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When you really need health care, how is our system working?

When you really need health care, how is our system working?

Is Healthcare a Right or an Entitlement?

By Michelle Chaffee, Founder & CEO, alska
LinkedIn Pulse, December 12, 2017

Some of you who have followed my posts over the past few years know that I am a cancer survivor. It’s been almost two years since I was very unexpectedly diagnosed with ovarian cancer. I have shared some of what it’s been like to suddenly find myself in the position of being a patient after spending a career caring for people who are sick, believing I wouldn’t find myself on the other side of this equation. I still struggle with the reality that I have had cancer and that I will have to monitor for it rearing it’s ugly head, for the rest of my life. What I haven’t shared is how the costs of healthcare contributed to my situation, delayed diagnosis and increased my chance for a recurrence. I am sharing it now because as I continue on this journey, I am starting to think the current system is discriminatory and I know it needs to change.

When I was diagnosed with ovarian cancer, I hadn’t been to my doctor for my yearly recommended examination for about 20 months. When I called to make my yearly appointment, I was told I had an outstanding bill I had been unaware of because I had moved and they didn’t have my new address. The bill was a result of “coinsurance” that was from a necessary and fairly routine procedure, still it was substantial enough that I had to set up payments over time because I couldn’t afford to pay it in full. I was told I could not see my doctor until there was a zero balance. I felt fine and had no concerns of any illness so I skipped my routine exam that year. Fast forward almost 2 years later when an unusually potent migraine resulted in a suggestion by my neurologist that I get my hormone levels checked. I contacted a new gynecology group because I couldn’t be seen by my regular ob/gyn because of the balance that still remained. On this routine exam, a very large mass was found on my ovary. So large that even though I was assured it was benign, it needed to be removed. During the surgery, the mass ruptured but the doctor told me not to worry because “It’s not cancer.” She told me the rupture was because it was so large that it made it difficult to remove. She called me about a week later to tell me it was in fact, cancer and the rupture, unfortunately complicated the staging and made recurrence more likely. The fact is, if I had gone to my regular appointment, it would have been discovered when it was much smaller and may not have ruptured. I am not blaming the doctor or the organization where I received care but, it wasn’t discovered because I owed the clinic money and they wouldn’t see me until the bill was paid. I don’t let myself think about that too much, but it’s the truth and it’s the way healthcare works in our current system.

The cost of just the surgery to remove the cancer was over $250,000. This included just one night in the hospital and no chemotherapy or radiation treatment. I had a good insurance plan but even with that, my responsibility was over $30,000. I can safely say most Americans would find it a challenge to add that expense to their yearly budget. The ongoing costs of testing for a possible recurrence are approximately $20,000 every year. That is on top of the nearly $10,000 I pay in premiums each year because I am self employed. I can’t afford this so I stretch out the time between scans and labs further than my doctor recommends.

In the back of my mind I know this could mean I don’t detect something as soon as I should again and that it can literally mean the difference between life or death.

I also know that if I owe a balance again at the hospital where I get my testing, they can refuse to treat me and I have been down that road before.

So as I write this, I find myself waiting again to find out if something discovered on a diagnostic test done almost 9 months after the doctor ordered it, is something that could take my life. Not only that, I brace myself for the cost of repeated imaging, biopsies and what may follow and I am angry, frustrated and of course, afraid. I know I am not alone and for many, it has been worse. I have worked in healthcare long enough to remember when people were denied insurance coverage because they had an illness like cancer or diabetes or a heart defect. I heard the desperation of new mothers who were grateful their precious newborn had received life saving heart surgery but had already reached their life time insurance maximum and had no idea how they would pay for the ongoing care their child needed to stay alive. The Affordable Care Act changed some of that, at least we aren’t denied coverage but it costs too much and patients can still be denied care if they owe a system money. So we constantly pray we don’t get sick again and try to find the right balance between what we can afford and what will keep us alive.

For those of you out there who say “Healthcare isn’t a right,” I tell you to save your breath unless you have faced a condition that could take your life or the life of someone you love.

To those of you who say patients should forego a smartphone or daily “fancy” coffee drink in order to pay for healthcare I say, what fantasy world do you live in where eliminating those things would make even a miniscule dent in the healthcare costs millions face?

You can also put aside the delusion that someone is sick because they did something wrong. I hate to break it to you but just because you exercise, eat healthy or have no family history of disease doesn’t mean you are magically immune to a life changing diagnosis. It can happen to anyone and I am walking proof of that reality. I ate right, exercised, never smoked, have no family history of cancer and like millions of others in this country I got sick anyway.

I find it especially ironic as I travel to other nations and collaborate with healthcare leaders to improve delivery of care to their citizens that I, a struggle to access the care I need in the United States of America. So I pose the following to ponder:

Should we get the same rights as prisoners?

Shouldn’t we at least get the same rights that criminals in this country get? The supreme court has held that those under government control must have “ Adequate food, clothing, shelter, and medical care as a component of the protections accorded by the Eighth Amendment and that “Deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain,’… proscribed by the Eighth amendment,” equating this pain with cruel and unusual punishment. Does “Cruel and unusual punishment” only apply to prisoners? It seems pretty cruel to make law abiding citizens suffer because they can’t afford medicine or treatment or to force them to choose between food or medical care.

Are we discriminated against if we are sick?

It used to be that healthcare provided through programs like Medicare, Medicaid and CHIP seemed sufficient to mitigate an accusation that there was discrimination based on a citizen’s ability to pay for adequate healthcare. Unfortunately, over time there has been an increasing group of Americans that don’t meet the criteria to receive these supplementary services but also can’t afford the cost of the healthcare available to them. I don’t consider myself poor but I can’t afford $30,000 a year or more for basic healthcare. Do I have the same rights to life and general welfare as anyone else? If treatment to save my life is available, should I be denied it because I don’t have the ability to pay? Did the founders of our country mean to make good health only available to the wealthy? It isn’t just what used to be considered the poor or elderly who can’t afford basic healthcare or medication anymore. Hard working people who have made contributions to their communities and are necessary to our countries security and growth can’t afford necessary care. This is a problem for all of us.

