AcademyHealth
March 2005
Managed Care Mandates Fall Short of Curbing California Medicaid Costs
By Bonnie J. Austin, J.D.

Over the past several years, growth in Medicaid spending has far outpaced the growth in state tax revenues and now accounts for nearly 22 percent of total state government spending. Rapid health care cost increases during the 1990s led many state governments to shift Medicaid recipients into managed care plans in an effort to control costs. The conventional wisdom at the time suggested that states would save money as a result. Like many other states, California sought relief through managed care; it passed legislation to foster enrollment and county by county, Medicaid recipients moved from a fee-for-service (FFS) system to managed care plans.

To shed light on the effects of transitioning beneficiaries from FFS Medicaid to Medicaid managed care, Mark Duggan, Ph.D., and colleagues from the University of Maryland and the National Bureau of Economic Research examined how mandatory enrollment in managed care has affected both spending and health outcomes for California Medicaid recipients. They found that despite a dramatic increase in Medicaid managed care enrollment-from less than 12 percent in 1993 to 51 percent in 1999-there was neither a significant reduction in spending nor improved health outcomes.

“Our findings suggest that managed care contracting reduced the efficiency of the Medicaid program in California,” says Duggan. “In fact, Medicaid spending appeared to increase by almost 20 percent following the shift to managed care and persisted long after the mandates first took effect” (suggesting that they are not simply driven by startup costs of a new plan).

The researchers also found that the switch from FFS to managed care did not lead to significant improvements in health outcomes.

Although the burden of administrative costs on the health care system is enormous, Duggan did not have data on these costs. Nevertheless, anecdotal evidence suggests that the shift from FFS to Medicaid managed care contracts resulted in increased administrative costs for the state. Therefore, the increase in Medicaid spending resulting from the shift to Medicaid managed care in this project may be understated.

Clearly, California’s goal of reducing Medicaid expenditures by shifting beneficiaries from FFS to managed care plans was not successful. While these results may not apply across the board, policymakers should consider the possibility that managed care may not be the mechanism through which to curb budget shortfalls.

http://www.hcfo.net/pdf/findings0305.pdf

Comment: Many explanations can be given as to why private takeover of publicly administered health care financing programs have failed to deliver on the promise of higher quality at lower cost. One more quote from this brief provides further insight: “…commercial plans will contract with Medicaid only if they believe that they can earn a profit…”

It may seem obvious that the lesson learned from this (and innumerable other studies) is that we should reject the private plans and work on adopting more efficient, publicly administered health care coverage for all of us. But our resistance to public solutions has caused policymakers to turn elsewhere. They have decided that we should control the costs of coverage simply by reducing what is covered. This works very well for those of us who are and will remain healthy, and it relieves us of the burden of being our brother’s keeper. Why should we assume any greater responsibility?

(That last rhetorical question was prompted, in part, by this quote from an e-mail that I received from a very dedicated physician: “Policy science is behind a lot of stuff that isn’t and won’t happen.”)

🙁

Statistics Canada
Median waiting times for non-emergency surgeries, household population aged
15 and over, Canada and provinces, 2003

Median waiting time (weeks): 4.3

http://www.statcan.ca/english/freepub/82-401-XIE/2002000/tables/html/at007_en.htm

About Statistics Canada:
http://www.statcan.ca/english/about/abtstc.htm

Comment: Calls for national health insurance in the United States are
frequently countered with the claim that such a transformation would result in excessive delays in care, “like they have in Canada.”

First of all, implied in that comment is the principle that queues should be reduced by removing some individuals from the waiting list. We currently do this up front by the simple measure of making care unaffordable for the uninsured and under-insured. Most policymakers across the political spectrum
believe that this is not ethically acceptable.

But what is the reality in Canada? Emergency surgeries are not a problem; they are provided for immediately. On the other hand, the median time for non-emergency surgery is four weeks, which is an interval that is comparable to that in the United States. The major difference is that queues in the United States are accessible only for those with the ability to pay, whereas, in Canada, no person is excluded based on inability to pay.

