe has accumulated his 150 talks in Powerpoint on the open-access website, and invited others to submit presentations and key documents. He’s now got more than 1,000 links on the website to external organizations working on various social justice issues organized in categories such as access to reproductive care and the pharmaceutical industry.

Donohoe’s original concept of the “Public Health and Social Justice Reader” was meant just to include his own articles, but he and his publisher at Jossey Bass worked together to make it more comprehensive.

“The tough part was to figure out what to exclude, because there’s so much good writing out there on these subjects,” Donohoe said.

He started the “Reader” with the human rights declaration adopted by the United Nation in 1948, as what he calls the “fundamental document on the rights of humanity,” which demands everyone have free elementary education and a standard of living “adequate for the health and well-being.”

As a member of the social justice committee of Physicians for Social Responsibility, he’s delivered lectures across the country on the public’s responsibility to address heath issues. He’s concentrated that effort at Portland State University since 2001, where he’s an adjunct associate professor at the School of Community Health.

Hundreds of thousands of lives would have been saved between 1994 and 2004 if black and white mortality ratios were equalized, whereas advances in medical technology, where most of the government and corporate investment is, realized much smaller gains. Equalizing the mortality rates of whites and African-Americans would have averted 686,202 deaths between 1991 and 2000, a 2004 study in the American Journal of Public Health showed, while medical advances averted 176,633 deaths during the same time period.

Social, economic, environmental and cultural factors especially contribute to health and disease in the Third World, so he sees “the real heroes” of public health as the doctors who work there. But all healthcare professionals “share a responsibility to recognize the causes and health consequences of environmental degradation and social injustice.” In what he calls a moral obligation to take up the mantle of opposing these forces, people should contribute to public health education, speak out against poverty and inequality, and make positive changes in their own health.

“So much illness is caused by environmental factors, so the best way people can help themselves is to eat low-fat foods and avoid environmental toxins like smoking,” Donohoe said.

One of the early inspirations for Donohoe, now a part-time senior physician at the Kaiser Sunnyside Medical Center, was the Social Medicine Portal at Montefiore Medical Center (Albert Einstein College of Medicine). While attending UCLA for college and medical school, he received a small grant in 1988 from the psychology department to look at what physicians had written about the physician-patient relationship. He then explored the topic of literature as a means of vicarious experience into homelessness and alcohol dependence through a Robert Wood Johnson Clinical Scholars Program Foundation-funded fellowship at Stanford before serving in St. Lucia, in rural medicine and at a homeless shelter.

‘Essential Reference’ Topic Areas

“Reader” has received positive feedback. Dr. Shafik Dharamsi, professor of medicine at the University o
f British Columbia, called Donohoe’s work an “essential reference” for students, teachers and practitioners in the health and human services.

“This compilation unifies ostensibly distant corners of our broad discipline under the common pursuit of health as an achievable, non-negotiable human right. It goes beyond analysis to impassioned suggestions for moving closer to the vision of health equity,” wrote Dr. Paul Farmer, chairman of the Department of Global Health and Social Medicine at Harvard Medical School.

Part two of the “Reader” covers special populations, and it’s nearly impossible to see who’s left out. Topics include homelessness, migrant farm workers, American Indian health disparities, prejudice in the medical profession, gender minority health, mental disorders and our “incarceration nation.”

An entire section devoted to women’s health includes an essay titled “The Way It Was,” by Eleanor Cooney, describing the options that women faced in the 1950s and ‘60s. Most of the students who read the book will have only lived in the post-Roe-v-Wade era, so Donohoe hopes it will be “eye-opening” for them. He also sees that work as a necessary reminder for old timers.

“Especially in an era where governments are trying to take away access reproductive care, this is mandatory reading,” he said.

The environmental health topic areas bring some surprising associations, culminating with his essay “Flowers, Diamonds, and Gold: The Destructive Public Health, Human Rights, and Environmental Consequences of Symbols of Love.” Most purchasers are unaware, Donohoe said, that gifting their lovers with these aesthetic symbols supports industries that damage the environment, use forced labor, cause health problems and contribute to violent conflicts.