Where do we draw the line?

For those of you who continually argue that the government doesn’t pay for our car insurance or life insurance I will explain the difference. Driving a car isn’t necessary for survival, neither is providing an inheritance for your heirs. These things aren’t the same as access to professional healthcare services that prevent you from dying. Suggesting these things as examples of why healthcare isn’t a right, is a faulty argument and insulting to anyone who is sick. Our founding fathers and leaders were concerned for the health and welfare of our citizens. Franklin D. Roosevelt even tried to enact a “Second bill of rights” that included access to adequate medical care and the opportunity to enjoy good health. They couldn’t have imagined how costly healthcare would become as the model ushered in with the advent of health insurance, has progressed and costs have skyrocketed.  I am not even insisting the government cover the cost. Even making it affordable, meaning something I can pay for that doesn’t consume my entire grocery budget for a year is a good place to start. At the very least, insuring people with truly life threatening disease have an opportunity to take advantage of the treatment we can provide seems reasonable to me and maybe it’s time to make it an undeniable right of every American.

https://www.linkedin.com…

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Comment:

By Don McCanne, M.D.

When President Obama rejected the single payer model of reform, he said that he did not want to disrupt the part of our system that was working well, especially the most prevalent coverage – private health plans.

As Michelle Chaffee says, she had “a good insurance plan,” but look where it left her – broke and still struggling to get the additional care that she needs. “It’s the truth, and it’s the way healthcare works in our current system.”

When the system is not working well for productive individuals like Michelle Chaffee, it has to be a pretty sick system. ACA didn’t fix it for her. Time to replace it. Single payer.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

U.S. and European lessons on health care reform

Rethinking Health Care Delivery: What European And United States Health Care Systems Can Learn From One Another

By Katharina Janus and Etienne Minvielle
Health Affairs Blog, December 15, 2017

Unlike the United States, where abolishing Obamacare was a key pillar of the new president’s pre-election platform and a big focus of his first year in office, Germany and France seem to agree that they would, in general, like to keep the systems they have. After all, they perform relatively well in terms of outcomes, life expectancy, and other critical indicators in comparison to resources consumed as a percentage of GDP.

What can we learn nevertheless from each other across the pond, taking the newly established European axis as one unit and the evolving United States system as the example from a new world.

Solidarity, “Health Care For All,” And (Almost) “The Same Services For All”

Many European health care systems go back to the idea of Bismarck (roughly 150 years ago) that when individuals’ incomes and ability to pay for care are unequal, we carry a social responsibility as citizens to redistribute resources. Under this redistribution, administered by the government, the rich pay for the poor, smaller families pay for larger families, and the younger pay for the older. Most Europeans willingly accept this notion—it is deeply ingrained in their culture. What is more, Europeans accept that we have to kick in some money, from time to time, to prevent the failure of an important market—such as the health care market— that has not found its own equilibrium. On the other hand, large parts of the United States society have elected leaders who favor a smaller government and believe that market forces require only limited regulation. Instead of fearing market failure, these leaders seem to relish a Darwinian view of health care markets where only the wealthy have true access and wide choice in the care they receive.

Free Choice—No “Gated Health Care Community”

A major right of both French and German health care systems is the right to choose your doctor freely and have those services he or she deems necessary covered with co-pays that are as little as €10 in Germany and more nuanced in France where a visit without referral to any specialist might reduce reimbursement rates to 30% of total costs, but is covered with referral. How can Europe afford this luxury of free choice and (nearly) full coverage?

The first answer is to look at prices: If you compare services in Europe with those in the United States, you will realize that prices for regular lab, x-ray, and doctor visits are a fraction of what they amount to in the United States.

Second, European medicine does not have the same level of provider dominance as the United States where clinicians, making all diagnostic and treatment decisions, have the greatest influence on costs. In European systems, governmental regulation frequently caps expenses. Developing closed networks to keep costs in check, the United States system has essentially rationed access while requiring additional resources to manage and coordinate these networks.

This management awareness in the United States has facilitated advances in population health management and created a better mindset for actually managing care in pathways across sectors.

The Comparative Paradox

And here lies the cross-pond health care system paradox: European systems—like Germany and France—pursue a strictly regulated ideological framework that is based on solidarity, equality, and social responsibility but once people have been socialized into this framework they can eat à la carte—choosing to utilize care freely and as much as they want. The United States represents the opposite: a free market system as a framework in which participants can (or cannot, due to limited financial resources) choose freely from the “prix fixe formule” (as one says in France). In this scenario, one can buy insurance at various levels, pay co-pays and deductibles, eventually having to find help to understand all these options, and then once they are “in”—though not necessarily fully covered—they must live with limited choices in a gated system.

What can we learn from each other? This question puts Europe in a much better position because, even though the United States might benefit from learnings from Europe at a macro-level (including those social care reforms that improve living conditions and are known to reduce health care costs as a consequence), these ideas are unlikely to find fertile ground in the United States where ideology makes many policymakers less receptive to such lessons. Europe in turn can learn a lot from the United States system on a micro level—how to manage populations and connect sectors. Nobody really coordinates or manages care in many European systems, so there is room for improvement. As a caveat, one might say that the European systems work well and one should never change a system that is already running well.

It remains to be evaluated whether a further investment in health care management contributes to better outcomes as a result of coordinated care pathways. And the assessment to what extent these outcomes are “better” than with less management will most likely lie in the eye of the beholder.