It is true that selected elective surgeries may be delayed longer than four weeks (offset by an equal number that have their surgeries in less than four weeks). But it is important to realize that these numbers were for 2003. Since then, Prime Minister Paul Martin made improving access to health care his number one priority in his election campaign. He is already delivering on his promise by providing federal funds to improve capacity in areas where deficiencies exist.

Our current level of health care spending, $1.9 trillion, is more than enough to ensure adequate capacity in our entire system. The opponents of national health insurance simply are not telling the truth when they claim that including everyone will automatically result in excessive delays in care. I won’t call them liars, even if that’s what they really are.

The Henry J. Kaiser Family Foundation
April 2005
Low-Income Subsidies for the Medicare Prescription Drug Benefit:
The Impact of the Asset Test
By Thomas Rice, Ph.D. and Katherine A. Desmond, M.S.

Conclusions

This study estimates that in 2006, when the new Medicare prescription drug benefit goes into effect, 2.37 million low-income Medicare beneficiaries will not qualify for subsidized coverage because they fail the asset test. As a result, these individuals will face the same “doughnut hole” cost-sharing requirements as wealthier beneficiaries. This means that in addition to paying full monthly premiums, they will be responsible for substantial out-of- pocket costs – e.g., $3,600 of the first $5,100 of annual prescription drug spending on covered drugs in 2006.

The study further examines the types of beneficiaries who will be excluded by the asset test, as well as the types of assets responsible. Perhaps the most noteworthy finding is that the asset test will fall most heavily on those who are widowed. Whereas only 29 percent of Medicare beneficiaries are widowed, nearly half – 46% – of those failing the asset test are widowed and nearly all of these (43% of the 46%) are women. Widows tend to be older, live alone, and have more chronic illnesses necessitating prescription drug purchases, but have less family support as well. Put another way, the life event (death of a husband)leads to reduced income and thus more of a need for subsidies, but as written, the legislation effectively excludes many widows from these subsidies.

It is hardly surprising that most individuals who do not meet the asset test have relatively modest assets, which tend to be bank accounts rather than stocks, mutual funds, and bonds. They have little in the way of private retirement accounts such as IRAs and 401(k)s, real estate beyond their own home, and almost no equity in businesses. This would be expected among a population of low-income individuals.

The study’s findings raise serious questions about the equity of the asset test. During their working years, Americans are encouraged to save for retirement and the possibility that they will face sizable long-term care expenses. Those to whom this message is most salient will have little or no income beyond what they receive from Social Security. By accumulating modest amounts of assets, either through bank accounts or retirement-savings vehicles, these same people have guaranteed that they will not qualify for the low-income Medicare drug subsidies – but the vast majority use prescription drugs every day. Using more common parlance, they find themselves in a “Catch-22.” If they do save, they are disqualified from the subsidies. If they do not save, they will receive the subsidies but will have almost nothing to fall back upon besides their Social Security checks. And this burden tends to fall on the most vulnerable of seniors: older, low-income widows living alone.

This dynamic appears to be inequitable, given the groups of seniors who are most affected, and unfair because it penalizes both savings and widowhood. Modifying or eliminating the asset test would help protect those disadvantaged by low incomes who would be excluded from subsidized prescription drug benefits due to the asset test.

http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=52270

Comment: Is the asset test a good idea? After all, why should taxpayers purchase prescriptions for individuals who have some money set aside in a bank account? And why shouldn’t we make seniors sensitive to the costs of prescription drugs so that they’ll fill only the prescriptions that they really need?

It should be presumed that all prescriptions are selected in consultation with the patient’s health care professional based on an anticipated maintenance or improvement in physical health that exceeds any potential risk of the medication. Thus there should be no prescription that shouldn’t be filled because it’s not really needed. Prescription medication should be rejected only on the basis of lack of benefit, but not on the basis of lack of affordability.

