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U.S. Seniors Experience Worst Cost Barriers to Care

U.S. Seniors Experience Worst Cost Barriers to Care

The Commonwealth Fund just published a ten-nation survey of health care affordability for seniors. Guess who had the highest financial barriers to care? Yup, the U.S. Medicare helps (beats being young & uninsured or having massive deductibles), but needs lower cost-sharing.

Health Care Affordability for Older Adults: How the U.S. Compares to Other Countries, Commonwealth Fund, Dec. 4, 2024, by Munira Z. Gunja et al.

Like several other countries, nearly all adults age 65 and older in the U.S. have health coverage. But high out-of-pocket costs in the Medicare program may still make it more difficult for older Americans to receive affordable care compared to older adults in other countries.

Comment:

By Jim Kahn, M.D., M.P.H.

I just spent 3 days in Amsterdam, the Netherlands. Everyone seemed quite content. No wonder, given the extremely low prevalence of medical care cost barriers observed in this survey. Similar for most other nations included. The U.S. performs worst overall, by far, and worst or 2nd worst on each measure. I’m beginning to think that uncertainty in the U.S. on medical care affordability is a major underlying cause of stress, anxiety, and the drive for political upheaval (more on that in a future post).

Now I’m in Nairobi, Kenya, at a meeting about addressing dementia in low-income countries. These nations face huge challenges not only for treatment and care, but also for prevention programming. Because … they have very little money. We in the high-income nations need to do a lot more to help them, and they should more emphatically prioritize heath in their budgets.

The U.S. doesn’t have the excuse of being poor. We have plenty of money – the most in the world. Our problem is that we build our massive health care system (fully 40% of global health spending) to benefit for-profit intermediaries and providers. This drives up costs. And insurance coverage is designed on the flawed premise of “skin-in-the-game” (empirically, it does not control costs). Lots of pain, no real gain.

Best practices, learning from successful approaches, following the leaders … whatever phrase you prefer, it’s long past due for the U.S. to adopt proven practices from peer nations – to assure access while controlling costs.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Choice Among Private Insurance Options Isn’t Real Choice

The new Commonwealth survey of health insurance reveals persistent failings in coverage and access. The myth of “choice” in health insurance should be ended, in favor of real choice – of providers, enabled by excellent universal public insurance.

The State of Health Insurance Coverage in the U.S., Findings from the Commonwealth Fund 2024 Biennial Health Insurance Survey, Nov. 21, 2024, by Sara R. Collins and Avni Gupta

Survey Highlights:

More than half (56%) of U.S. working age adults were insured all year with coverage adequate to ensure affordable access to care. But there are soft spots requiring policy attention: 9 percent of adults were uninsured, 12 percent had a gap in coverage over the past year, and 23 percent were underinsured, meaning they had coverage for a full year that didn’t provide them with affordable access to health care.

Among adults who were insured all year but underinsured, 66 percent had coverage through an employer, 16 percent were enrolled in Medicaid or Medicare, and 14 percent had a plan purchased in the marketplaces or the individual market.

Nearly three of five (57%) underinsured adults said they avoided getting needed health care because of its cost. 44 percent said they had medical or dental debt they were paying off over time.

Delaying health care has health consequences: two of five (41%) working-age adults who reported a cost-related delay in their care said a health problem had worsened because of it.

Nearly half of adults (48%) with medical debt are paying off $2000 or more; half of those with debt said it stemmed from a hospital stay.

Comment:

By Don McCanne, M.D.

When we discuss the problems with financing our health care system, many in the policy or political communities brag about the advances we’ve made through insurance coverage. But these increases have largely been through private insurer models that hamper access: There has been a sharp increase in the numbers of individuals in Medicare Advantage plans, which typically offer narrow provide networks while vastly overcharging the government through diagnostic upcoding and risk selection. States rely widely on private Medicaid intermediaries, which have significant provider network issues. Employer-sponsored private plans increasingly shift direct costs to employees through higher premiums, greater deductibles and copayments, and more aggressive prior authorization. Similarly in ACA marketplace plans. Thus, increased reliance on private plans is really an expansion of the problems that are peculiar to the private insurance industry, as revealed in the newest Commonwealth Fund Health Insurance Survey.

