PNHP

Is the NBT an individual mandate?

Is the NBT an individual mandate?

State health law could be template
By Bob Kievra
Worcester Telegram & Gazette
June 16, 2006

The state’s 65-day-old health care law could have national significance – legislation that might alter presidential politics in 2008 and shift the vexing topic out of the “hopeless” category for the first time in a generation, a Harvard University professor said last night.

Robert J. Blendon, professor of health policy and political analysis at the Harvard University of Public Health and the John F. Kennedy School of Government, said the new Massachusetts law – if it can be made to work – offers hope that the problems of the uninsured can be tackled in a thoughtful, bipartisan manner.

The 145-page law, intended to provide health care coverage to the state’s 550,000 uninsured adults, imposes an individual mandate for everyone in Massachusetts to obtain health insurance by July 1, 2007.

http://www.telegram.com/apps/pbcs.dll/article?AID=/20060616/NEWS/606160517/1002/BUSINESS

And…

AMA: Penalize some uninsured Americans
By Bruce Japsen
Chicago Tribune
June 13, 2006

The AMA’s policy-making House of Delegates vote in favor of what it called “individual responsibility” comes as state and federal lawmakers are weighing similar ideas in the form of legislation in Congress and state houses across the country.

In the past, the Republican-leaning AMA has shied away from government mandates as a way to provide health insurance coverage for more Americans.
In this instance, the group acknowledged Tuesday at a press briefing that its support of tax penalties to incentivize people to buy coverage would be a “significant shift” in the organization’s thinking on matters of covering the uninsured.

http://www.chicagotribune.com/business/chi-060613ama,1,3515691.story?coll=chi-news-hed

And…

Can Massachusetts Lead the Way in Health Care Reform?
By Stuart H. Altman, Ph.D., and Michael Doonan, Ph.D.
The New England Journal of Medicine
May 18, 2006

Massachusetts will require everyone who can afford health insurance to buy it – an individual mandate.

We don’t know exactly what the new insurance plans will look like, how much they will cost, and whether government subsidies will prove adequate. The cost of the reform will be contingent on the actual price of available plans and subsidy levels, which will not be known until regulations are drafted and insurers and health plans offer new products for this market.

http://content.nejm.org/cgi/content/full/354/20/2093

And…

Editorial
Los Angeles Times
June 14, 2006

…the real solution to the nation’s healthcare problems will have to come from a Washington ZIP Code. If it’s smart, Congress will study some of the states’ innovative ideas to determine whether they could work on a national level.

Requiring all citizens to have health insurance, for instance, is an interesting idea that could gain bipartisan traction.

http://www.latimes.com/news/opinion/editorials/la-ed-vermont14jun14,0,4682219.story?coll=la-news-comment-editorials

And…

Cheers and jeers for Mass. insurance mandate By Leah Carlson Shepherd
Employee Benefit News
June 1, 2006

In a groundbreaking move with far-reaching implications, Massachusetts adopted a law in April to require state residents to obtain medical insurance by July 1, 2007. Previously, no state had required people to carry medical insurance.

U.S. Sen. Edward Kennedy (D-Mass.): “Massachusetts once again leads the nation with an innovative plan that will achieve our longstanding goal of expanding health care for all.”

http://www.benefitnews.com/detail.cfm?id=9026

Comment:

By Don McCanne, M.D.

There has been a dramatic surge in media reports that there is a developing consensus that the individual mandate, requiring each individual to purchase his or her own insurance, is the common ground which will bridge the partisan divide on health care reform. It is rumored that even the leading candidate for the 2008 Democratic Party presidential nomination is currently working with consultants to develop an individual mandate model.

The individual mandate does not displace consumer-directed health care as the leading right-wing proposal for reform. On the contrary, it would greatly expand the market for consumer-directed products such as HSAs and high-deductible health plans. It merely reframes the rhetoric, making the individual mandate appear to be the politically feasible compromise. But do the politicians really understand what they are supporting?

The fundamental flaw with the individual mandate model is that insurance plans will have a new responsibility. They will have to cover not only the relatively healthy: healthy employees, their healthy families, and those who pass underwriting standards in the individual market. Since the individual mandate means that everyone must be covered, the plans will have to cover those with higher health care costs as well. Pooling everyone together is expensive. This year we are already spending $7110 per person for health care. Can a middle-income family of four really afford to pay nearly $30,000 for their share of the health care spending pool? Of course not.

A universal individual mandate can work only if the insurance product is affordable. By mandating that everyone be included, there are only two ways of keeping premiums affordable.

The current consumer-directed trend is to strip benefits out of the plans, and to increase out-of-pocket spending through high-deductibles, co-payments and coinsurance. That way, the health insurance premium is affordable, but access to care is not affordable for those who have needs. This totally defeats the purpose of insurance: providing financial protection against the losses of adverse medical events.