And why shouldn’t we require a spending down of assets before providing protection against prescription drug costs? Requiring a person to deplete their limited assets before they can have affordable access to prescription drugs is simply an inhumane policy.

Means testing of income and assets theoretically is a method of improving equity in access to health care for those with very low incomes and very limited assets. The problem is that those of relatively modest means who fall above the thresholds will be victims of this inequitable method of establishing health benefits. As you adjust the thresholds upwards, eventually benefits become available to individuals who really don’t need financial assistance from taxpayers, creating yet another inequity.

We should begin with the presumption that everyone should be able to receive prescription drugs, and, indeed, any health care that they need. Rather than attempting to create financial equity at the time of accessing the health care system, it is far easier to create equity at the time of funding the system. That is one of the great advantages of social insurance. Everyone receives the health care that they need, while the entire system is funded equitably.

Unfortunately, our national policymakers have a different set of priorities. They wish to reduce the tax burden on those who have no financial barriers to care by reducing health care utilization of the great majority of citizens of modest means. Is that really what America is about?

The Orange County Register
April 10, 2005
Private plans haven’t delivered the cure
By Don R. McCanne, M.D.

Bruce Bodaken, CEO of Blue Shield of California, warns that, unless we reduce health-care costs and provide coverage for the uninsured, we will likely turn to a government-run single-payer system [“‘Vicious cycle’ of care,” Business, March 30].

That raises two questions. Why hasn’t Bodaken’s own industry been able to solve the problems during the past half-century that it has had control of health care spending? And what is there about a single-payer system that would cause policy-makers to turn to that option?

Private health plans should be providing us with higher quality at lower cost. But by most measures, we are receiving relatively mediocre care that is rife with error and wasteful excesses, while many are not receiving even the most basic essential services. And over 90 percent of Americans agree that health care costs are out of control. Since private plans are failing us on cost and quality issues, are there any other reasons to keep them in charge?

Do private plans avoid the inherent waste of government bureaucracies?Unfortunately, private plans actually consume a far greater percentage of health care dollars in administrative costs than do public programs such as Medicare. And worse, our fragmented system of funding care places a tremendous,wasteful administrative burden on the providers of health care.

Bodaken exemplifies this inefficiency in admitting that he can’t figure out the benefits of his own personal health plan provided by his own company. Do private plans provide us with choice? The American Medical Association just released a report confirming, by Justice Department standards, that 93 percent of HMO/PPO markets are “highly concentrated.” So much for true market choice of health plans. Besides, the choice we really want is choice of our own physicians and hospitals. Most private plans limit our choice and assess severe financial penalties for failing to use their preselected choices.

If we leave the plans in place, what options do we have? Everyone agrees that the status quo will never do since costs are skyrocketing, access is diminishing and quality is not improving.

Should we relax regulatory oversight, allowing the markets to work more effectively? We know that the plans invariably attempt to sell to the healthy and avoid the sick. That might be appropriate for the marketplace, but it shifts the burden of risk from the plans to the taxpayers.

Should we instead increase regulatory oversight? Requiring that plans jointly guarantee affordable coverage for everyone would create a de facto single-payer system since the plans then would provide primarily only the administrative services that we actually do need for health care financing.

The $1.9 trillion that our nation is already spending on health care is more than enough to pay for comprehensive health care services for everyone. But there is an urgent need for us to demand much more accountability for our health care spending. Just don’t expect it to come from the health plans.

http://www.ocregister.com/ocr/2005/04/10/sections/commentary/READER%20REBUTTALS/article_474432.php

The Orange County Register
April 10, 2005
Private plans haven’t delivered the cure
By Don R. McCanne, M.D.

Bruce Bodaken, CEO of Blue Shield of California, warns that, unless we reduce health-care costs and provide coverage for the uninsured, we will likely turn to a government-run single-payer system [“‘Vicious cycle’ of care,” Business, March 30].