***

From the comment by Ted Marmor:

This article raises issues about learning policy lessons in health care, especially between the industrial democracies of continental Europe and the US. The descriptions are useful, the evaluation of the European experience is optimistic, but the interpretation of their meaning for lessons is misleadingly simple and negative. The US cannot learn because our ideology prevents. Why then did Medicare pass, which in 1965 was an example of social insurance (Part A in the model of Germany’s sick funds)? What about Social Security as social insurance? There is no reason to cut off discussion and limit the discussion so sharply.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

What can we learn from Europe about health care? That’s simple – solidarity, equity, and social responsibility.

And what can Europe learn from the United States? Managed care under the nebulous ideology of free markets? But the authors appropriately caution, “one might say that the European systems work well and one should never change a system that is already running well.”

If you look at the cost/performance ratios of the various health systems, the United States is an outlier, in the worst way. Maybe it is time for us to finally accept the facts and start becoming more diligent students of better systems of health care.

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‘Health care is a human right’

Longtime Provincetown doctor enters retirement with goal of fixing health care.

By Cynthia McCormick
Cape Cod Times, December 19, 2017

When he retired this year after nearly 40 years as a primary care physician in Provincetown, Dr. Brian O’Malley set his sights on fixing an ailing medical system.

A proponent for decades of a single-payer system — think “Medicare for all” — O’Malley is on the advisory board of MassCare, a Massachusetts organization campaigning for such a system in the Bay State.

“It’s my passion,” said O’Malley, 69.

“I’m of the belief single-payer will happen,” he said. “Health care has become a profit-driven industry. It’s becoming a budget buster.”

The state Senate recently approved a health care omnibus bill that includes an amendment proposed by state Sen. Julian Cyr, D-Truro, that would require the state to study the cost of a single-payer system.

“If it turns out single-payer would’ve saved us a bunch of money, we go to single-payer,” O’Malley said.

The amendment was adopted by Democratic state senators, 35-3, marking a breakout moment for single-payer, Cyr said. “We’ve really seen a groundswell of support.”

The state House of Representatives has yet to take up the bill, but Cyr said he expected that to happen by late winter or spring.

O’Malley has been an inspiration and model of an effective voice on single-payer, said Cyr, who was a patient of O’Malley’s late wife, pediatrician Wilsa Ryder, as a child.

Cyr said his parents went to O’Malley for their primary care for years.

“When you’re a primary care doctor in a small town, you really see from a delivery perspective all the challenges people in your community face,” Cyr said.

“Because (O’Malley) is a physician, his voice is heard at the Statehouse,” said Ture Turnbull, director of MassCare.

O’Malley comes from a “point of authority,” Turnbull said.

In decades past, O’Malley was involved in an effort to bring a single-payer system to Cape Cod.

The Cape Care Coalition floated an idea to charge a local tax to cover the cost of care, but the proximity to Boston health centers made the idea of cost containment impractical, O’Malley said.

“Boston’s too close, too tempting and too expensive,” he said. “The place for us to (bring about) single-payer is at the state level.”

O’Malley said single-payer would reduce health care costs by cutting much of the administrative overhead.

A single-payer model would also eliminate the battles with multiple insurers and pharmaceutical benefits managers that made his life and the lives of his patients increasingly difficult, said O’Malley, who in recent years had to devote his afternoons to paperwork instead of patient care.

Doctors now receive bonuses from insurers if they do well and “dings” if they don’t, he said.

But “doing well is a different set of standards for each insurance,” O’Malley said. “In single-payer, you’d have standards. You’d have goals. But they’d be the same for everyone.”

Not all Cape politicians are singing the single-payer song, however.

State Rep. Timothy Whelan, R-Brewster, said “it seems to be a precarious step to socialized medicine.”

Relatives of his from Ireland, which has a single-payer system, come to the U.S. for advanced care, Whelan said.

The Irish system seems to have turned into a two-tiered system, with people of economic means also purchasing private insurance that allows them access to a higher quality of care, Whelan said.

“We want the best medical care for everyone regardless of income,” he said. “We certainly have to find a way to make it more affordable.”

Neither President Bill Clinton nor President Barack Obama championed single-payer, O’Malley said.

But as health costs skyrocket, people are looking for an alternative method of paying for health care, and single-payer has a proven track record in other countries throughout the developed world, he said.

A former trustee of Cape Cod Healthcare and former head of the Cape Cod Preferred Physicians, a group of 400 doctors affiliated with Cape Cod Healthcare, O’Malley is not afraid to stick his neck out.

A longtime supporter of the environment and liberal causes, O’Malley helped his wife with the home births of their two children, Grace and Robin.

Ryder’s death at age 70 in October devastated him, he said in the office of the medical building he still owns at 30 Shank Painter Road.

Ryder ran the business end of the office while O’Malley met with patients at his wooden table desk.

“I’ve been kind of lost” since losing Ryder, just four months after his retirement, O’Malley said.

But he said he was optimistic about the future, having seen amazing turnarounds in medicine.

O’Malley diagnosed the first case of HIV in the community after recognizing a patient’s symptoms from an article he read about a mysterious new disease in the New England Journal of Medicine.

“I sent him up to Lahey Clinic. He was dead within days,” he said. “It was scary. Several funerals a week were happening.”

But thanks to antiviral treatments administered by specialists, O’Malley started seeing longtime survivors who came to him to control their cholesterol and weight.

O’Malley believes health care financing is reaching its own pivotal point.

“I’m a believer health care is a human right,” he said.

http://www.capecodtimes.com…

Single-payer plan

By Henry Abrons, M.D.
San Francisco Chronicle, Letters, December 18, 2017

Regarding “Voters like it until they learn taxes will rise” (Open Forum, Dec. 12): Although Sally Pipes is correct that “implementing a single-payer system would require tens of billions of dollars in new taxes,” we should reject her conclusion that “voters won’t like it.”