The other way to keep premiums affordable would be to shift the bulk of health care costs to the government. Very large tax credits would help, but that would add even more to the current, relatively-opaque taxpayer burden that is already funding 60 percent of our health care. Another government role would be to provide re-insurance, protecting the insurance companies from major losses (i.e., that 20 percent of individuals who use 80 percent of our health care). But then what good are insurers if they are not going to insure us against loss?

Even if we did adopt a government-funded individual mandate, we would perpetuate the tremendous losses that we are already experiencing due to profound administrative excesses, and due to a highly wasteful and even harmful maldistribution of our health care resources. Now that’s what’s not affordable!

So the NBT (Next Big Thing) is the individual mandate? Single payer advocates – get on your horses!

HMO rate increases decline to a mere 11.7 percent

HMO Rate Increases Continue to Decline for Fourth Consecutive Year, According to Hewitt Associates U.S. Employers Remain Focused on Managing Costs
Hewitt Associates LLC
Press Release
June 13, 2006

Preliminary information from Hewitt Associates, a global human resources services company, shows that 2007 HMO rates will increase approximately 11.7 percent — representing the fourth consecutive year of declining rate increases.

“Although there has been a steady decline in the level of HMO rate increases over the past several years, double-digit increases are still very difficult for employers to absorb,” said Paul Harris, senior health care strategist, Hewitt Associates. “The good news is that there do not appear to be market pressures that might cause rates to begin increasing again.”

Although increases are moderating, companies are still facing double-digit increases and, as a result, continue to make plan design changes and share more of the cost with employees.

http://was4.hewitt.com/hewitt/resource/newsroom/pressrel/2006/06-13-06.htm

Comment:

By Don McCanne, M.D.

This is good news? Rates are stabilizing at low double digit increases? Employers are managing costs by sharing more of the costs with employees?

These rate increases are well in excess of inflation, and costs are being shifted to employees at a time when their wages are failing to keep up with the rest of the economy. Patients are bearing much of the brunt of our failed health care funding policies.

It’s not that we don’t understand how to control health care costs. We do. The single payer model does precisely that (with the not insignificant additional advantage that it also provides truly comprehensive coverage for absolutely everyone).

The problem is that we continue to depend on private sector plans to manage costs, which now means that they manage to shift more of the costs to patients. Their model doesn’t work and it needs to be dumped. It’s time for single payer.

AMA supports individual mandate for higher-income individuals

2006 Annual Meeting of the House of Delegates Reference Committee highlights
AMA

The AMA voted to support a requirement that individuals and families earning greater than 500 percent of the federal poverty level obtain, at a minimum, coverage for catastrophic health care and evidence-based preventive health care, using the tax structure to achieve compliance. Upon implementation of a system of refundable tax credits or other subsidies to obtain health care coverage, this requirement would apply to individuals and families earning less than 500 percent of the federal poverty level.

http://www.ama-assn.org/ama1/pub/upload/mm/471/refcom_highlights.pdf

Comment:

By Don McCanne, M.D.

For 2006, an income of 500 percent of the federal poverty level is about $50,000 for an individual and about $100,000 for a family of four. Only about one-tenth of the uninsured have incomes at that level or higher. This is obviously only a tiny step towards universal coverage.

What is important is that the AMA is now officially on record as supporting an individual mandate to purchase health coverage in the private insurance market. They would eventually expand that to cover all of the uninsured through a system of refundable tax credits. The good news is that the AMA is explicitly supporting universal health care coverage.

The bad news is that individual mandates for private plans is the most expensive method of achieving universal coverage, and it leaves patients vulnerable to medical debt because of the deterioration in the quality of plans available in the private market.

Let’s not simply settle for universal coverage. Let’s also make it efficient, affordable and comprehensive through a single payer program of national health insurance.

How Hillary Clinton could work with the Republicans on health care reform

The Huffington Post
The Blog
(Accessed June 13, 2006)

In today’s NY Times (June 10), Hillary Clinton states, “I think you should cover all children who don’t have other access to coverage. We shouldn’t have any uninsured children. But we have to take that step by step.”

For decades, we have been reforming health care “step by step.” These steps have resulted only in more uninsured and in an explosion in medical debt due to deteriorating coverage. These financial barriers to care have resulted in impaired health outcomes.

John Conyers’ HR 676 would replace our inefficient, inequitable, fragmented system with an affordable national health insurance program providing comprehensive benefits for everyone. For those concerned about skyrocketing costs, this is the only effective proposal (which expands coverage) that actually brings costs under control. It should appeal to progressives who want access and coverage for everyone, and to the business community which wants relief from unrelenting cost escalation while ensuring adequate coverage for employees.

This should no longer be a partisan issue. If the Republicans would begin to discuss the business rationale of single payer, then Sen. Clinton should be willing to concede that comprehensive reform really is feasible. But we do need to sit down with our Republican friends to be sure that they understand the single payer business model.