Promoters of these plans say that they are giving us freedom of choice by placing health insurance coverage in the marketplace, which touts competition as being an important mechanism for controlling costs. But look more carefully at the choices we supposedly have. Insurance category is dictated: Medicare by age or disability, Medicaid by poverty, employer sponsored plans by your job, or ACA plans or individual private market plans merely because no other choice is available. Many retirement plans mandate Medicare Advantage, and dropping physician payments in traditional Medicare undermine that option. Most of all, we have no choice about the higher non-clinical spending required by superfluous private insurance intermediaries, via profits, cumbersome administration, and administrative tasks forced on providers.

Besides, what choice do we really want? Don’t we really want free choice of physicians, hospitals, and other medical services – that would be available through an equitably funded, universal, public, single payer program, a program that belongs to all of us rather than just to the millionaires and billionaires, a program where all of our health care dollars are spent just on health care? I don’t think we really want a choice of private plans that are designed specifically to use what should be our health care dollars to create greater wealth for the intermediaries that find innovative ways of diverting our funds away from health care?

Look at the choice we made through the recent election. We elected a president who is choosing administrative personnel who intend to eliminate our traditional government Medicare program that is free of private carriers, and replace it with a universal private Medicare Advantage program which has already been demonstrated to divert hundreds of billions in health care dollars to their private industry. Furthermore, our president-elect has brought in the richest man in the nation who intends to manipulate our government in a manner that will make him the world’s first trillionaire. Is that the choice that we want? giving our health care dollars and other funds to the wealthiest individuals in our nation, while leaving out many of those with genuine health care needs that are inaccessible to them under our current system so reliant on private insurers?

Let’s give everyone the freedom of choice in selecting the health care that they need and want instead of having false choice of which intermediary is going to take much of our health care dollars away and leave too many of us without the health care that we need.

What is our choice to be? Profits over patients? Billionaires over health care budgets? Or patients over our own health care system that is designed to take care of everyone? It doesn’t seem like that is a very difficult choice.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

New Government: Time to Revisit Single Payer?

Our fragmented, predominantly private health insurance serves corporations and shareholders, at the expense of financial affordability for patients. This is nothing new, but it’s worsening. What’s new is the shake-up of politics. Let’s insist on shaking up our failed insurance.

Complexity in the US Health Care System Is the Enemy of Access and Affordability, JAMA Forum, Oct. 26, 2023, by Larry Levitt and Drew Altman

Lack of insurance coverage, high costs, and poor outcomes are well-documented problems in the US health care system, and policies to address them have been hotly debated for decades. However, complexity is another under-appreciated problem that hinders access and affordability.

Almost 6 in 10 people with insurance reported a problem with using their health insurance during the past year (2022). The share increases to two-thirds of people in fair or poor health, three-fourths for those who need mental health services, and almost 8 in 10 for people who use the health system the most. The result is that many delay or skip care or accumulate bills they cannot afford.

The reality is that many people are hopelessly confused by how their insurance works. In Medicare, beneficiaries can now choose from an average of 43 private Medicare Advantage plans, and during open enrollment season, the airwaves are flooded with ads that may do more to confuse rather than illuminate. And people getting ACA coverage through healthcare.gov have a choice of more than 200 plan options on average. The complexity of too many choices can also lead to paralysis on the part of consumers.

Yet, any push for health care simplification inevitably clashes with commercial interests. The system is structured to simultaneously maximize profits, control costs, and serve customers, which are competing goals that add to the challenge of simplifying it.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Although Health Justice Monitor commented on this article a year ago, political developments have not only failed to provide significant improvement in our expensive but underperforming health care system, it appears that the malfunctioning of our system will only become worse.

We have been increasingly reliant on private insurers as demonstrated by the increase in conversion of traditional Medicare to private Medicare Advantage plans and the greater reliance on commercial plans through the Affordable Care Act. So we are spending ever more of our health care dollars on an industry with a mission that places a higher priority on diverting health care dollars to private investors instead of directing all of those dollars to achieving comprehensive health care for everyone.