That raises two questions. Why hasn’t Bodaken’s own industry been able to solve the problems during the past half-century that it has had control of health care spending? And what is there about a single-payer system that would cause policy-makers to turn to that option?

Private health plans should be providing us with higher quality at lower cost. But by most measures, we are receiving relatively mediocre care that is rife with error and wasteful excesses, while many are not receiving even the most basic essential services. And over 90 percent of Americans agree that health care costs are out of control. Since private plans are failing us on cost and quality issues, are there any other reasons to keep them in charge?

Do private plans avoid the inherent waste of government bureaucracies?Unfortunately, private plans actually consume a far greater percentage of health care dollars in administrative costs than do public programs such as Medicare. And worse, our fragmented system of funding care places a tremendous,wasteful administrative burden on the providers of health care.

Bodaken exemplifies this inefficiency in admitting that he can’t figure out the benefits of his own personal health plan provided by his own company. Do private plans provide us with choice? The American Medical Association just released a report confirming, by Justice Department standards, that 93 percent of HMO/PPO markets are “highly concentrated.” So much for true market choice of health plans. Besides, the choice we really want is choice of our own physicians and hospitals. Most private plans limit our choice and assess severe financial penalties for failing to use their preselected choices.

If we leave the plans in place, what options do we have? Everyone agrees that the status quo will never do since costs are skyrocketing, access is diminishing and quality is not improving.

Should we relax regulatory oversight, allowing the markets to work more effectively? We know that the plans invariably attempt to sell to the healthy and avoid the sick. That might be appropriate for the marketplace, but it shifts the burden of risk from the plans to the taxpayers.

Should we instead increase regulatory oversight? Requiring that plans jointly guarantee affordable coverage for everyone would create a de facto single-payer system since the plans then would provide primarily only the administrative services that we actually do need for health care financing.

The $1.9 trillion that our nation is already spending on health care is more than enough to pay for comprehensive health care services for everyone. But there is an urgent need for us to demand much more accountability for our health care spending. Just don’t expect it to come from the health plans.

http://www.ocregister.com/ocr/2005/04/10/sections/commentary/READER%20REBUTTALS/article_474432.php

The New York Times
April 8, 2005

U.S. Plans New, Deep Cuts in Housing Aid
By David W. Chen

If the changes sought by the administration take effect, they will result in one of the biggest cuts since Washington first began subsidizing housing: as much as $480 million, or 14 percent, of the $3.4 billion federal budget for day-to-day operations, including labor, maintenance, insurance and utilities, at the nation’s 3,100 housing authorities.

“I’ve never seen anything this devastating occur in public housing,” said Stephanie W. Cowart, executive director of the Niagara Falls Housing Authority.

Michael Liu, HUD’s assistant secretary for public and Indian housing, said in an interview that housing agencies had been warned for months that “there was always the possibility of changes,” especially “in an era of tight budgets on the domestic front.”

“For a housing authority that has been on a particular diet for, say, 40 years, facing a different kind of diet, cutting out fats and sugars and other stuff that tastes good – well, it’s tough to change, and that’s a natural reaction,” he said. “But in the long run, it’s going to make us more effective, more efficient.”

“I’m confident that those who are concerned, once they sit down, they’ll get over it, and deal with it,” Mr. Liu said.

And…

Hunger-Based Lines Lengthen at the Faith-Based Soup Kitchens By Francis X. Clines. The sight of masses of Americans gratefully chowing down on free food
is indeed a show, an amazingly discreet one that is classified not as outright hunger but as “food insecurity” by government specialists who are busy measuring the growing lines at soup kitchens and food pantries across the nation. There were 25.5 million supplicants regularly lining up in 2002; they were joined by 1.1 million more the next year. And even more arrive as unemployment and other government programs run out.

Most immediately, food charities are pleading against further cuts in the federal emergency food and shelter program, which directly fights hunger. Last year, 48 soup kitchens closed in the city as supplies were exhausted, and hundreds of others reported to be making do by cutting back on daily portions.