Another passion of his is exposing how corporations profit off of unnecessary testing and the general suffering of social health. In an essay about combating corporate control through education, media, legislation and healthcare, he delves deeper into the reason medical ethics overemphasizes dilemmas involving expensive technologies such as gene therapy, cloning and face transplants at the expense of global bioethics and human rights.

“This is in part due to the availability of funding for ethics projects related to high-technology interventions, but also due to the perceived intractability of public health problems and fear of criticizing corporate structures,” he says.

Donohoe supports gene therapy, but not cross-species gene splicing. Face transplants can be literally lifesaving for someone in certain cases, Donohoe says, because getting a face back after an injury is equivalent to getting back your identity. But even gene therapy and face transplanting could be a much smaller portion of the nation public health agenda, he argues.

Order the book at http://www.josseybass.com/WileyCDA/WileyTitle/productCd-111808814X.html or by phone 800-956-7739. It’s also available on Amazon.com and BarnesandNoble.com.

http://www.thelundreport.org/resource/dr_martin_donohoe%E2%80%99s_new_book_cites_major_advances_in_public_health

Medicare-for-All Is The Only Way To Go

By James Besante
Albuquerque Journal, Nov. 25, 2012

Winthrop Quigley, “Health Care Landscape Changing” published on Nov. 13, is quite correct that the chaos and disruption being experienced by thousands of New Mexicans who must choose between their medical care provider — doctor or nurse practitioner — and their Lovelace Health Plan insurer is a very strong argument for a single-payer, improved-Medicare-for-all health system.

With single-payer, similar in many ways to Medicare, every patient gets to choose his own provider and hospital. The government, using tax dollars, is the sole insurer and the patient never receives a bill.

No other Western nation, all with single-payer or nonprofit government-regulated insurance, would allow their citizens to be mistreated like the Lovelace patients.

Quigley understands this but casts doubt on research showing a single-payer system would cover everyone and be less costly than our extremely expensive and wasteful system. Such doubts are unmerited.

Multiple studies in peer-reviewed scientific journals such as the New England Journal of Medicine, Aug. 21, 2003, have shown that hundreds of billions of dollars a year could be saved by streamlining the administrative costs that result from having hundreds of private insurance companies. Nonpartisan government agencies including the Government Accounting Office (1991) and the Congressional Budget Office (1993) have reached similar conclusions.

Here in New Mexico, The Lewin Group, a health care consulting firm, found in 1994 that single-payer reform could save $151.8 million and cover all the uninsured. A more recent Mathematica study (2008) found even greater savings.

Yes, the health care system is certainly undergoing rapid changes. The question is whether these changes will ultimately be in the interest of patients or of the investor-owned corporations such as Ardent, the owner of the Lovelace Health Plan.

Quigley points out that “Obamacare is designed to preserve the insurance industry.” Thus, under the Affordable Care Act, we can expect to see more disruption of care that we are seeing at Lovelace.

The reliance on the private insurance industry is the plan’s fatal flaw and will lead to its eventual failure.

We must lay the groundwork now for the single-payer, Medicare-for-all system that will better serve my patients and all New Mexicans.

James Besante is co-chair, N.M. Network of Health Professionals for a National Health Program.

http://www.abqjournal.com/main/2012/11/25/opinion/medicareforall-is-the-only-way-to-go.html

Health insurance exchanges may be too small to succeed

Health Insurance Exchanges May Be Too Small to Succeed

By Dana P. Goldman, Michael Chernew and Anupam Jena
The New York Times, November 23, 2012

With the re-election of President Obama, the Affordable Care Act is back on track for being carried out in 2014. Central to its success will be the creation of health-insurance exchanges in each state. Beneficiaries will be able to go to a Web site and shop for health insurance, with the government subsidizing the premiums of those whose qualify. By encouraging competition among insurers in an open marketplace, the health care law aims to wring some savings out of the insurance industry to keep premiums affordable.

Certainly, it is hard to be against competition. Economic theory is clear about its indispensable benefits. But not all health care markets are composed of rational, well-informed buyers and sellers engaged in commerce. Some have a limited number of service providers; in others, patients are not well informed about the services they are buying; and in still others, the quality of the service offerings vary from provider to provider. So the question is: What effect does insurer competition have in a marketplace with so many imperfections?