We have an abundance of health policy research that demonstrates that the defective private insurance model increases costs and decreases access to care. It should be eliminated and replaced by a public single payer program that would, by design, not only provide health care for absolutely everyone, but also control costs while improving the allocation of health care dollars. That model would be similar to traditional Medicare except that it would offer more comprehensive benefits, eliminate cost sharing that currently causes financial hardship, assure free choice of providers and facilities, and equitably finance via progressive taxes which would be affordable for everyone without materially diminishing the lifestyles of the wealthy despite their paying more (they can afford to!).

In our recent presidential election, one of the major parties emphasized neoliberal policies which eliminated any consideration of the superior single payer model, instead supporting small incremental changes which would have negligible impact in healing our sick health care system. The other major party vaguely promised system improvement but hinted major cuts in public spending. They also selected individuals as likely heads of HHS and CMS who would shred the program that we have at a cost of lives, health, and worse financial hardship for patients.

Wouldn’t it be better set aside politics, and instead adopt policies that provide definitive solutions to the problems of high personal health care costs and financially squeezed providers? We have ample examples from countries of varied political leanings of how to use funds well.

Shouldn’t we encourage our legislators, all of them, to join together to approve a system that would work so well for everyone? Now that we have an incoming president who would like to take personal credit for radically redirecting government to serve the public, maybe we have a chance.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Health care policy hurts Hawaii patients

By Stephen Kemble, M.D.
Honolulu Star-Advertiser, Nov. 19, 2024

The current health policy fad is “value-based payment” — blaming high health care cost on fee-for-service and overutilization of care and instead, offering upfront payment per member, or capitation, as an incentive to reduce utilization and control costs.

This analysis is contradicted by Hawaii’s experience. Hawaii’s Prepaid Health Care Act has included an employer mandate since 1974, with the broadest coverage of the population, richest commercial insurance benefits, lowest patient cost-sharing, and among the lowest insurance premiums in the country. And we had the lowest per-capita Medicare spending in 2009, when everyone was paid with fee-for-service.

But since widespread imposition of “value-based payment,” encouraged by the Affordable Care Act and aggressively implemented by HMSA and MedQUEST, health insurance premiums have more than doubled. By 2019 our per-capita Medicare spending had climbed from lowest up to 9th-lowest and rising. And many Hawaii doctors are quitting practice or exiting the state, leaving a severe and worsening doctor shortage and worsening access to care.

Capitation requires defined “members” to enable payment per-member, whether the payee is a health plan, such as a Medicare Advantage (MA) or Medicaid managed care plan, or an organized group of doctors or doctors and hospitals paid as an Accountable Care Organization (ACO). In any case, the performance of a capitated plan depends heavily on which “members” it captures.

Many studies claim to show that MA plans and ACOs can reduce Medicare spending and demonstrate improved quality measures. BUT, the savings for Medicare are quite small, and if the administrative costs for the MA plan or ACO are included, capitation always costs more than fee-for-service.

And very few studies account for the ability of capitated plans to capture healthier “members” and avoid or eject sicker, more expensive ones. If the pool of “members” in a plan or ACO is healthier than average, then of course cost will be lower and quality measures will be higher because the members were healthier to begin with, without any improvement in care.

Upfront payment with capitation introduces perverse incentives to capture the healthy and avoid the sick; to up-code to game the risk adjustment formula; and to skimp on care, necessary and unnecessary alike. And capitation of health plans creates major opportunities for profiteering, fraud and abuse in health care.

The poster child for these problems with “value-based payment” is Medicare Advantage. The Medicare Payment Advisory Commission has concluded that MA plans are overpaid by 22% compared to if the same beneficiaries were in traditional fee-for-service Medicare. Studies show MA plans do capture healthier-than-average members and up-code, often to the point of fraud, and they skimp on care, including denial of necessary care.

MA is the most profitable line of business for health insurance companies, far outstripping commercial insurance. It is rapidly draining the Medicare trust fund, threatening insolvency in less than a decade.