Beyond that, however, administrators know that the myriad of severe program cuts looming in Washington – for everything from low-income wage supplements
to health care spending for poor people – can only lead to further cuts down the revenue food chain in statehouses and city halls and, finally, longer lines of people silently begging for food.

Comment: How could politicians possibly understand the need for a universal health program if they don’t even understand the need for basic housing and food? Or did the majority of Americans support these policies at the polling booths? If so, have they no shame?

Health Affairs
April 5, 2005
It’s The Premiums, Stupid: Projections Of The Uninsured Through 2013
By Todd Gilmer and Richard Kronick

Abstract:
Increases in the cost of health care from 1979 to 1999 accounted for the decline in health insurance coverage that occurred during that time period, as our earlier work demonstrated. Here we examine whether the model we presented adequately accounts for the observed changes in health insurance
coverage from 1999 through 2002, and we show that the model accurately
predicted the increase in uninsured people during that time period.

Using the model and projections for national health spending, we project that
the number of nonelderly uninsured Americans will grow from forty-five million
in 2003 to fifty-six million by 2013.

From the Discussion:
In 2001 we published a paper titled “The Calm Before the Storm,” projecting
that the number of uninsured Americans would increase rapidly as a result of
health insurance premiums rising more rapidly than personal incomes. It is clear that a full-force storm blew in from 1999 to 2002 and that the actual path of the percentage uninsured… followed the path we expected based on our estimated relationships between affordability and coverage.

We expect the storm to continue during the next decade. However, based on
CMS spending projections, its ferocity will lessen. The CMS predicts that health spending for insured people under age sixty-five will grow 2.4 percent per year faster than personal incomes from 2002 to 2013. At this “moderate” rate of spending growth, we expect that the number of uninsured people will increase “only” thirteen million over the next decade from its 2002 level, or eleven million from the estimate of forty-five million uninsured people in 2003. Based on estimates from the Institute of Medicine, this will lead to an increase of 4,500 deaths annually and to an increased annual loss of human capital of $16-$32 billion. If the estimated growth rates for health care prices and income are wrong (as they almost certainly are), it seems much more likely to us that affordability will decline more quickly than expected rather than more slowly, and it seems more likely that the number of uninsured people will increase more quickly than projected rather than more slowly.

It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance coverage requiring contributions from some combination of employers, employees, and taxpayers. It is also unlikely that either our current system of employer-sponsored coverage or an alternative system of universal coverage will be sustainable without more effective efforts at cost containment.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.143

Comment: Professors Gilmer and Kronick have provided objective evidence of
what we instinctively knew. Lack of affordability of insurance premiums has
prevented tens of millions from being covered, and, without major change, the problem will only get worse. A few comments are warranted.

The term “affordability” is often avoided by economists because it is not well defined and includes an element of subjectivity based on varying opinions on what is and what is not affordable. Gilmer and Kronick have demonstrated that there is a degree of objectivity in the concept of affordability since the
“affordability index” (per capita health spending for nonelderly insured adults divided by the median income of nonelderly adult workers) does correlate quite predictably with the percentage uninsured among nonelderly workers. This article provides us with credibility when we state that health care is becoming less and less affordable.

This article also provides us with a prediction of what would happen if we were able to bring the rate in growth of health spending down to the rate of inflation, assuming no other structural reform of health care financing. They project that an additional 13 million will be without insurance in 2013. Of those, 4.4 million would be due merely to the increase in the population, whereas 8.6 million would be due to a further deterioration in affordability. Though many suggest that all will be well if we merely control health care costs, the numbers of uninsured would still expand by 4.4 million. Obviously structural reform must involve more than merely containing costs.

