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The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch

By Sara R. Collins, David Radley, Munira Z. Gunja, Sophie Beutel
The Commonwealth Fund, October 26, 2016

Abstract

Issue: Although predictions that the Affordable Care Act (ACA) would lead to reductions in employer-sponsored health coverage have not been realized, some of the law’s critics maintain the ACA is nevertheless driving higher premium and deductible costs for businesses and their workers.

Goal: To compare cost growth in employer-sponsored health insurance before and after 2010, when the ACA was enacted, and to compare changes in these costs relative to changes in workers’ incomes.

Methods: The authors analyzed federal Medical Expenditure Panel Survey data to compare cost trends over the 10-year period from 2006 to 2015.

Key findings and conclusions: Compared to the five years leading up to the ACA, premium growth for single health insurance policies offered by employers slowed both in the nation overall and in 33 states and the District of Columbia. There has been a similar slowdown in growth in the amounts employees contribute to health plan costs. Yet many families feel pinched by their health care costs: despite a recent surge, income growth has not kept pace in many areas of the U.S. Employee contributions to premiums and deductibles amounted to 10.1 percent of U.S. median income in 2015, compared to 6.5 percent in 2006. These costs are higher relative to income in many southeastern and southern states, where incomes are below the national average.

Employee Premium Contribution and Deductible as Percent of Median Household Income

2006 – 6.6%
2010 – 8.4%
2015 – 10.1%

From the Conclusion

But the findings also offer evidence as to why many insured Americans view their health care costs as unaffordable. While growth in employee premium contributions have slowed along with premiums, deductibles continue to proliferate and their annual growth rate exceeds premium growth by a wide margin. Compounding this trend, growth in median family incomes — despite a recent surge — has lagged health insurance cost growth. Middle-income families continue to see a growing share of their household budgets going to health care. Where employees have less generous health plans as well as lower median incomes, the combination is particularly toxic. People with high deductibles relative to income are far more likely to avoid getting needed care than those with more affordable out-of-pocket costs. For those who do get health care, large medical bills can quickly exceed assets.

http://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

With all the talk this week about double-digit percentage increases in premiums for plans offered in the ACA exchanges, there is risk that this report my be lost in the background, though, for most Americans, this report is of far greater importance. For employer-sponsored health plans – where most individuals receive their health coverage – the percentage of household income used to pay premiums and deductibles has increased sharply in the last decade – from 6.6% to 10.1%.

To quickly dismiss the concern about premium increases in the ACA exchanges, although the average increase will be about 25%, of the 10.5 million enrolled only about 1.5 million in the exchanges will see the full increase since the others will be protected by premium subsidies. It may also impact the 7 million who buy individual plans outside of the exchanges. That 8.5 million combined is about 2.7% of the population, though most will have the option to shop for lower premium plans. Besides, these increases do not represent health care inflation but are rather due to intrinsic defects with the business model of competing private health plans. Healthier individuals are less inclined to enroll, making the risk pools more expensive, but it is likely that the greater factor was the insurers low-balling the initial premiums in an attempt to gain greater market share (though they will never admit this).

In contrast, about 154 million people – 57% of the U.S. population under 65 – obtain their insurance through their work – a far larger group than those who buy plans on the exchanges. But look at what is happening to them. Their share of insurance costs are consuming an ever larger percentage of their incomes. This financial burden on the typical working family is great enough to prevent them from receiving some of the essential health care services that they should have – impairing access due to lack of affordability.

Note that this is not due to the Affordable Care Act. These individuals and families do not buy their plans through the exchanges, and they receive no public subsidies (except for regressive tax expenditures unfairly benefiting primarily higher income individuals). Rather than blaming the Affordable Care Act, we need to blame legislators and the policy community who insisted that we keep this dysfunctional health care financing system in place.

While rejecting single payer, some of our political leaders are suggesting that we fix what we have – tweak the system until it works. One candidate for president suggests enacting a refundable tax credit of up to $5000 to help pay excessive out-of-pocket health costs, and that would help these individuals. But the problem is that it only pours more tax funds into our overpriced and administratively-burdened system without correcting any of the defects that have made our financing system so dysfunctional. And who pays those taxes? A bit of a shell game, I’d say.