MA plans often restrict beneficiary choice with narrow and “ghost” networks of doctors not actually available to plan members. Doctors complain of excessive time wasted on prior authorizations. And worse, when for-profit insurance companies and private equity firms buy up physician practices and secure “value-based” government contracts with Medicare and Medicaid, they then seek return on investment by pressuring doctors to compromise patient care to serve their corporate owner’s financial goals, driving an epidemic of “moral injury” and burnout.

“Value-based payment” carries much higher administrative costs than fee-for-service, so capitated plans can be profitable only by gaming the payment formula to be overpaid and/or by denying care. This is no way to achieve real value in health care.

Dr. Stephen Kemble is a retired psychiatrist; in 2011, he was appointed to the now-inactive Hawaii Health Authority, charged with designing a universal health care system for Hawaii residents.

https://staradvertiser.com…

Medicare Advantage can’t deliver the moon

By Carol Paris, M.D.
Chattanooga Times Free Press, Letters, Nov. 16, 2024

During Medicare open enrollment, seniors are asked to choose from a dizzying array of plans. As a retired physician, and now a senior on Medicare, I know how confusing these choices can be, and what an impact they can have on our health and our pocketbooks.

Medicare Advantage plans, run by corporate health insurers, tend to promise the moon and the stars, but deliver aggravating restrictions. Not so with traditional Medicare.

Advantage plans also put a strain on the patient-doctor relationship. Many physicians are distressed when they feel corporate interests prevent them from delivering the care they know their patients need.

I saw this firsthand when I visited an orthopedic surgeon for knee pain. He balked when I asked which he would recommend.

“It doesn’t matter what I recommend,” he said, “only what your insurance will authorize.” But when I explained that I had traditional Medicare instead of a corporate plan, his face brightened. “In that case,” he said, “I can give you my best advice and administer the injection today.”

We would all be better off with an improved version of traditional Medicare, and both patients and physicians are fighting to realize that vision. Until that day comes, seniors should be aware of the impact privatized plans can have on their quality of care and choose wisely.

https://timesfreepress.com…

HJM with the US Political Shift

HJM is refining its mission in light of political realignment in the U.S.

Comment:

By Jim Kahn, M.D., M.P.H. and Don McCanne, M.D.

First, sincere apologies for the two-week lapse in HJM postings. We were consumed with worry leading up to the election, followed by shock and despair with the result. For those of us on the Left, the upcoming period is fraught with major socio-political risks and challenges. HJM readers no doubt feel similar intense and complex emotions.

Where does HJM fit into this new and fraught political environment? We’ve been contemplating this tough question.

Without a doubt, we need to keep monitoring the performance of current health insurance, which is likely to deteriorate with pursuit of the Project 2025 health policies. Other advocates do that exceptionally well, including HEALTH CARE un-covered on private insurer misbehavior, JustCare on Medicare issues, and PNHP laser-focused on Medicare Advantage.

HJM will still highlight discussing research and policy news that reveals the inefficiencies and inequities of our fragmented insurance system. We will, as always, get geeky in the interest of understanding the dynamics behind the news, and of making connections between issues. We will always analyze and educate about single payer / improved Medicare-for-All.

And, we will increase our attention to front-and-center political issues: How does single payer help us meet the current challenge to US democracy? How can single payer broaden support for progressive policies? How can it help heal the left-right political rift, by demonstrating the compatibility of efficiency and equity? How can we best convince skeptical right-leaning audiences of the common sense of single payer?

We welcome HJM reader input on refining our mission. What do you most value in HJM? What topics would you like us to address? How can we best support the struggle for health care justice, and invigoration of American democratic ideals? You can reply to the HJM email, or email healthjusticemonitor@gmail.com.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Our health care system includes a lot of hidden costs

By Daniel Bryant, M.D.
Bangor (Maine) Daily News, Nov. 12, 2024

One of my most unpleasant experiences as a physician was our small practice’s monthly review of patients’ unpaid bills. Our bookkeeper would ask me whether I wanted to call my delinquent patients about their bills, keep seeing them even if they weren’t paying or send them to a collection agency.