By: dmccanne on June 10, 2006 at 01:05pm

http://www.huffingtonpost.com/deborah-burger/a-walking-tour-of-america_b_22478.html

Wounds Salved, Clinton Returns to Health Care (NY Times, June 10):
http://www.nytimes.com/2006/06/10/washington/10hillary.html?pagewanted=all

Comment:

By Don McCanne, M.D.

Seriously. Let’s make every effort to be certain that the Republicans and the business community clearly understand the single payer business model. The efficiencies and cost containment mechanisms should appeal to anyone who is struggling with budgets.

Kevin Drum and Uwe Reinhardt on social insurance

Washington Monthly
Political Animal

By Kevin Drum
June 11, 2006

THE S-WORD….Ezra Klein, practicing for his career as a TV talking head, responds to a question about whether national healthcare is “socialist”:

“We should stop running from that moniker. If we’re going to call what Canada, France, Germany, England, Japan, and essentially every – actually, not essentially, just every – other industrialized nation offers socialized health care, but they cover all of their citizens with better outcomes and lower costs than we do, then I’m happy to associate myself with that.”

OK, it was only a training session. But still. Can I suggest something a wee bit different?

“Socialist” is a scare word conservatives use when they’ve run out of serious arguments. But national healthcare isn’t socialism any more than Medicare is. It’s just a practical and efficient way of providing medical treatment for everyone in the country, the same way that interstate highways are a practical and efficient way of providing roads for everyone in the country.

The facts are simple: A well-designed national healthcare plan gives you greater choice of doctors, it’s less expensive than private insurance, it helps rein in spiraling costs, it keeps you covered even if you temporarily lose your job or have a preexisting condition, it helps out small companies that can’t afford to provide health coverage for their employees, it helps out big companies like GM and Ford that are nearly bankrupt because they do provide health coverage, and it covers everyone all the time.

And best of all, it gets rid of the bureaucratic hodgepodge we have now:
Medicare for the old, employer coverage for people who work for big companies, 50 different versions of Medicaid for the poor, emergency rooms for the destitute, and no coverage at all for people who are unlucky enough to work for Wal-Mart. It’s an expensive mess that drives doctors nuts and provides most of us with mediocre care.

Or something like that. In any case, the basic answer to “Is national healthcare socialist?” should always be no, not yes. We are not in favor of command economies, ownership of the means of production, or state control of doctors, and that’s what most people think of when you say “socialist.”

And that’s Kevin’s media training for the day.

-Kevin Drum

http://www.washingtonmonthly.com/archives/monthly/2006_06.php

Uwe E. Reinhardt, Ph.D., James Madison Professor of Political Economy, Princeton University, responds:

“Socialism” is an arrangement under which the means of production are owned by the state. Government-run health insurance is not “socialism,”and only an ignoramus would call it that. Rather, government-run health insurance is a form of “social insurance,” that can be coupled with privately owned for-profit or not-for-profit health care delivery systems.

Conservative critics of “social insurance” often forget that they benefit from many other forms of “social insurance” — e.g., the principle of limited liability of shareholders, which is the rockbed of capitalism. In a real sense, the national defense system also is a form of “social insurance” against threats from abroad. People in the farmbelt may never rail against “socialized medicine,” because so much of their income is protected by another form of social insurance, agricultural price supports and import restrictions (like the sugar quota.)

In fact, none other than Hank Greenberg, former CEO of the huge AIG insurance company, asked for government help to protect insurance companies from catastrophic losses such as those following 9/11. That, too, is “social insurance.”

I have gotten tired of ignoramuses who call social insurance “socialism,”
all the while being beneficiaries of it. One has the right to argue with them quite aggressively and ad hominem (or ad feminam), if the case fits.

Republican Governors think nothing of going to Washington, hat in hand, demanding federal emergency funds after a natural disaster has struck their state. Well, breast cancer or severe neonatal illness is a natural disaster too, and there is nothing socialist about an individual in Texas or Mississippi asking her fellow Americans for helping financially with coping with that natural disaster as well.

Perhaps I am wrong, of course, in my assumption that this is a nation, and not just a bunch of people sharing a geography, and that the “national” flag we may not burn actually means something. I grew up in nations — Germany and Canada — where the idea of nationhood and the national flag do mean something (even though there one may burn the flags, I believe). I haven’t a clue what Americans actually think of that big blob of land south of Canada and north of Mexico.

-Uwe Reinhardt

Big UAW Auto Assembly Plant Endorses HR 676

Conyers’ Single Payer Legislation

Newark, DE-On the eve of the UAW’s international union convention this week in Las Vegas, UAW Local 1183, representing 2,000 workers at the Daimler/Chrysler assembly plant here, has endorsed HR 676, a bill introduced by Congressman John Conyers (D-MI) to institute a single payer health care system in the U.S.