We’ve had a lull in spending, but that was partly due to the recession. The other important factor that has slowed spending is what this report is all about. Regardless of ACA, health care costs are being shifted to plan beneficiaries strictly to protect the markets for the insurers by slowing the rate of premium increases. This has the deleterious effect of slowing spending by reducing the affordability of care and thus reducing access to the care that patients should have. Bad policy.

The solution is really simple. Fund a single universal risk pool with equitable taxes that everyone can afford, and then use that risk pool to pay for all necessary health care for everyone. Why didn’t those single payer people think of that? Oh. They did.

Why the U.S. Still Trails Many Wealthy Nations in Access to Care

By Aaron E. Carroll
The New York Times, October 24, 2016

Many are still unhappy with Obamacare.

The main intent of the Affordable Care Act was to expand the safety net (Medicaid), regulate the non-employer-based private insurance market (the insurance exchanges) and help people buy that insurance (subsidies) in order to reduce the number of Americans who are uninsured.

On those metrics, it appears to be succeeding.

First and foremost, Obamacare was about improving access to health care. While it did improve access to insurance, in many, many other ways the United States is falling short. Things are likely to get worse before they get better.

Even with Obamacare, the United States still ranks poorly among comparable countries in insurance coverage. Even in 2016, when the rate of insured is the best it has ever been in the United States, Americans still have a greater percent of the population uninsured than pretty much any other industrialized nation in the world.

Access is about more than insurance, though. Every few years, the Commonwealth Fund conducts an international survey of patients. The last time the fund fielded the survey was in 2013, and it sampled patients in 11 different countries, all of them on the high end of the worldwide socioeconomic spectrum.

When asked if patients could get a same-day or next-day appointment with their provider when they were sick or needed care, 52 percent of Americans said no. This placed the United States next to last among these countries. Only Canada (59 percent) was worse.

When asked whether it was “somewhat” or “very easy” to get care after regular working hours, the United States placed eighth, beating France, Canada (again) and Sweden. Because of this, at least in part, Americans are more likely to use the emergency room for care.

Primary care physicians feel this pinch as well. When the Commonwealth Fund surveyed them in 10 countries, doctors in the United States ranked ninth (ahead of Canada) in being “well prepared” to manage the care of patients with complex needs. They ranked last in whether staff made home visits. They also ranked last, by far, in whether practices had arrangements so that patients could see a doctor or nurse after hours without going to the emergency department.

Why is this? One of the reasons is manpower. The United States, for all its spending, has fewer general practitioners per population than any of these other countries.

The biggest access problem in the United States is the expense of obtaining care. More than one third of Americans said they did not fill a prescription they were given, did not visit the doctor they should have or did not get the tests that were ordered because of the cost.

Perhaps most telling, when adults were asked about their views of the health care system in 2013, 75 percent of Americans said that it needed fundamental change, or that it needed to be completely rebuilt. This percentage was higher than for any other country surveyed, Canada included. Primary care physicians feel similarly. Yet years after the Affordable Care Act was passed, Americans are still litigating whether to return to the previous system.

Access was a problem before. Access is a problem now. Americans can’t seem to have a discussion on how to make that better. Without that, it’s hard to see how things will improve.

http://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

The point here is that, although the Affordable Care Act (ACA) did expand the percentage of people with some form of health insurance, it still leaves us worse off than other nations in the percent of individuals remaining uninsured, and it didn’t fix other problems such as impaired access to health care.

Canada also scored poorly, near the United States, on some of these measures. This is partly due to our similar cultures, and both nations need to improve. In fact, Canada is making a concerted effort to address its problems with queues. But it is important to note that this does not mean that Canada’s single payer system has failed them. Not reported here are much more important measures in which Canada is clearly superior to the United States as a direct result of their single payer financing system: universality, equity, portability of coverage, elimination of financial barriers through first dollar coverage, reduction of administrative waste through public administration, and other efficiencies that have resulted in much lower per capita spending.