As a physician, I spent decades explaining complicated issues to patients, and financing health care is less complicated than the problems people discuss with their doctors and nurses every day. So I have confidence that when voting, people are intelligent enough to understand that a tax for single-payer health care will replace all other payments. The bottom line: Individuals and businesses will come out ahead with many more “tens of billions of dollars” in savings than in new taxes.

The best estimate shows that California could cover everyone, expand benefits (including prescription drugs, dental care and more), and still save $37 billion over current spending. Single-payer can do that by replacing for-profit health insurance with a public program that gets rid of needless profit, simplifies administration, and negotiates fair prices. Proponents now include many elected officials and most doctors and nurses. Voters will hopefully agree that programs to improve health care should be based on evidence and not derailed by scare tactics.

http://www.sfchronicle.com…

My message to Darrell Issa

December 18, 2017

H.R. 1, the Tax Cuts and Jobs Act, not only increases inequality, it further expands the deficit in the face of an austere budget. That will create greater pressure to reduce essential spending on important social programs, including Medicare. These tax policies are the exact opposite of what we need. Please vote against this cruel tax bill.

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

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Comment:

By Don McCanne, M.D.

What does this message to my congressman have to do with single payer?

We already have a major budget deficit.

The congressional leadership has already indicated that spending on social programs, including Medicare, will have to be modified to reduce the deficit.

The tax bill before Congress, H.R. 1, the Tax Cuts and Jobs Act, will be voted on this week, and that would further increase the deficit if it passes (considered a near certainty now).

Therefore even greater reductions in social programs will be used to close the deficit gap.

Medicare is already an inadequate program, paying only about half of the health care costs of our senior citizens. If we expect to use an improved version of Medicare as the basis of a single payer national health program then we need to halt the march towards the privatized premium support model (vouchers) that would shift even more costs onto the backs of Medicare beneficiaries.

We need to protect, improve and expand Medicare instead of taking a sledge hammer to it. Tell your members of Congress today to vote against this cruel tax legislation. (My Senators, Dianne Feinstein and Kamala Harris, have already committed to voting against it.)

Incidentally, this tax bill includes applying chained CPI to the tax code. This will negatively impact future Social Security benefits. The process of clobbering social programs has already begun.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Drug pricing a symptom of our sick health care financing system

Prescription Drugs May Cost More With Insurance Than Without It

By Charles Ornstein and Katie Thomas
The New York Times, December 9, 2017

In an era when drug prices have ignited public outrage and insurers are requiring consumers to shoulder more of the costs, people are shocked to discover they can sometimes get better deals than their own insurers. Behind the seemingly simple act of buying a bottle of pills, a host of players — drug companies, pharmacies, insurers and pharmacy benefit managers — are taking a cut of the profits, even as consumers are left to fend for themselves, critics say.

Pharmacy benefit managers, the companies that deal with drug benefits on behalf of insurers, often do negotiate better prices for consumers, particularly for brand-name medications, but that’s not necessarily true for some generic drugs.

As a result of these complicated layers of negotiation — which are not made public — different insurers end up paying different prices for individual drugs. Further compounding confusion for consumers, some insurers require a set co-payment for each prescription — say, $15 or $20 — even when the insurer reimburses the pharmacy at a much cheaper rate.

Consumers also may face penalties if they don’t use their insurance and pay cash to save money. In many cases, insurers won’t let them apply those purchases to a deductible or out-of-pocket spending maximum.

Still, many find that leaving their prescription card at home is worth it. Some have found a better deal even at pharmacies that are owned by their drug plan, like CVS.

Even as more Americans have health insurance since the Affordable Care Act was passed, insurers are increasingly asking consumers to pay a larger share of their costs. In 2016, about five million people in Medicare hit a stage in which they had to pick up a greater share of their expenses.

Consumers may also pay more if they are covered by plans that require them to pay a set co-payment, no matter the cash price. In some of those cases, the insurers require the pharmacies to send them the difference between what they collect from the consumer and what the insurers have agreed to reimburse the pharmacies.

https://www.nytimes.com…

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Poison pill

By Jacob S. Hacker and Theodore R. Marmor
Boston Globe, December 7, 2003

Tomorrow, President Bush is set to sign Medicare’s biggest overhaul in 38 years into law. But after watching the shrill yet perfunctory debate that culminated last week in the passage of the bill, even close observers of Washington politics can be forgiven for wondering just what exactly it was all about. On one side, congressional Republicans and President Bush described the $400-billion legislation as a moderate, sensible means of providing long-overdue drug coverage to seniors.

On the other, Democratic opponents — including most House Democrats, Senate minority leader Tom Daschle, and Senator Ted Kennedy, who led an unsuccessful filibuster — decried it as a monstrous giveaway to insurers and drug companies. They also charged that it was a “Trojan horse” aimed at crippling Medicare’s universal benefits in order to foster go-it-alone competition.

All this becomes more understandable when one recognizes that the bill is really two bills. The first provides a much-needed, if modest and excessively complex, drug benefit. But while this new benefit is generous for some low-income seniors, it will end up raising out-of-pocket drug costs for other poor beneficiaries. And because it is poorly designed and does not include effective ways of controlling drug costs, the plan will ultimately leave most seniors little better off than they are today, and some worse off.

The second, darker side of the new Medicare bill is a slew of changes that have little or nothing to do with drug coverage and everything to do with special-interest demands and ideological animus toward Medicare. These include huge new subsidies for private insurers, and provisions that ensure that drug companies will be spared from their greatest fear: that Medicare will use its massive buying power to demand reductions in drug prices. Perhaps most ominous, the bill also contains elements that favor private plans and risk further degeneration of Medicare’s all-in-the-same-boat structure.