UAW local unions and CAP Councils in Birmingham, AL, West Mifflin, PA, Detroit, MI, Chicago, IL, and Holyoke, MA, have sent resolutions to the convention urging support for HR 676.

HR 676 now has 70 congressional co-sponsors in addition to John Conyers. It would institute a single payer health care system in the U.S. by expanding a greatly improved Medicare system to every resident.

HR 676 would cover every person in the U. S. for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, chiropractic and long term care. HR 676 ends deductibles and co-payments. HR 676 would save billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

#30#

HR 676 has been endorsed by 144 union organizations including 26 central labor councils, two state AFL-CIO’s (KY and PA), and two area labor federations.

For further information and a complete list of union endorsers contact:
Kay Tillow
All Unions Committee For Single Payer Health Care-HR 676
c/o Nurses Professional Organization (NPO)
1169 Eastern Parkway, Suite 2218
Louisville, KY 40217
(502) 636 1551, (502) 459-3393
email: nursenpo@aol.com

A Walking Tour of America's Broken Health Care System

by Deborah Burger
June 7, 2006
on-line at The Huffington Post

June 7th 2006 is a national day of action for HR 676, Rep. John Conyers’ landmark bill to create Medicare for All. To mark this day, California’s nurses are taking a walking tour of the country’s broken healthcare system. Won’t you join us?

Everything you need to know about can be found in just one block of America, a quiet business-park block in a San Fernando Valley town named Woodland Hills. Here we find such the headquarters of such titans of the healthcare world as Blue Cross/Blue Shield, Wellpoint, Health Net, and Meridian Healthcare Management.

In just this handful of companies, we find the three values that mark today’s system of big-business healthcare: denial of care, cash register politics, and huge profits amidst a growing crisis.

Our tour guide Sue Cannon, RN, starts at Blue Cross, to talk about the corporate need to save money by denying care–hardly the way a health CARE system is supposed to work. We’re at Blue Cross because they’ve just been sued by numerous patients who’ve for”retroactive denial of coverage.” Here’s how that works: you get sick and Blue Cross approves a certain medical procedure. Then they go over your original application to see if they can find any inconsistencies; if so, they boot you out of the system, and leave you with the bills they just approved.

Nurse Cannon moves on to Health Net to talk about cash register politics and how it hurts patients. Between 1998 and 2004, healthcare corporations spent $1.2 billion on federal lobbying, winning favors such as George Bush’s Medicare Part D Prescription Drug benefit that forces seniors to enroll in a private health plan to qualify for the benefit and blocks the federal government from negotiating drug price discounts. Health Net symbolizes this excess. In California alone, for example, Health Net spent $580,615 lobbying in the 2005-2006 legislative session (to date).

Our final stop is WellPoint, to discuss the disparity between huge healthcare industry profits and the growing crisis of the uninsured. WellPoint used to be a for-profit division of non-profit Blue Cross. Subsequently, it bought Blue Cross of California, turning the whole organization for-profit. Why? In the words of one stock analyst, to “liberate them from their social responsibilities.” This liberation led to $2.5 billion in profits in 2005, and $157 million in direct compensation to their top five executives over the past three years. Yet HMOs have led the fight against a universal healthcare system based on a single standard of care for all, despite the fact that some 50 million Americans and over 6 million Californians have no health insurance,.

Denial of care, cash register politics, and record profits from a health care crisis. That’s the health care system we enjoy in America today. Thousands of people die unnecessarily each year because of this, and every year we fall further behind countries like Canada and England that haven’t handed their health care off to big corporations like these in Woodland Hills.

John Conyers’ has a plan to fix this, with Medicare for All, building on the most popular and effective federal program (George Bush’s efforts notwithstanding).

California nurses are taking up the fight to help Conyers revive our broken healthcare system. Here’s one way you can help: click here and send a message to your members of Congress, telling them it’s to extend Medicare to every single American.

_____________________________

Comment by PNHP Senior Health Policy Fellow, Dr. Don McCanne June 10, 2006

In today’s NY Times, Hillary Clinton states, “I think you should cover all children who don’t have other access to coverage. We shouldn’t have any uninsured children. But we have to take that step by step.”

For decades, we have been reforming health care “step by step.” These steps have resulted only in more uninsured and in an explosion in medical debt due to deteriorating coverage. These financial barriers to care have resulted in impaired health outcomes.

John Conyers’ HR 676 would replace our inefficient, inequitable, fragmented system with an affordable national health insurance program providing comprehensive benefits for everyone. For those concerned about skyrocketing costs, this is the only effective proposal that actually brings costs under control. It should appeal to progressives who want access and coverage for everyone, and to the business community which wants relief from unrelenting cost escalation while ensuring adequate coverage for employees.