This month there is a campaign to tout the successes of ACA in order to reduce concerns about the announcement of the double digit increases in premiums for the ACA exchange plans. But when you objectively evaluate the successes, with the exception of the expansion of Medicaid, these improvements are almost negligible when compared to the improvements that Canada already has in place by virtue of the Canada Health Act that provides support for the single payer systems in their provinces.

As Aaron Carroll states, if we want improvement, we need to have a discussion on how to make the system better. Since ACA is falling so short, that discussion needs to center around truly effective reform, including a single payer national health program.

Struggling to Serve at the Nation’s Richest University

By Rosa Ines Rivera
The New York Times, October 24, 2016

I’ve been at Harvard University for 17 years, but I’ve never been in a classroom here. I’m a cook in the dining halls. I work in the cafeteria at the T.H. Chan School of Public Health, where every day I serve amazing students studying medicine, nutrition and child welfare, as well as the doctors and researchers who train them.

While I’ve earned no college credits here, I’ve had a lesson in hypocrisy.

On my way to work each morning, I pass a building with the inscription: “The highest attainable standard of health is one of the fundamental rights of every human being.” If Harvard believes this, why is the administration asking dining hall workers to pay even more for our health care even though some of us pay as much as $4,000 a year in premiums alone?

I serve the people who created Obamacare, people who treat epidemics and devise ways to make the world healthier and more humane. But I can’t afford the health care plan Harvard wants us to accept.

That’s why I have been on strike with 750 co-workers for more than two weeks. That’s why the other day, co-workers and I were arrested after we sat down in Harvard Square, blocking traffic, in an act of civil disobedience. And that’s why the medical school students, in their white coats, have been walking the picket line with us in solidarity.

Medical students analyzed Harvard’s proposal and found that the cost of premiums alone could eat up almost 10 percent of my income.

The students say that Harvard’s proposal is unaffordable for nearly all of us according to state government guidelines. If it goes through, I will keep avoiding the doctor to save that money for my kids’ co-pays. Any increase puts me at the breaking point.

Harvard is the richest university in the nation, with a $35 billion endowment. But I can’t live on what Harvard pays me. I take home between $430 and $480 a week, and this August, I fell behind on my $1,150 rent and lost my apartment. Now my two kids and I are staying with my mother in public housing, with all four of us sharing a single bedroom.

I know that health care costs are going up everywhere, and I don’t have all the answers. But there must be some way not to shift costs onto Harvard’s poorest workers.

If good health is truly “one of the fundamental rights of every human being,” then shouldn’t that also apply to the human beings working in Harvard’s cafeterias?

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Published comment:

By Don McCanne, M.D.
San Juan Capistrano, CA

In my work, volunteering as a health policy fellow for Physicians for a National Health Program, I follow the health policy literature, including that produced by Harvard’s T.H. Chan School of Public Health.

They devote much of their research to tweaking the highly flawed policies that have resulted in the most expensive health care system but one that is infamous for its mediocre performance for far too many. In spite of the Affordable Care Act, tens of millions remain uninsured or underinsured, creating for them financial hardship and impaired access.

The academic community is quite aware that a well designed single payer system funded with the 3 trillion dollars that we are already spending would provide high quality, comprehensive care for everyone with no financial barriers such as those that are being forced upon their dining hall workers.

It is reassuring for our future that the students seem to understand, but it is astonishing that too many of the academics seem to be oblivious. They should be leading the protest, not only at Harvard, but throughout the nation.

President Obama gave a great speech this past week defending our dysfunctional system while once again dismissing single payer, yet he cited many deficiencies that would be adequately corrected only with comprehensive reform and not mere tweaks. He knows that single payer is the way to go, and he need only look at the dining hall workers at his alma mater as a reminder of why we need to take that course.

http://www.nytimes.com…

Affordable Care Act: imploding and beyond repair

By John Geyman
The Hill, October 21, 2016

Our experience with the first six and a half years of the Affordable Care Act already tells us whether it will work.