What I did about any of those delinquent patients, I don’t remember (or have repressed out of guilt), but their difficulty paying their medical bills has led me to look into why that problem exists in the health care system in which I worked for many years. I’ve learned two things: Health care prices in the U.S. are higher than in peer countries and many costs are hidden, making it hard for people to fully anticipate how much they will owe for their medical care.

The costs of health care in Maine extend far beyond what we see on our own medical bills. Workers contribute directly to Medicare through payroll deductions and indirectly through federal income taxes, with a significant portion of those taxes supporting Medicare, our federal health insurance program for seniors. And nearly a third of our state and sales taxes go to the Department of Health and Human Services and MaineCare, the state’s Medicaid program.

Also, employees bear the burden of their health care premiums and these include hefty administrative fees paid to insurance companies. Employers, facing rising health benefit costs, may hold back on wage increases, adding to the hidden cost of health care for workers.

Even property taxes contribute: I found in my town’s budget that 6 percent of those taxes go to funding health insurance for municipal employees, a cost passed on to homeowners and renters alike. As businesses spend roughly 7 percent of their labor costs on employee health coverage, the prices we pay for everyday goods and services, including utilities, groceries and entertainment, may be inflated to accommodate these expenses.

All these factors mean that Mainers are likely paying up to three times more for health care than they realize. We have to acknowledge and address these hidden costs in our ongoing discussions about health care reform.

To address these high and hidden health care costs, some propose replacing the current system with a simpler one where everyone pays a clear, straightforward premium based on their income, not their health care needs. This so-called single-payer system, which would continue free choice of private and public providers, would make costs and benefits more transparent. Nationally, it’s represented by the Medicare for All bill, and more than 20 states have considered similar single-payer plans at the state level. For most people, this income-based premium would be much simpler and, as I found in my research, published recently in the Maine Policy Review, should cost no more than what they are currently paying.

Anyone interested in pursuing this approach has several options to do so. Contact organizations supportive of the single-payer model, such as Maine AllCare or Physicians for a National Health Program, to learn more. Submit testimony to the new Maine Office of Affordable Health Care at one of their annual hearings, asking them to study it and compare it to the public option (a state plan that would compete with commercial plans) they are now considering. Ask their U.S. senators and representatives to co-sponsor the Medicare for All Act as well as the State Based Universal Health Care Act, passage of which would facilitate further study of a single-payer plan for Maine.

That’s what I should have talked to my patients about when I called them.

Daniel Bryant is a retired internist who practiced in Portland, as well as at Naval Air Station Jacksonville in Florida.

https://bangordailynews.com…

Medicare Advantage plans are a huge rip off

By H. Dixon Turner, M.D.
Portsmouth (N.H.) Herald, Letters, Nov. 6, 2024

To the Editor:

It’s that time of year again, namely the annual Medicare Enrollment period. At times it seems that every other commercial on TV is for another Medicare Advantage plan. I would urge people to be very cautious when considering enrolling for one of these plans as opposed to remaining in Traditional Medicare. A report by the organization, Physicians for a National Health Program, titled “Our Payments Their Profits” revealed that insurance companies offering Medicare Advantage plans can “earn” profits that are estimated at 88 to 140 Billion dollars every year!! That is money from the Medicare Trust Fund which is NOT going to direct medical care for seniors, but instead is lining the pockets of these companies.

Medicare Advantage (MA) companies reap these exorbitant profits through various means: First, MA companies charge overhead expenses averaging 15-20% whereas Traditional Medicare has an overhead of 2-3%. MA companies aim to enroll healthier patients than the average Medicare recipient and they function like an HMO, often with a very limited panel of providers. Prior approval is often required for procedures which result in delays or denials of necessary care–services which would normally be covered under Traditional Medicare. Upcoding of patient diagnoses frequently occurs by adding on non-existent diagnoses or by exaggerating the severity of existing diagnoses to increase payments. Finally, if a patient does develop a serious illness, such as cancer, those patients – either voluntarily or involuntarily – are often dropped from the MA program.