This should no longer be a partisan issue. If the Republicans would begin to discuss the business rationale of single payer, then Sen. Clinton should be willing to concede that comprehensive reform really is feasible. But we do need to sit down with our Republican friends to be sure that they understand the single payer business model.

The Best Corporate Health Plan

Jonathan Tasini
June 30, 2005
Tom Paine.com

Jonathan Tasini is president of the Economic Future Group and writes his “Working In America” columns for TomPaine.com on an occasional basis.

The imploding health care system is finally making one thing crystal clear: Corporate America is shredding its own global competitiveness because it can’t shake the death grip of an anti-government ideology. This short-sighted ideology leads big business to shun single-payer national health insurance, which could save businesses hundreds of billions of dollars.

The simple fact is that private-sector insurance has failed. According to the 30-member-country Organization for Economic Cooperation and Development, in 2003, “the United States spent $5,635 per person on health, more than twice the OECD average and around ten times more than the lowest-spending countries, Mexico and Turkey.” According to the National Coalition on Health Care, “Health insurance premiums will rise to an average of more than $14,500 for family coverage in 2006.” The United States devotes 15 percent of its gross domestic product to health spending.

Because health care expenditures come either out of business profits or get passed on to consumers as higher prices, U.S. companies put themselves at a competitive disadvantage compared, at least, to every other country in the industrialized world. And that doesn’t even touch the issue of China. Though the China competitive issue is bigger than health care, The New York Times reported this week that a Chinese auto worker earns $1.50 an hour in wages and benefits, compared to $55 an hour at General Motors.

There are two responses that the business community has to this crisis: eliminate health coverage altogether or shift the costs of health care to workers. You want a headache, check this out: according to the Henry J. Kaiser Foundation, the annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $9,950, or $829 a month in 2004; workers contributed $2,661, or 10 percent more than they spent in 2003; and, for single coverage, workers contributed an average of $558 toward the $3,695 annual premium.

I’m not here to argue the moral imperative for single-payer national health care. Instead, progressives need to turn their rhetoric to hard-core, good ‘ole patriotic, rally ‘round the flag” American business interests. In a “Working in America” column six months ago , I wrote that “companies that don’t advocate for a single-payer system are endangering shareholder value, throwing money into a system that is dragging down profits and competitiveness.” That has become clearer as time passes.

What better example can one give than GM, the once-proud gold standard of American industry whose bonds’ credit rating has plummeted to junk status? GM will spend $5.6 billion this year on health care for its employees and retirees—more money than it shells out for steel for its cars—which means every GM car we buy costs $1,500 more because of health care. Speaking to GM shareholders recently, GM’s CEO Rick Waggoner said, “Our $1,500-per-unit health care expense represents a significant disadvantage versus our foreign-based competitors. Left unaddressed, this will make a big difference in our ability to compete in investment, technology and other key contributors to our future success.”

Now don’t get me wrong: GM has an obligation to its workers. And its saber-rattling threats that the United Auto Workers must agree by today to health care benefit cuts for auto workers is outrageous, and perhaps illegal (full disclosure: I am a UAW member). But the problem is unavoidable.

Even that poster child for corporate malfeasance, Wal-Mart, would have good reason to get behind a single-payer plan, if only to get some good press. Wal-Mart workers, who make an average of $14,000 a year, are forced to pay a $1,000 deductible—when they qualify at all for the company’s stingy plan. Since most workers can’t foot that bill, taxpayers already subsidize Wal-Mart: 13 percent of its 91,000 workers in Florida are enrolled in the state Medicaid program, 10,000 children of Wal-Mart workers in Georgia rely on state-funded health care and the company leads the pack in this dubious category in other states such as Iowa, Tennessee, Wisconsin, Arkansas and New Hampshire.

Some executives are starting to see the light. I recently had an exchange with a senior executive from a national employer lobbying group who said, “You’re right that some are thinking, ‘How much worse can it be?’ Thus far, though, national health care is a bridge too far.” Instead, companies are fiddling around the edges, engaging in discussions with various health care advocacy groups—but always falling short of the single-payer option. So we have to build that bridge and lead—or kick—corporate America across it.

Only a single-payer national plan will work. All the other gimmicks relying on market-based, employer-centered insurance have failed. The premiums for employer-based health insurance rose by 11.2 percent in 2004, the fourth consecutive year of double-digit increases—and every single type of plan (health maintenance organizations, preferred provider organizations, and point-of-service plans) registered double-digit increases. And, ultimately, state-based single-payer plans, while admirable, can’t survive in the long term because they will lack the economies of scale only a sweeping national plan can make possible.

We need to put the real onus on corporate executives with a carrot-and-stick approach that is based on a clear principle: your ability to compete depends on single-payer health care. For those who refuse, it’s time to mount an aggressive corporate and public relations campaign. One shareholder approach might be to cut back executive pay and benefits each year by the same percentage total health care costs amount to in the corporate bottom-line. If that doesn’t work, a more serious step would call for divesting from companies that oppose single-payer.