The evidence is mixed, but some of it points to a counterintuitive result: more competition among insurers may lead to higher reimbursements and health care spending, particularly when the provider market – physicians, hospitals, pharmaceuticals and medical device suppliers – is not very competitive.

In imperfect health care markets, competition can be counterproductive. The larger an insurer’s share of the market, the more aggressively it can negotiate prices with providers, hospitals and drug manufacturers. Smaller hospitals and provider groups, known as “price takers” by economists, either accept the big insurer’s reimbursement rates or forgo the opportunity to offer competing services. The monopsony power of a single or a few large insurers can thus lead to lower prices. For example, Glenn Melnick and Vivian Wu have shown that hospital prices in markets with the most powerful insurers are 12 percent lower than in more competitive insurance markets.

So health insurance exchanges are probably welcome news for hospitals, physicians, and pharmaceutical and medical device companies throughout the United States. If health insurance exchanges divide up the market among many insurers, thereby diluting their power, reimbursement rates may actually increase, which could lead to higher premiums for consumers.

There is some evidence on how insurer market power affects premiums. Leemore Dafny, Mark Duggan, and Subramaniam Ramanarayanan have found that greater concentration resulting from an insurance merger is associated with a modest increase in premiums — suggesting that concentration may not help consumers so much — although they did report a reduction in physician earnings on average. Over all, however, the evidence is limited and mixed.

Greater competition in the insurance industry — either through health insurance exchanges or other measures — may not lower insurance premiums. Weakening insurers’ bargaining power could instead translate into higher costs for all of us in the form of higher premiums.

In financial markets, we ask if banks are too big to fail. When it comes to health care, perhaps we should ask if insurers are too small to succeed.

****

NYT Reader Comments:

Don McCanne
San Juan Capistrano, CA, Nov. 23, 2012

It is true that very large insurers within the exchanges can use their monopsony power (controlling the market as exclusive buyers) by demanding lower prices for health care services, but only for their own plans. Most health care costs will still be covered by employer-sponsored plans, Medicare, Medicaid and other programs. Thus plans offered by the exchanges cannot have much impact on our total national health expenditures.

Another difficulty with the monopsony power of private insurers is that when they are investor owned (WellPoint, UnitedHealth, Aetna, etc.), their first priority must be to use their leverage to benefit their investors. That results in insurance innovations that often are not particularly transparent, but have adverse consequences for the patients they insure. The private sector exercising power as a monopsony can be as evil as a monopoly.

In contrast, a public monopsony can be very beneficial in getting prices right – high enough to ensure adequate capacity in the delivery system, yet low enough to ensure value in health care.

The ultimate beneficent monopsony would be a single public program covering absolutely everyone (“single payer”). We could achieve this easily by improving Medicare and then making it universal. Health policy studies have proven that this would not only cover everyone, but it would finally bring us that elusive goal of health care reform – bending the cost curve to sustainable levels.

http://economix.blogs.nytimes.com/2012/11/23/health-insurance-exchanges-may-be-too-small-to-succeed/

AHIP response to new rules on essential health benefits

Essential Health Benefits, Actuarial Value, and Accreditation Standards: Ensuring Meaningful, Affordable Coverage

HealthCare.gov (HHS)
November 20, 2012

On November 20, 2012, the Department of Health and Human Services (HHS) published a proposed rule that helps consumers shop for and compare non-grandfathered private health insurance options in the individual and small group markets by promoting consistency across plans, and protecting consumers by ensuring that plans cover a core package of items and services.

Specifically, this rule outlines health insurance issuer standards related to the coverage of essential health benefits (EHB) and the determination of actuarial value (AV), while providing significant flexibility to states to shape how EHB are defined.