An additional problem which may occur when patients switch from a MA plan back to Traditional Medicare is that they may not be able to get a Medigap or supplemental insurance policy at all or only at a very high cost. Currently only 4 states (Connecticut, New York, Massachusetts and Maine) mandate that Medigap plans must be offered at community rates. Attempts to pass such a mandate in NH failed to pass in the legislature this year.

The ”Our Payments Their Profits” report estimates that Medicare and Medicaid could cover dental, hearing and vision benefits for ALL Medicare and Medicaid recipients for $80 billion per year, which is less than the lowest estimate of the profits which MA companies are projected to receive this year. These huge profits very likely will rapidly deplete and could bankrupt the Medicare Trust Fund.

Thus, I believe that Medicare Advantage plans are a huge rip off foisted on the American public and should be avoided. I encourage seniors to sign up for or to stick with Traditional Medicare. Also, please lobby our national representatives to terminate or restrict these MA plans and seek instead to increase the benefits currently available under Traditional Medicare.

https://seacoastonline.com…

Dr. H. Dixon Turner is a member of the Granite State (N.H.) chapter of Physicians for a National Health program.

Rebecca Cerese on NBC News

Rebecca Cerese, health policy advocate at the North Carolina Justice Center and a member of PNHP, was interviewed by NBC Nightly News for a segment on September 20, 2024. Ms. Cerese discussed the surprise announcement by Advocate Health that it would cancel outstanding medical debts and put a halt to its aggressive collections—following an unflattering national news story.

“Dealing with an illness or loss of a loved one is hard enough,” she said. “We should not be compounding that with this additional stress of facing financial ruin.”

The Single Solution for a Myriad of Health Care Challenges

Esteemed medical academics are adept at documenting and debating the failings of our health care system. Yet they fail to focus on the technically superior insurance solution used around the world. Our job is to bring US public discussion and policy action to single payer.

Perspective Roundtable: Critical Health Care Challenges for the Next U.S. President, New England Journal of Medicine, October 16, 2024, by Robert J. Blendon, et al.

The next U.S. president, as well as Congress and state governments, will have to address some major challenges to Americans’ health and health care. On September 27, 2024, the Journal and the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health hosted a symposium exploring three critical topics: access to health care, affordability of care, and health and health care equity.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

This NEJM article is quite long because it is a transcript of the entire symposium, but you should read it anyway because it represents where we are on the policy issues that currently impact our health care system in the United States, and where we should be going, in the opinion of these noted health policy experts.

So where do our policy academics and the government policy community stand today?

Much of the discussion you will be able to relate to since it addresses issues covered by the press and in the lay literature. You will find points with which you agree and other points with which you either disagree or which have not been addressed adequately by the policy community.

Since many of you are quite knowledgeable about health policy and the single payer model of reform, you will likely discover that most of the policy issues for which these experts have not provided satisfactory solutions can be quite satisfactorily addressed in a well-designed single payer model. We discussed this failure of health policy economists and other policy experts last week.

Our tasks:

  1. Read the symposium transcript.
  2. Join together with colleagues to create a short, bold explanation of what is wrong with our current fragmented system: most expensive among wealthy nations, nonetheless falling far short of providing high quality, affordable, equitable health care to everyone. And why: Rife with financial incentives that undermine the mission of a health care system. And, how we can fix it: describe simply how the streamlined and generous approaches in single payer should appeal to everyone, regardless of political affiliation.
  3. Join with other individual advocates and organizations to deliver that message to the public at large. Use all the communication tools available to us, just like an election campaign: in person, in traditional media, in social media.
  4. Inspire the public to use all communication resources, including direct contact, to persuade our legislators that this is the reform that we need and that we demand.
  5. Rejoice as our president responds to the will of the people by signing legislation enacting a single payer, improved version of Medicare that will provide affordable, equitable, comprehensive, high quality health care for absolutely everyone.

Of course, we (still) face an uphill battle. Yet we must preserve and pursue this vision. We must eventually break through the US inertia and conflicts of interest, with so many other countries showing the way of efficient, generous, and effective health care.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.