Another crucial point is that the authors’ model implicitly assumes that health insurance premiums will continue to purchase coverage that would provide financial protection against significant medical losses. Unfortunately, current trends could change their model. Competition based on premiums is resulting in a shift of risk to patients. Reports such as the recent Harvard bankruptcy study are demonstrating that we are facing an epidemic of underinsurance. Although this could reduce the upward pressure on premiums and lessen the growth in the uninsured, it could also have the paradoxical affect of causing even more to drop coverage when they recognize that it no longer protects against financial catastrophe. Why invest large sums in insurance premiums when major illness will drain all of your resources anyway?

Gilmer and Kronick are quite right that we need both universal coverage and
more effective cost containment. But our current demand side efforts utilizing private plans can only increase the problem of underinsurance and affordability of health care. We need to change to supply side economics if we expect to have affordable, comprehensive care for everyone.

A single payer system, by design, is universal, comprehensive, and utilizes supply side mechanisms to contain costs. In the United States, the $6423 per
capita that we are already spending on health care supplies some of us with too much care that is not beneficial, while leaving many with unmet needs. But we won’t get our spending right until we decide to adopt supply side funding of a universal system. It won’t be perfect (no system is), but it’ll be vastly superior to what we have.

Or we can continue to do nothing. The lack of insurance will then cost us 22,500 nonelderly adult lives per year. Is that a price that we are willing to pay for our inaction? Before grumbling about another stupid rhetorical question, think about the consequences of merely walking away and going about your usual business. Tens of thousands of people will continue to die.

The Christian Science Monitor
April 04, 2005
Congress’ implicit healthcare rationing
By John Kitzhaber

As an emergency physician and former governor, I am struck by the towering contradictions – and indeed the hypocrisy – in the controversy over the tragic plight of Terri Schiavo. On the same day that the US House of Representatives voted to involve the federal courts in her case, it also approved a 10-year $92-billion cut in Medicaid funding – $30 billion deeper than the cut recommended by President Bush.

The relationship between these two decisions – virtually unreported by most media – goes to the very heart of why we’re unable to resolve the growing crisis in our healthcare system. While involving the federal courts in an attempt to save the life of one highly visible individual, Congress made a fiscal decision that will deny thousands of other Americans timely access to healthcare, some of whom may die as a result.

http://www.csmonitor.com/2005/0404/p09s02-coop.html

And…

The Daily Princetonian
April 1, 2005
Seeking to understand life, death
By Uwe Reinhardt

Terri Schiavo dies, reads the Washington Post’s news alert on my desktop. After gradually starving her to death, in accordance with American law and our jurists’ interpretation thereof, Schiavo finally has left us.

Unwittingly, she has helped us understand, once again, what a confused, ill-informed, sometimes opportunistically cynical, but ever bizarre nation we are.

Let us start with the seemingly pious politicians and pundits who saw in this case an opportunity to proclaim the sanctity of human life. Really? In a recent series of books on the plight of the millions of Americans without health insurance, the medical and social scientists working with the prestigious institute of Medicine of the U.S. National Academy of Sciences reminded the nation that 18,000 people die each year as a direct result of the lack of health insurance, making it the sixth leading cause of death among people aged 25-64, after cancer, heart disease, injuries, suicide and cerebral vascular disease, but before HIV/AIDS or diabetes. The nation’s infant mortality rate is one of the highest in the OECD nations. Citing the CIA Fact Book 2005, economics professor Alan Krueger reminds us in The New York Times (March 31) that our infant mortality rate is higher even than Cuba’s.

It can fairly be asked what the pundits and politicians who waxed so pious on the sanctity of Schiavo’s life have ever done to avoid this tragic, avoidable loss of human life in the rest of America. If we searched their records, we would discover that many and probably most of them either have countenanced that loss with equanimity, doing little to avoid that loss, or, worse still, have opposed as “socialism” any attempt to provide health insurance to all American children and, indeed, to all people living in this land.

http://www.dailyprincetonian.com/archives/2005/04/01/opinion/12531.shtml

Comment: For Congress to hear, voices must speak.