Organized labor and their allies in the huge public employee pension funds should lead the fight. If unions represented the same proportion of the workforce they did in the 1950s—35 percent—40 million people would not be without health insurance because more people would be under unionized, employer-based health plans. And we’d end up with a different system because unions—whose main fight at the bargaining table today is over health care costs—would have a stronger hand to play in lobbying for single-payer. But even in its smaller state, unions need to take the fight on for the public good. Pension funds, representing hundreds of thousands of current and retired workers who face health care cost pressure, have a significant financial interest in seeing the system changed; the California Public Employees Retirement System alone has $177 billion that it could use as leverage.

When I first broached this notion with colleagues, they snorted, “Yeah, but how do you pass this kind of thing with Republicans controlling the government?” That’s a fair point—if your thought process is driven solely through a “red state, blue state” prism.

But I’d wager that the wind could shift dramatically, driven by a population of all colors that can coax or bludgeon the business community into doing what’s in its best economic self-interest. And here’s a prediction: A serious campaign based on single-payer national health insurance could propel someone to the White House in 2008.

MedPAC update of Medicare Advantage overpayments

Medicare Advantage benchmarks and payments compared with average Medicare FFS spending
MedPAC
Medicare Briefs

The purpose of this report is to present data on the level of Medicare Advantage (MA) payments for Parts A and B services relative to the spending on similar beneficiaries in Medicare’s traditional fee-for-service (FFS) program. This responds to requests from Congressional committees to update our past analyses.

CMS no longer determines MA plan payments based solely on administratively set payment rates. Plans now submit formal bids, and then CMS compares the bids with benchmarks to determine payment. Medicare’s payment declines if bids are lower than the benchmarks.

Plan service areas have expanded to more rural and other areas with benchmarks that are high relative to Medicare FFS spending. The benchmarks were relatively high because these areas were given increases in payment rates under earlier law.

Finally, the risk adjustment system has changed payment rates. In 2004, the Centers for Medicare & Medicaid Services (CMS) adjusted plan payments with a blend of 70 percent demographic factors and 30 percent health risk factors.

For 2006, 25 percent of each payment is based on the demographic factors and 75 percent is based on the health risk factors. By 2007, payments will be based 100 percent on risk-adjusted rates.

With the introduction of risk adjustment, the payment system now explicitly takes into account the relative disease burden of the MA population. Risk adjustment (applied to 75 percent of payments in 2006) generally would lower payments to plans if they enrolled beneficiaries who were healthier. But CMS has taken steps to prevent overall payments to plans from going down. A hold-harmless adjustment increases the benchmark rates in 2006 by the amount that CMS expects payments would fall because of risk adjustment.

We find that the combined benchmarks are set at an average of 115 percent of FFS Medicare in 2006. After taking into account the amount that plans return to the trust fund through the bidding process, the 115 percent figure falls to 111 percent. In sum, this 111 percent includes all three factors we have discussed: the relationship of the MA benchmarks to FFS rates, the effect of bidding and returning funds to the trust funds, and the hold-harmless provisions.

http://www.house.gov/stark/news/109th/pressreleases/20060606_MedPAC.pdf

Comment:

By Don McCanne, M.D.

Hold-harmless!?

The private Medicare plans have always benefited by their ability to selectively market their products to healthier Medicare beneficiaries, even though they have received payments at a higher level that assumes that they enroll their fair share of those in poor health. Congress and the administration have promised us, and have now required by law, that the payments to the plans would be adjusted to reflect the risk based on the level of health of the enrollees.

The required risk adjustments are now in place. But what has CMS done? By giving back to the plans the required adjustments, CMS is ensuring that the plans will not be harmed by their success in excluding, by selective marketing, the higher-cost Medicare patients with greater health care needs.

“Hold-harmless” is yet another abuse of rhetoric that characterizes this administration. Granting a gift of taxpayer funds to the private Medicare Advantage plans certainly harms the taxpayer.

Worse, they promised to us and enacted measures that would establish fairness by adjusting for risk. They lied to us!

Interim Recommendations of the Citizens' Health Care Working Group

Interim Recommendations of the Citizens’ Health Care Working Group June 1, 2006

The Citizens’ Health Care Working Group was created by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Sec. 1014 to provide for the American public to “engage in an informed national public debate to make choices about the services they want covered, what health care coverage they want, and how they are willing to pay for coverage.”

Following this nationwide citizen engagement, the Working Group is required to prepare and make available to the public this interim set of recommendations on “health care coverage and ways to improve and strengthen the health care system based on the information and preferences expressed at the community meetings.” Following a 90-day public comment period on these recommendations, the Working Group will submit to Congress and the President a final set of recommendations.