Despite the law’s goals of containing costs and making health care affordable, it’s proven to be too expensive to be sustainable, overly complex and bureaucratic, and a gift to the private health insurance industry and other corporate stakeholders in the medical-industrial complex.

To be fair, the ACA has brought some kind of coverage to about 20 million Americans, in good part through the expansion of Medicaid in 32 states (including D.C.) and the subsidized exchanges. But its negative results far outweigh its gains, as shown by these data points:

(The article then lists concise, bulleted points with links to references that explain why ACA is beyond repair.)

Multiple studies have demonstrated that in the U.S. we could save about $500 billion a year by enacting a nonprofit single-payer national health program that streamlines administration. Those savings would be sufficient to guarantee everyone high-quality care, with no cost sharing, on a sustainable basis.

http://thehill.com…

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Comment:

By Don McCanne, M.D.

This article is a great resource that explains why the Affordable Care Act has not and will not provide us with the health care reform that we need.

The full article is relatively concise so it would take little of your time to access it today at the link above.

The Hill has a 14 day exclusivity on the article, but after that time it can be distributed widely as long as The Hill is credited and a link back to the original article is included. It would be worthwhile downloading it for your advocacy work.

Regulators approve higher health premiums to strengthen Obamacare insurers

By Jacquie Lee and Jayne O’Donnell
USA TODAY, October 19, 2016

State insurance regulators across the country have approved health care premium increases higher than those requested by insurers, despite a national effort to keep rates for policies sold on Affordable Care Act exchanges from skyrocketing, a USA TODAY analysis shows.

This year may be the last for dramatic premium increases as insurers now understand their new markets better, say some supporters of the law, including the head of the Centers for Medicare and Medicaid Services (CMS).

“The business was underpriced in many markets in the first couple years,” says Andy Slavitt, CMS’ acting administrator. “In retrospect, life would have been a lot better and easier if things had started 10% higher, the rate increases had been higher and it had been just a smooth steady climb.”

“Nobody really knew what it would cost to insure sick people,” Slavitt said. “I don’t know how (anyone) could have known.”

http://www.usatoday.com…

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Comment:

By Don McCanne, M.D.

Interesting. When the nation is upset about the very high increases in the insurance premiums for plans offered on the insurance exchanges, CMS acting administrator Andy Slavitt says that the insurers should have started with higher premiums, and the annual premium increases should have been greater.

Slavitt says that nobody could have known what it would cost to insure sick people, and, by implication, certainly not even the insurers.

But we, as a nation, are paying an extra half trillion dollars in administrative expenses to maintain our fragmented multi-payer system just to keep the private insurers in control of a major portion of our health care dollars. And their actuaries cannot even figure out how much money they need? Isn’t that fundamental to their business model?

Do we really want to keep on doing this? Or do we want to fill in our gaps in health care with that half trillion dollars? It doesn’t seem to be that difficult of a decision.

Regulators approve higher health premiums to strengthen Obamacare insurers

By Jacquie Lee and Jayne O’Donnell
USA TODAY, October 19, 2016

State insurance regulators across the country have approved health care premium increases higher than those requested by insurers, despite a national effort to keep rates for policies sold on Affordable Care Act exchanges from skyrocketing, a USA TODAY analysis shows.

This year may be the last for dramatic premium increases as insurers now understand their new markets better, say some supporters of the law, including the head of the Centers for Medicare and Medicaid Services (CMS).

“The business was underpriced in many markets in the first couple years,” says Andy Slavitt, CMS’ acting administrator. “In retrospect, life would have been a lot better and easier if things had started 10% higher, the rate increases had been higher and it had been just a smooth steady climb.”

“Nobody really knew what it would cost to insure sick people,” Slavitt said. “I don’t know how (anyone) could have known.”

http://www.usatoday.com…

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Comment:

By Don McCanne, M.D.

Interesting. When the nation is upset about the very high increases in the insurance premiums for plans offered on the insurance exchanges, CMS acting administrator Andy Slavitt says that the insurers should have started with higher premiums, and the annual premium increases should have been greater.