What is most striking about the bill is not the consistency of its vision, but its deep incoherence. In the name of greater free-market competition, the legislation offers massive new subsidies to the pharmaceutical and insurance industries. In the name of providing greater protection, it threatens Medicare’s guarantee of universal benefits. And in the name of greater cost containment, it encourages the expansion of private plans that have, to date, not saved Medicare money, while creating new budgetary rules that could very well make Medicare less equitable and affordable down the road.

Behind these glaring inconsistencies lies the one great fact of contemporary American politics: partisan and ideological polarization.

It’s also certain to cause political conflict — which may be the bill’s ultimate contradiction. Republicans hope to take off the table an issue with which they have been battered for years, and they may well do so through 2006. But by pushing through such an unwieldy bill, they are virtually ensuring that Medicare will be the biggest issue in American politics in the coming decades. Sadly, at the present juncture, that seems to promise more acrimony, confusion, and disappointment, rather than the constructive steps forward that Medicare so desperately needs.

https://pnhp.org…

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Comment:

By Don McCanne, M.D.

You know that there is something wrong with our health care financing system when you may have to pay more for your prescriptions when you use your insurance than you would if you simply paid cash. Fourteen years ago, when H.R. 1, The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 was enacted, Jacob Hacker and Theodore Marmor explained what a mess the Medicare Part D drug benefit was, and how it came to happen.

They wrote, “What is most striking about the bill is not the consistency of its vision, but its deep incoherence. In the name of greater free-market competition, the legislation offers massive new subsidies to the pharmaceutical and insurance industries. In the name of providing greater protection, it threatens Medicare’s guarantee of universal benefits. And in the name of greater cost containment, it encourages the expansion of private plans that have, to date, not saved Medicare money, while creating new budgetary rules that could very well make Medicare less equitable and affordable down the road.”

So where are we now? Their prescient comment: “But by pushing through such an unwieldy bill, they are virtually ensuring that Medicare will be the biggest issue in American politics in the coming decades. Sadly, at the present juncture, that seems to promise more acrimony, confusion, and disappointment, rather than the constructive steps forward that Medicare so desperately needs.”

The drug pricing nightmare is but one symptom of that sickness, leaving us in critical condition. We need to move our health care financing system into the health policy intensive care unit, immediately. We know how to save this patient, as long as we keep the quacks out.

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Trade-off of Medicaid vs. exchange plans for low-income adults

Medicaid Expansion And Marketplace Eligibility Both Increased Coverage, With Trade-Offs In Access, Affordability

By Thomas M. Selden, Brandy J. Lipton, and Sandra L. Decker
Health Affairs, December 2017

Abstract

Affordable Care Act (ACA) provisions implemented in 2014 provide a valuable case study regarding the merits of using public versus subsidized private insurance to help low-income people obtain and finance health care. In particular, nonelderly adults with incomes of 100–138 percent of the federal poverty level gained Medicaid eligibility if they lived in states that implemented the ACA’s Medicaid expansion, whereas those in nonexpansion states became eligible for subsidized Marketplace coverage. Using data for 2008–15 from the National Health Interview Survey, we found that as of 2015, adults with family incomes in this range had experienced large declines in uninsurance rates in both expansion and nonexpansion states (the adjusted declines were 22 percentage points and 18 percentage points, respectively). Adults in expansion and nonexpansion states also experienced similar increases in having a usual source of care and primary care visits, and similar reductions in delayed receipt of medical care due to cost. There were, however, important differences: Adults in expansion states experienced larger reductions in out-of-pocket spending but also faced greater difficulty accessing physician care relative to adults in nonexpansion states.

From the Discussion

Since we focused on the population with incomes of 100–138 percent of poverty, it might not have been surprising that the magnitude of the decline in uninsurance rates was similar in both groups of states. This is likely because Medicaid coverage imposed zero or near-zero premiums on enrollees, and adults in nonexpansion states with incomes in this range were eligible for Marketplace subsidies—which limited premiums to 2 percent of income for the second-lowest-cost silver plan.

From the Conclusion

As a general rule, care should be taken when applying the results of any study to other policy settings. Applying our findings to reform proposals with different combinations of premium subsidies, patient cost sharing, provider incentives, and eligible populations would be no exception to this rule. In particular, we urge caution in extrapolating our findings to lower-income adults, who may have greater unmet need, additional financial barriers, and different responses to public versus subsidized private insurance.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

By comparing states that expanded the use of Medicaid with those that did not, it was possible to examine the merits in Medicaid versus ACA exchange plans for low-income adults. Medicaid was more effective in reducing out-of-pocket spending whereas the private  ACA plans provided better physician access.

The reasons for the differences are intuitive. Medicaid uses very little cost sharing, thus providing greater financial protection for the beneficiaries, but in most states payment rates are so low that many physicians refuse to accept Medicaid patients, thus impairing access. In contrast, private ACA exchange plans use greater deductibles and other cost sharing, exposing patients to greater out-of-pocket spending, though physicians are more likely to accept patients with private insurance plans.

The authors caution against applying these results to other policy settings because of the great variability in coverage design and needs, so from this study alone we cannot say which is better, public or subsidized private insurance.

What we can say is that design is crucial. In a system designed to provide health care for everyone, design features should remove financial barriers to care and improve access through better resource planning and commitment. Well designed public plans do just that, whereas private insurance depends heavily on empowering patient-consumers to forgo beneficial care because of out-of-pocket costs, plus the only concern they have about distribution of resources is where the more lucrative areas are for them to market their plans.

Both Medicaid and ACA exchanges increased coverage, but we need to increase access and affordability, and neither did both. Rather than accepting trade-offs, we should enact a single payer national health program wherein no trade-offs in patient care are necessary. The trade-offs that do occur within the medical-industrial complex shouldn’t concern us beyond transitional issues.