The Affordable Care Act sets forth that EHB be equal in scope to benefits offered by a “typical employer plan.”  To meet this requirement in every state, the proposed rule defines EHB based on a state-specific benchmark plan, including the largest small group health plan in the state. The rule proposes that states select a benchmark plan from among several options identified in the proposed rule, and that all plans that cover EHB must offer benefits that are substantially equal to the benefits offered by the benchmark plan. This approach balances consumers’ desires for an affordable and comprehensive benefit package, our legal requirement to reflect the current marketplace, and issuer flexibility to offer innovative benefit designs and a choice of health plans.

http://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.html

And…

AHIP Statement on ACA Implementation

America’s Health Insurance Plans (AHIP)
November 20, 2012

America’s Health Insurance Plans (AHIP) President and CEO Karen Ignagni released the following statement on proposed rules released today by the U.S. Department of Health and Human Services on implementation of the Affordable Care Act (ACA):

“As implementation of the ACA moves forward, the focus needs to be on affordability for consumers and employers.

“For health insurance exchanges and new insurance market rules to work, coverage needs to be affordable and there needs to be broad participation in the system.  While additional flexibility on essential health benefits (EHB) is a positive step, we remain concerned that many families and small businesses will be required to purchase coverage that is more costly than they have today.  It also is important to recognize that the new EHB requirements will coincide with the new restrictions in age rating rules that also go into effect on January 1, 2014.  Both of these provisions may incentivize young, healthy people to wait to purchase insurance until they are sick or injured, driving up costs for everyone with insurance.”

http://www.ahipcoverage.com/2012/11/20/ahip-statement-on-aca-implementation/

Comment:

By Don McCanne, MD

The Department of Health and Human Services has provided states with considerable flexibility in establishing essential health benefits (EHB) in the individual and small group insurance markets. The states will not have to require benefits that are typical of large employer health benefit programs, but rather the benefits will correspond to existing small group plans, as long as some services in each of ten required categories are included. These plans will be inadequate for those who require benefits that are not covered, not to mention the limitations of excess cost sharing and insufficient provider networks.

Yet the insurance lobby group, AHIP, complains that many families and small businesses would have to purchase coverage that is more costly than they have today. The reason that plans with the minimal essential benefits would be more costly is that the current individual and small group market is saturated with plans that are so substandard that they fail to provide adequate financial security in the face of medical need. With the new essential health benefits requirement, the insurance industry would lose the right to sell these highly profitable, but substandard plans. They will have to raise their standards to the level of mediocrity, as required by the new EHB rule.

Once again they state that “coverage needs to be affordable.” They have previously stated that health care costs need to be controlled, but, in the absence of any truly effective method of doing that, they need to be able to use innovative product design to keep their premiums competitive in the insurance market. The new EHB rule along with the actuarial value rule allows them the flexibility to be quite innovative. The bottom line is that in the conflict between affordable insurance premiums and adequate protection for patients, they will always choose to protect their market rather than protect patients.

The insurance industry understandably is interested in its own welfare. If that means compromising the adequacy of their plans, then so be it. But does that mean that we have to accept compromise in our health and in our financial security? We wouldn’t if we dismissed the private insurers and established our own improved Medicare program for everyone.

Uninsured have higher mortality after surgery for brain tumors

Postoperative Mortality After Surgery for Brain Tumors by Patient Insurance Status in the United States

By Eric N. Momin, MD; Hadie Adams, MD; Russell T. Shinohara, PhD; Constantine Frangakis, PhD; Henry Brem, MD; Alfredo Quiñones-Hinojosa, MD
Archives of Surgery, November 2012

Among patients with brain tumors with no other major medical condition, uninsured patients (but not necessarily Medicaid recipients) have higher in-hospital mortality than privately insured patients, a disparity that was pronounced in teaching hospitals. These findings further reinforce prior data indicating insurance-related disparities in medical and surgical settings.

These insurance-related disparities might be explained by 1 of 3 possible mechanisms. Insurance status could influence health outcomes by affecting (1) a patient’s overall state of health, (2) the ability to access care (affecting the acuity of disease presentation), or (3) the quality of treatment that is provided.