Slavitt says that nobody could have known what it would cost to insure sick people, and, by implication, certainly not even the insurers.

But we, as a nation, are paying an extra half trillion dollars in administrative expenses to maintain our fragmented multi-payer system just to keep the private insurers in control of a major portion of our health care dollars. And their actuaries cannot even figure out how much money they need? Isn’t that fundamental to their business model?

Do we really want to keep on doing this? Or do we want to fill in our gaps in health care with that half trillion dollars? It doesn’t seem to be that difficult of a decision.

The Final Rule

By Kip Sullivan, JD
The Health Care Blog, October 19, 2016

I have read a substantial portion of CMS’s final rule, published last Friday. It is clear to me CMS intends to implement its original rule with only minor changes. I predict the implementation process will be a nightmare.

The most fundamental problem with the rule is its insane complexity. The complexity is a function of both the complexity of medicine and the impossibility of what Congress has asked CMS to do – to measure the cost and quality of physician services at both the individual and group level and to punish and reward doctors based on inaccurate scores, and to oversee the creation of vaguely defined and unproven entities like ACOs and “medical homes” which will also dish out penalties and rewards based on inaccurate data.

Implementing such a monstrously complex law, or even portions of it, would be very difficult even for an agency run by clear thinkers. But CMS is not run by clear thinkers. It is run by people who think like employees of advertising agencies. They think their job is to persuade their listeners that their product is wonderful. They think they are supposed to exaggerate what MACRA will do, and to deny or obfuscate MACRA’s obvious defects.

CMS committed both types of errors – exaggeration and denial – in its first rule, and it committed identical errors in the final rule. At this point I think it’s reasonable to predict that CMS won’t admit either type of error until long after implementation has begun and reality has repeatedly smashed its staff over the head. Of course, by then much time and money will have been wasted, and many patients may have been harmed as well.

I’ll devote the rest of this essay to examining the worst examples of both types of errors – hyping that which should not be hyped, and overlooking that which should not be overlooked. I will close with a comment on how similar MACRA and the Affordable Care Act are. Both laws are already in trouble because they rely on the same bankrupt theory of cost-containment. Their troubles have only just begun.

Republicans and Democrats share the blame for the MACRA mess

In this post I have aimed my criticism at CMS for approaching MACRA with the mindset of a PR agent. CMS deserves harsh criticism because they are not being forthright, and in some cases they have been downright dishonest. [1] CMS’s unwillingness to tell the truth about MACRA does not bode well for its implementation and the ensuing public debate.

But the ultimate blame for MACRA’s nightmarish complexity falls on Congress. Democrats and Republicans voted overwhelmingly for MACRA. How quickly we resolve the mess created by MACRA will depend ultimately on how quickly leaders of both parties understand MACRA’s defects. If both parties engage in some honest introspection, they will at some point realize both parties have subscribed to the same bankrupt theory of cost containment.

http://thehealthcareblog.com…

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Comment:

By Don McCanne, M.D.

As Kip Sullivan explains, MACRA is bringing us considerable administrative complexity and grief without evidence that it will achieve its goal of containing costs while improving quality. You may want to use the link above to read the rest of his article, including the footnote on CMS not being forthright.

Although MACRA did have strong bipartisan support in Congress, that support was not based on the merits of MIPS (merit-based incentive payment system) and APMs (alternative payment models including ACOs). Rather the support was based on bringing an end to the flawed SGR Medicare payment system that had plagued Congress for a couple of decades. MIPS and APMs were included as a seemingly benign replacement for SGR (sustainable growth rate). It was not benign, as some of us protested, but we were ignored largely for political reasons, as described by Kip Sullivan.

Besides being a flawed model of cost containment, MACRA will absorb much of the energy in health care reform, delaying for perhaps decades a serious consideration of a model of reform that has already been proven to contain costs while improving access and quality and ensuring universality – a single payer national health program. What a shame.