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It’s not just health care

1 in 4 at Risk for Hunger in Silicon Valley

By Ellen Coppins
Second Harvest Food Bank of Santa Clara and San Mateo Counties, December 12, 2017

Second Harvest Food Bank of Santa Clara and San Mateo Counties has released results of its Food Insecurity Study for Silicon Valley revealing that hunger is far more pervasive in Silicon Valley than previous studies have shown – 1 in 4 people in Santa Clara and San Mateo counties is at risk for hunger. This is an alarming level of need, indicating that food insecurity is a widespread issue impacting approximately 720,000 people. Currently, Second Harvest provides food to an average of over 257,000 people every month, leaving a gap of over 450,000 residents who are struggling to put food on the table.

Underneath the veneer of prosperity in Silicon Valley there are many children, families and seniors who aren’t getting enough to eat. These results are particularly surprising when considering that unemployment is at an all-time low. Unfortunately, economic growth in Silicon Valley is creating immense wealth for a minority, while driving the cost of living up for everyone. As economic growth drives costs, like rent, higher, many residents are more at risk for hunger including a significant population of children in our community. It’s the Silicon Valley hunger paradox, and for the first time Second Harvest was able to measure its magnitude.

The majority of those the study found to be at risk for hunger do not earn enough money to afford the high cost of living in Silicon Valley – 95 percent report earning less than $45,000 annually. According to recent numbers from the U.S. Department of Housing and Urban Development which sets income limits that determine eligibility for assisted housing programs, a family of four in Santa Clara County earning $84,750 or less is considered low-income. In San Mateo County, that number is $105,350. Furthermore, the study found that of the almost 720,000 people at risk for hunger in Silicon Valley, nearly a quarter are families with children.

Faced with such high housing and living costs, any issue affecting income can easily lead to a situation where many Silicon Valley residents are suddenly food insecure. Of those who identified as food insecure:

* 28 percent said their rent had increased in the past year
* 12 percent faced eviction or foreclosure
* 25 percent lost their job in the past year
* 11 percent had their hours cut
* 17 percent encountered unexpected healthcare costs

http://blog.shfb.org…

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The Silicon Valley paradox: one in four people are at risk of hunger

By Charlotte Simmonds
The Guardian, December 12, 2017

In a region famed for its foodie culture, where the well-heeled can dine on gold-flecked steaks, $500 tasting menus and $29 loaves of bread, hunger is alarmingly widespread, according to a new study shared exclusively with the Guardian.

Matt Sciamanna is the sort of person you would assume is fine. He’s young, clever, and a recent graduate from San Jose State University. Yet here on campus, he says, food insecurity is a daily problem. Students, and even part-time professors, have been known to sleep in their cars or couch surf to save money. Sciamanna, who works on the Student Hunger Committee, says a survey of more than 4,000 students found about half have skipped meals due to the cost.

His investment in the issue is informed by his own experience. With his parents unable to finance all his living costs, Sciamanna worked in a restaurant while studying full time. But at 20 he was hit with a life-changing diagnosis: multiple sclerosis, a disease that left his grandmother bedridden. Unable to keep up with the pressures of restaurant work, he took a job on campus that paid just $400 a month.

“My weekly food budget, after other expenses, was $25-$30,” he says. Trips to the grocery store became a game of numbers: a bag of apples and bananas cost less than $5 and would last a week. A bag of frozen vegetables, another $5. “Sometimes I would see a ripe peach, and I would want it, but then I’d think, damn, they’re $1.50 each. It’s not like I’m asking for a car. I’m just talking about a peach. That feeling leaves a scar.”

While Sciamanna says his food situation has improved, another fear looms: healthcare costs. His father, a garbage man in San Francisco, has already postponed retirement so that his son can stay on the family’s insurance. Without it, Sciamanna says he could face out-of-pocket costs of thousands of dollars a month for his medication. In that scenario, obtaining food would become even more difficult.

This article contains the faces of many other individuals who are vulnerable:
https://www.theguardian.com…

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Comment:

By Don McCanne, M.D.

Although our attention has been directed to ensuring health care for all in the United States, related social problems are quite prevalent as well. In a way, Silicon Valley represents an amplified microcosm of the problems in our nation.

Because of the phenomenal successes of the high tech companies, wealth is well represented. Yet with those successes the sharp divide has left far too many with housing insecurity, health insecurity, and, remarkably, food insecurity. One-fourth of the residents are at risk of hunger.

Clearly, those of us fighting for health care justice need to work in coalitions with others who share the common goal of social justice for all.

Today many are celebrating the defeat of a candidate for a Senate seat from Alabama who seemed to reject egalitarian views of social justice. Some are suggesting that we have turned the corner. But keep in mind that almost half of the voters selected him anyway. The problems run very deep. We have a lot of work to do. Our odds of achieving social justice for all are much better if we all work together.

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The Single-Payer Healthcare Debate Revisited

Interview with Robert Kiefner, M.D.
The Exchange, NHPR, December 13, 2017

With uncertainty over the Affordable Care Act’s future, and Congressional inaction on an alternative, some lawmakers in D.C. and New Hampshire are re-branding an old idea: government-financed universal healthcare. We look at the pros and cons from a medical and budgetary perspective with the following guests.

Robert Kiefner: Retired family physician, he practiced for more than 30 years in Concord. He has taught at the Geisel School of Medicine and is a member of the Granite State Physicians for a National Health Plan.

Peter Schmidt: Democratic Representative from Dover and sponsor of a bill that would establish a single-payer health care system in New Hampshire.

Barbara Biggie: Republican Representative from Milford and vice chair of the Commerce and Consumer Affairs Committee.