Across every venue we explored, we heard a common message: Americans should have a health care system where everyone participates, regardless of their financial resources or health status, with benefits that are sufficiently comprehensive to provide access to appropriate, high-quality care without endangering individual or family financial security.

Interim report:
http://www.citizenshealthcare.gov/recommendations/interim_recommendations.pdf

Comment:

By Don McCanne, M.D.

Those who have followed and participated in this process should agree that the “common message” above represents the prevailing views of the participants. We want a universal, comprehensive, high-quality system that does not endanger financial security for anyone.

Unfortunately, some of the actual details of the report do not seem to reflect this view but rather reflect the opinions of the current administration. Following, in quotations, are a few excerpts from the report, each followed by my comment.

* “No specific health care financing mechanism is optimal.”

There was a clear preference for an equitable, progressively-funded system of insurance for everyone. The administration’s tax credit proposal was rejected by most of those who were offered that option in the sessions. This statement seems to reflect the opinion of the individuals preparing the report rather than the view of the majority of citizens participating.

* “We understand that the transition from the current system to a system that includes all Americans will take time and that multiple financing sources will need to coexist during the move to universal coverage.”

Incrementalism was not a concept discussed in the sessions. This statement, calling for an incremental process, also seems to represent the view of those preparing the report.

* “Define a ‘core’ benefit package for all Americans”

“Core” is a term selected by those preparing this report which suggests that only basic services should be covered by a universal program, and that, by inference, second-tier benefits should be provided only for those who can afford them. The “common message” in this report states that benefits should be “sufficiently comprehensive to provide access to appropriate, high-quality care.” However “core” is defined, it implies that access to other appropriate care will be impaired due to financial barriers. This does not seem to be the intent of the citizen-participants.

* “Guarantee financial protection against very high health care costs”

The report does call for financial protection for low-income individuals, but out-of-pocket health care expenses now threaten average-income Americans. Protection against “very high health care costs” is a call for high-deductible, catastrophic coverage, a policy supported by the administration. In contrast, the majority consensus of the citizen-participants is that the system should not endanger “individual or family financial security,” though many participants seemed to be uninformed about the adverse consequences of high-deductible health plans.

* “Expanding and modifying the Federally Qualified Health Center concept to accommodate other community-based health centers and practices serving vulnerable populations”

Rather than ensuring that every individual has comprehensive health care coverage, the administration supports the expansion of community health centers to serve low-income individuals, especially those who are uninsured.
Although community health centers serve a very important role, they should not be viewed as a substitute for adequate health care coverage.

* “Consumer-usable information about health care services that includes information on prices, cost-sharing, quality and efficiency, and benefits”

This statement supports the consumer-directed health care movement, the current market diversion from the need to focus on a comprehensive system of health care coverage.

It is likely that members of Congress will select those portions of this report that support their own individual agendas while ignoring the overriding message supporting an equitable, comprehensive, high-quality system for everyone. The Working Group has requested comments on this interim report before it is formally submitted to the President and Congress. You should provide those comments to help ensure that this process is not hijacked by the opponents of comprehensive reform.

Use the following link to submit your comments on the interim recommendations: http://www.citizenshealthcare.gov/speak_out/ircomment1.php

Look north for answers

By Dr. Susanne King
Thursday, June 08
LENOX

THE CANADIAN health care system hit the news again last week. A new study by Harvard Medical School researchers reported that Canadians are healthier than U.S. citizens, even though the United States spends twice as much per person for health care.

The study analyzed data from a joint survey carried out by U.S. and Canadian governmental agencies. The authors found that U.S. residents had higher rates of nearly all serious chronic illnesses, including chronic lung disease, arthritis, diabetes and high blood pressure. In addition, race and income disparities in health care were larger in the United States. Despite the fact that we currently spend $2.1 trillion annually on health care in the U.S., cost is the biggest barrier to care: 30.4 percent of U.S. residents reported having an unmet health care need because they could not afford it.

“Most of what we hear about the Canadian health care system is negative; in particular the long waiting time for medical procedures. But we found that waiting times affect few patients, only 3.5 percent of Canadians, vs. 0.7 percent of people in the U.S. No one ever talks about the fact that low-income and minority patients fare better in Canada,” said Dr. Karen Lasser, the study’s lead author.

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AA co-author, Dr. Steffie Woolhandler, commented, “Our study, together with a recent study showing that people in England are healthier than Americans, is a terrible indictment of the U.S health care system. A single payer national health insurance system would avoid thousands of needless deaths, and hundreds of thousands of medical bankruptcies each year. In 1971, Congress almost passed national health insurance. Since then, at least 630,000 Americans have died because they failed to act. (18,000 people die each year because of lack of access to health care). “How much longer must we wait?”