Insurance-related disparities are not unique to the field of neurosurgery. Uninsured patients fare worse than privately insured patients in the settings of critical illness (higher chance of having life support withdrawn), ischemic or hemorrhagic stroke (higher mortality and neurologic impairment), myocardial infarction (higher mortality), and physical trauma (higher mortality). However, it is not clear that enrolling in a state-funded health plan would help the uninsured because Medicaid recipients also seem to experience a similar disparity in other settings, including pneumonia, appendicitis, abdominal aortic aneurysm repair, limb-threatening ischemia, and surgery for colorectal carcinoma. Of note, this Medicaid disparity was also present in our full cohort but was not convincingly present in the adjusted analysis of patients with no comorbid disease, especially in teaching hospitals.

http://archsurg.jamanetwork.com/article.aspx?articleid=1392156

Comment:

By Don McCanne, MD

Uninsured patients operated on for brain tumors have a higher in-hospital mortality than do insured patients. Regardless of the reasons why, this study adds to the abundance of studies that demonstrate that being uninsured can be bad for your health. Even patients with Medicaid may experience similar adverse outcomes.

The Affordable Care Act will leave 30 million uninsured, and it relies partially on Medicaid to expand coverage. Thus the Affordable Care Act may still be bad for the health of many of us.

We need a single program that provides all of us with high quality care – an improved Medicare for all. We should not put up with a deficient health care program that leaves some of us sick or even dead.

Many younger vets among the ranks of uninsured

By Chris Adams — McClatchy Newspapers
Belleville (Ill.) News Democrat – McClatchy, Nov. 19, 2012

WASHINGTON — More than quarter of all veterans who served in Iraq and Afghanistan don’t have health insurance and aren’t part of the Department of Veterans Affairs health system, according to an analysis of VA data.

The uninsured rate among these recent veterans is higher than for other war periods and for veterans as a whole, raising concerns that veterans recently back from the wars might not be taking advantage of care to which they are entitled.

Veterans advocates and some lawmakers have pushed to automatically enroll veterans in the VA health care system, which could fill in the gap for some of the veterans not now covered by the VA or the private market.

“It is critically important that we continue to reach out and inform veterans of the health care and benefits they have earned through their service to country,” said VA spokesman Josh Taylor. “We have made progress, but there is more work to do.”

The numbers are from the 2010 National Survey of Veterans, conducted by the VA periodically to determine the state of America’s veteran population.

Veterans who have left combat operations from the recent wars are eligible for VA health care for five years and after that must qualify based on the disability- or income-based standards. While some veterans can use the VA health system for life, most don’t; of 22 million veterans, 8.6 million are part of the VA’s system, 2011 numbers show.

That’s a surprise to many people, who assume all veterans qualify for the VA’s network of hospitals and clinics, said Steffie Woolhandler, a researcher who has tracked veteran health insurance status.

“I’m quite sure that most doctors believe that vets have health insurance, because they generally express surprise when I present my work on vets at meetings and in medical journals,” said Woolhandler, a professor of public health at City University of New York and a visiting professor at Harvard Medical School. “I’m pretty sure most of the lay public thinks so, too.”

McClatchy analyzed the 2010 national survey, categorizing veterans by their most recent period of service. Of those who indicated they served in the recent wars, 26 percent said they neither had health insurance nor were part of the VA health system. For veterans from previous periods – the 1990s, including the first Persian Gulf War; Vietnam; and peacetime periods – the comparable percentage uninsured was between 10 percent and 16 percent.

Veterans from World War II or the Korean War are old enough to qualify for Medicare, and their uninsured rate was less than 2 percent.

Lack of insurance can be a significant problem. Woolhandler’s research found that uninsured veterans are five times more likely to need but not get medical care than are insured veterans, and they are four times more likely to delay care because of cost. Nearly half of uninsured vets said they had “no place to go when sick,” according to her 2007 research.

Young people in general are less likely to have insurance than middle age or older Americans. They have lower incomes and less secure jobs; some choose to skip the expense, figuring they are healthy enough to get by.

But veterans have health issues that deserve special attention, said Rep. Bill Owens, D-N.Y., who has introduced legislation that would automatically enroll returning service members into the VA health care system rather than requiring they seek out the VA.

“Many of these folks suffer from post-traumatic stress disorder or traumatic brain injuries,” Owens said. “Unless they have someone who is able to work with them, I think a lot of them slip through the cracks. We’re trying to avoid that slippage.”

http://www.bnd.com/2012/11/19/2400741/many-younger-vets-among-the-ranks.html