Joseph Hannon: Doctor and former Republican Representative from Lee. He gave up his medical practice after the Affordable Care Act was passed and now works with several organizations on issues of substance abuse, prevention, and recovery.

full audio:
http://nhpr.org…

About that actuarial value

Marketplace Plans Provide Risk Protection, But Actuarial Values Overstate Realized Coverage For Most Enrollees

By Maria Polyakova, Lynn Mei Hua, and M. Kate Boundary
Health Affairs, December 2017

Abstract

The Affordable Care Act (ACA) has increased the number of Americans with health insurance. Yet many policy makers and consumers have questioned the value of Marketplace plan coverage because of the generally high levels of cost sharing. We simulated out-of-pocket spending for bronze, silver, or gold Marketplace plans (those having actuarial values of 60 percent, 70 percent, and 80 percent, respectively). We found that for the vast majority of consumers, the proportion of covered spending paid by the plans is likely to be far less than their actuarial values, the metric commonly used to convey plan generosity. Indeed, only when annual health care spending exceeds $16,500 for bronze plans, $19,500 for silver plans, and $21,500 for gold plans do plans in these metal tiers cover the proportion of costs matching their actuarial values. While Marketplace plans substantially reduce consumers’ exposure to financial risk relative to being uninsured, the use of actuarial values to communicate plan generosity is likely to be misleading to consumers.

From the Introduction

While the Affordable Care Act (ACA) has increased the number of Americans with health insurance, policy makers and consumers have questioned the value of Marketplace coverage because cost sharing in many plans is generally high. In a recent survey, 22 percent of people who purchased health insurance on their own reported having problems paying medical bills; copayments, deductibles, and coinsurance were the most frequently reported sources of problems.

The standard metric for measuring the generosity of a plan’s coverage is the plan’s actuarial value—that is, the ratio of a plan’s covered spending that is paid for by the plan, divided by the plan’s total covered spending for a standardized population. For example, an actuarial value of 70 percent indicates that for a standardized population, enrollees as a group pay 30 percent of total covered expenditures out of pocket, and the plan pays 70 percent. For Marketplace plans, actuarial values are used to define product tiers. Bronze plans must have an actuarial value of 60 percent, while silver, gold, and platinum plans must have actuarial values of 70 percent, 80 percent, and 90 percent, respectively—although as of 2018 some variation (from 4 percent below to 5 percent above the value, depending on the metal tier) is permitted.

Metal levels and their corresponding actuarial values are intended to provide standardized information on coverage generosity to help consumers choose among plans. The actuarial value simplifies cross-plan comparisons by aggregating complex cost-sharing features—including deductibles, copays, and coinsurance (which can vary across types of health care services)—into a single metric based on out-of-pocket spending. Using a standardized population for the calculation ensures that differences in actuarial values across plans are not driven by differences in the types of people enrolled.

In practice, however, the effect of cost sharing on out-of-pocket spending can vary substantially across people based on the number and types of services they use. As a result, the actuarial value, which is calculated at the population level, might not accurately represent the proportion of covered expenditures paid by a plan for any given enrollee. The distinction between population- and individual-level measurement, however, is often overlooked in the popular media and even in some of the information that insurers provide to consumers. For example, the Blue Cross Blue Shield Blue Care Network of Michigan’s website states, “If you choose a bronze plan, overall you’ll pay about 40 percent of your health care costs, and your insurance company will pay about 60 percent. If you choose a gold plan, overall you’ll pay about 20 percent and your insurance company will pay about 80 percent.”

From the Study Results

We found that although the actuarial value accurately describes the experience of the standardized population as a whole, it does not reflect what most people experienced in their plan. For each of the three metal tiers, plans covered the fraction of the costs corresponding to their actuarial value only for enrollees who had substantial annual health care spending. For example, in the average gold plan, an enrollee would have to spend approximately $21,500 before the plan covered 80 percent of spending, its actuarial value. For the silver and bronze tiers, the spending levels required for plans to reach their actuarial value were $19,500 and $16,500, respectively. Because more than 90 percent of people had annual spending of less than $15,000, for the vast majority of enrollees, the proportion of expenditures covered by a plan would have been much lower than its actuarial value. For the enrollees with the highest spending, assumed to be those using the most services because of illness, plans in all three metal tiers covered more than 85 percent of their spending. However, very few people used that much care.

From the Discussion

While Marketplace plans provide significant financial risk protection, communicating plans’ generosity based on actuarial value may create a mismatch between coverage people expect and coverage they experience. Health care expenditures are highly skewed: As noted above, only a small percentage of people have very high spending in a given year. In other words, an adverse health event that causes very high spending is rare, but it represents a substantial financial risk. Marketplace plans provide relatively comprehensive coverage, as measured by the proportion of total expenditures they cover, for the small proportion of people who experience very high spending. The remainder of the covered population (the vast majority of enrollees) get protection from the risk of catastrophic health care expenditures but experience relatively little direct benefit from their coverage in any given year. They pay premiums but ultimately pay for most of their services out of pocket because their expenses fall below the deductible limits.

More generally, a weakness of using actuarial value is that doing so distracts consumers from the key purpose of insurance, which is financial risk protection. Actuarial value is driven by the average across the population and provides no information on the likelihood of different levels of spending or how specific consumers would fare financially under different scenarios.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The actuarial value of a health plan is the percentage of covered health care costs paid by the insurer, but for the entire population covered, not necessarily for the insured individual. As this study shows, the overwhelming majority of individuals with plans in the ACA exchanges pay a much higher percentage of their covered costs than they might expect to based on the actuarial values of their plans.

The insurers depend heavily on the amount of the deductible to adjust the actuarial values of their plans. Those with low or modest expenses will have a much smaller percentage of costs covered because of their deductibles, whereas those with high medical costs who have already exceeded the deductible will have their additional costs covered at a percentage greater than the actuarial value. Although about 80 percent of spending occurs amongst the 20 percent of individuals with high costs, the other 80 percent of us will find that a much higher percentage of our costs will be out-of-pocket because of the deductible that must be paid.