We spend twice as much per person for health care in the United States as they do in Canada (in Massachusetts we spend almost three times as much), yet as the recent comparative study shows, we get much less for our health care dollar than our neighbor to the north. The percentage of the U.S. gross domestic product used for health care is almost double what is spent in Canada, taking away funds from other vital services in the U.S, like education. Yet our life expectancy is 2.5 years less in the United States, and the incidence of chronic illness is higher.

Last month, former president Bill Clinton was in Canada speaking at the World Leaders Forum. Responding to a question about the interest of some in Canada for privatization of their health care system, Clinton said the last thing they should do is “let the health care finance tail wag the health care dog.” He said our system is a mess because the U.S. spends 34 percent of its health care dollar ($280 billion) on administration “to pay two million people to go to work every day for all the providers and insurers, and play tug of war. It is insane. It is a colossal waste of money. Don’t go down that road.”

By contrast, our Medicare system spends 3 percent for administrative costs.

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I was at the Democratic Convention last weekend, staffing a table for Physicians for a National Health Plan (PNHP), a group of 14,000 physicians who advocate for a single-payer health care system. Single-payer health care is just like the Canadian system, in which the government is the “single payer” for health care, eliminating the multiple insurance companies with their exorbitant profits and high administrative costs.

In Massachusetts, 62 percent of physicians have said they support single-payer. The movement for significant health care reform is growing. The extraordinarily flawed health care “reform” bill recently passed in Massachusetts will maintain our current system, which is much more expensive than Canada’s and leaves us sicker.

A change to a single-payer system is the only reform that will provide universal, affordable and comprehensive care, as well as contain rising health care costs. This is not an experiment. We have only to look to Canada to see that they not only do it cheaper, they do it better; with a healthier population that lives longer than we do.

Health-care reform is more urgent than ever

By John A. Ameriks, MD Health policy analyst
Las Cruces Sun-News

The U.S. population will rise above 300 million this year, and health care expenditures are projected to exceed $2.1 trillion. Simple arithmetic leads to the alarming realization that the price of health care in 2006 will be $7,000 for each American. Yet the Senate has failed to take up health reform and our governor vetoed funding for a similar effort in New Mexico.

Few will see the entire $7,000 taken from personal savings or paychecks. The more fortunate and healthy half of the population have small medical expenses in any given year, a circumstance that helps to insulate them from the “up close and personal” experience of health-care sticker shock. And historically only 20 percent of the population is sick enough to use 80 percent of the money, while the sickest 1 percent account for 22 percent of all expenses in the average year. The odds are that you and I are not likely to fall into the 20 percent or 1 percent this year; but the lifetime odds are that eventually we will.

So how do we respond to a problem that absorbs 16 percent of the dollars spent in our country and will demand 20 percent of the gross domestic product by 2015? The suggestions to be heard on the campaign trail will include personal choice, individual responsibility, health savings accounts and consumer-directed plans. Yet none of these provide sufficiently for the costs incurred by us when illness expenses overwhelm our personal economic resources. Simply put, the politically opportune solutions aren’t applicable.

Reforming health care is a troubling prospect. The only group unquestionably in favor is the 16 percent uninsured segment of the population. The remaining 84 percent with current access to insurance view reform with anxiety. They fear losing their existing level of protection or increasing the cost of what they presently have. And they remain unaware that a stealth version of insurance reform is already occurring by the introduction of higher deductibles, increased co-pays, limits on employer contributions and restrictions on provider choice. Yes, even those insured are gradually, and in many cases unknowingly, becoming underinsured. The discomforting truth is that most of us have already lost this game; but few have yet experienced the pain.

This is an election year, and voters have increasing reason to demand meaningful health care reform. We should not be diverted from that demand by the delaying tactic of promises to reform health care once the candidate discovers a uniquely American way to do it. Profound change of our health-care system is not only inevitable but desirable. We do not suffer from distinctly American diseases that require strictly American treatments. While there is no perfect health-care system on this planet, the systems in France, Japan, Germany and the Scandinavian countries are cheaper, provide universal coverage and result in easier access and better outcomes. These are the same countries whose automobiles and electronics appear to be cheaper, better built and more fuel efficient than the domestic choices. We can learn from them. The United States stands alone in not providing health care to all its citizens; and because of that policy, America is finally encountering economic disadvantage in world markets. Without change, this will remain our fate. Our market-based approach has failed to deliver on its promises to provide higher quality at lower cost.

Health-care reform makes greater economic and common sense than ever. It need not cost more than we are already spending; and reform of the entire system offers the only realistic path to future cost containment. In a world with open borders and global economic competition the involvement of elected officials in this issue is unavoidable and even desirable. Under these circumstances the public has every right to know the candidates’ position on health care. We should not give them a pass in 2006. The lives and dollars we save will be our own.


John Ameriks, a retired physician who lives in Las Cruces, is a health policy analyst for the New Mexico chapter of Physicians for a National Health Program, a national advocacy group.