By United States Government Accountability Office
Report to Congressional Committees, October 2016

Health Care Quality

HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures

What GAO Found

While the full extent of misalignment among health care quality measures is unknown, it can have adverse effects on providers and efforts to improve quality of care. Misalignment occurs when health care payers require providers to report on measures that focus on different quality issues or define the measures using different specifications. GAO identified three studies that provided some information on the extent of misalignment. For the most part, these studies examined the number of measures that were used in common, among a narrow selection of public and private payers, and found that with few exceptions, only a small proportion of measures were commonly used by these payers. The Department of Health and Human Services’ (HHS) Centers for Medicare & Medicaid Services (CMS) agrees that misalignment exists, and some experts note that it adds to providers’ administrative burden and often results in quality information that is not comparable.

Factors Driving Misalignment of Health Care Quality Measures

*  Dispersed decision-making:  Among public and private payers and other stakeholders, each entity independently decides which quality measures it will use and which specifications should apply to those measures.

*  Variation in data collection and reporting systems:  Payers may choose different measures, or leave details about measure specifications up to providers in order to accommodate differences in data that providers collect and the systems they use to collect these data.

*  Few meaningful measures:  Although hundreds of quality measures have been developed, relatively few are measures that payers, providers, and other stakeholders agree to adopt, because few are viewed as leading to meaningful improvements in quality.

Conclusions

The use of health care quality measures is central to HHS’s and other payers’ efforts to improve health care quality. While quality measures can encourage improvements in care, they can also be burdensome to providers when the measures are misaligned and providers have to report different quality measures to different health care payers. Such misalignment has the potential to affect the success of HHS’s efforts to pay providers based on the quality of care they provide. HHS has acknowledged the need to substantially improve quality measurement for physicians and other providers, and has a stated goal of improving alignment between federal and private payers.

Although HHS has initiated a range of different efforts to reduce misalignment, we identified two deficiencies in these efforts. First, HHS has not prioritized the development of electronic quality measures with standardized data elements for the core sets of aligned measures. CMS and private payers have prioritized certain quality measures to be used in common so alignment is improved, but HHS has not focused resources on developing electronic quality measures for these quality measures. As providers increasingly use EHRs, HHS has the opportunity to pursue its stated objective to develop electronic quality measures that would allow physicians to collect automatically much of the clinical information needed for these measures as part of their normal clinical workflow, with a consequent decrease in the administrative burden faced by physicians.

Second, CMS has not comprehensively planned its measure development efforts to ensure the development of new, more meaningful quality measures targeted to reduce misalignment, which could jeopardize CMS’s efforts to achieve that goal. Some experts we interviewed told us that the paucity of meaningful measures makes it difficult for payers and providers to agree on aligned measures. In contrast, developing new, more meaningful measures to replace older, less meaningful ones could help to promote further agreement on aligned measures and gain broader support from physicians. However, CMS’s plans do not indicate how its efforts will target new measures that will lead to greater alignment, rather than simply adding to the array of available quality measures that has led to misalignment in the past.

http://www.gao.gov…

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Comment:

By Don McCanne, M.D.

The mantra today is to pay for quality instead of quantity, and the government and private sector are rapidly moving ahead with administratively burdensome programs to implement this vision. But they left out a step. As this GAO report reveals, they have not developed a program that can adequately measure quality.

Measuring minutia that does not represent even one percent of health care – measures that also are misaligned between the various stakeholders – can hardly give a fair assessment of the quality of health care services delivered. Plans to add more measurements of minutia certainly will not help much.

Yet these almost worthless measurements are adding to the administrative burdens and costs of our health care system while intensifying physician burnout. Further, they are being used to assess financial penalties against the providers, and to shame providers through public reporting of quality ratings. Talk about depressing.

If we want real quality in health care, we need to do it through structural reform. We need to quit listening to Orszag, Emanuel, McClellan, and the others who support simple sound bites rather than effective policy on improving quality. Instead we should move forward with the model presented in a JAMA article over two decades ago: “A Better-Quality Alternative: Single-Payer National Health System Reform” by Gordon Schiff and his working group colleagues. The link:

https://www.pnhp.org…