If it seems like health insurance doesn’t work very well for the 80 percent of individuals who have modest expenses, that’s because it doesn’t. Other studies have shown that modest expenses can create a financial hardship for many individuals and families. And those with higher expenses? They may have a higher percentage of the charges beyond the deductible covered, but they still have the up front out-of-pocket expenses which may constitute a hardship for many of them as well.

Why do we continue to leave in charge the private insurers who have figured out a way to pay less than the actuarial value for the care that most of us receive? It wouldn’t be an issue if we all had first dollar coverage – simply get the care we need when we need it without having to worry about deductibles and other cost sharing.

We should all have prepaid health care through a well designed single payer system instead of being victims of a numbers racket.

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The feminist case for single payer

By Natalie Shure
Jacobin, December 8, 2017

In June, Planned Parenthood of California refused to endorse a bill for a statewide single-payer system, contending that it was critical to focus on defending the Affordable Care Act (ACA) against GOP attacks instead. Vice cast it as a job-crusher for the mostly women of color who work in healthcare administration. In 2016, presidential candidate Hillary Clinton — whose campaign foregrounded her feminist credentials — famously declared single-payer would “never, ever come to pass.” More recently, Senator Bernie Sanders’s release of an expansive Medicare for All bill has been met with skepticism by media personalities who backed Clinton for her feminist credentials. At the very least, it seems clear that single-payer health care is rarely framed as a feminist issue.

Some mainstream feminists knock single payer as a distraction from the fight to defend the ACA. But while the Affordable Care Act undeniably improved some women’s lives, it could not dismantle gendered barriers to care.

Of all systems, single-payer is capable of going furthest to eliminate them. That’s the vision that Our Bodies, Ourselves adopted nearly half a century ago, and it must be taken up again today.

One of the pervasive ways women are disadvantaged under the ACA is its reliance on employer-based coverage. In the United States, World War II–era wage freezes helped entrench a system of employer-provided health insurance, a perk meant to attract workers in a squeezed labor market.

Eventually, Medicare and Medicaid were devised as a safety net for those shut out of private plans, and the ACA expanded that safety net. Still, job-based plans remain the bedrock on which our insurance system is built.

Under this system, it’s harder for women to get health insurance in the first place. The strains of childrearing and elder care make women more likely to seek more flexible employment, like part-time, remote, or freelance work. These forms of employment tend not only to pay less, but are less likely to include health insurance benefits.

Those that do provide inferior ones: companies with majority-female workforces tend to offer less generous health-care coverage than those that are majority male. And less than one-third of low-income workers receive any health insurance through work. Jobs paying at or around the minimum wage are most often occupied by women, the majority of whom are women of color. Trans women face even higher levels of poverty than cis women, and are frequently saddled with impossibly high out of pocket costs.

Then there are the 25 percent of non-elderly adult women insured as dependents of a working spouse, which weakens their control over both their insurance coverage and their relationship. Health insurance has been found to be a common reason for getting married — and for staying married when one would rather not — especially among low-income people. Upon the loss of a spouse’s coverage, it’s difficult and expensive to continue receiving the same care. COBRA coverage — a program that allows people who lose employer-based insurance to remain on it, so long as they pony up the amount formerly contributed by employers — is often the only way to maintain provider networks, but it’s wildly expensive and eventually expires. Ultimately, divorce leaves some sixty-five thousand women uninsured each year, with men being far more likely to maintain coverage after their marriages dissolve.

Women’s unpaid domestic work puts further pressure on the contradictory demands of home, work, and the need to access coverage. Women disproportionately shoulder the responsibility of caring for others, putting them in an impossible situation when it comes to child and elder care: in order to maintain health insurance, they can’t take too much time off work. As a result, they’re forced to spend a significant portion of their wages on private care for the hours they’re on the job. For low-income women who don’t qualify for insurance through employers, the problem can be severe, made worse still by right-wing efforts to impose higher copays and out-of-home work requirements on Medicaid recipients, or to defund programs like CHIP that help parents pay for their children’s health insurance.

During particularly urgent health episodes, like childbirth or a relative’s protracted illness, women opt to take unpaid time off instead of risking their jobs. Notoriously, the United States is one of only a handful of countries that doesn’t guarantee paid maternity leave, exacerbating the financial stress of an already pricey phase of life. The Labor Department has found that nearly one-third of women who take unpaid time off for their own or dependents’ health issues fall into serious credit card debt.

While state ACA exchanges offer an alternative to employer-provided plans, the exchange plans remain inferior. Both tiers of insurance are plagued by narrowing provider networks, and ever-rising out of pocket costs – leading millions to forego insurance because it’s too unaffordable, or find themselves stuck with plans they can’t even afford to use. And that’s with the ACA.

In short, the dynamics that make the American health-care system so hostile to women remain largely unscathed after the ACA: the pervasive commodification of healthcare and dependent care in the United States, coupled with employment-based gatekeeping, engineers an impossible bind for women: they face more challenges accessing the health-care system and pay more for their care when they do, out of lower incomes that are further squeezed by child and elder care costs.

By removing power over health care from employers and spouses, and replacing unequal tiers with one unified insurance pool, we could fund our health-care system with progressive taxes. That way, we could guarantee everyone the care they need, and make it free at the point of service. Ability to pay, pre-existing conditions, employment status, and gender would cease to be barriers. Building Medicare for All — with robust guarantees for tougher-to-access services like abortion and gender affirming care — would force American society as a whole to address the care disparities women face.

Natalie Shure is a TV producer and writer.

https://www.jacobinmag.com…

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Comment:

By Don McCanne, M.D.

Feminists, male and female, should be leading the way on single payer reform.

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Urgent call for action on Paul Ryan’s attack on Medicare

Ryan eyes push for 'entitlement reform' in 2018

By Nathaniel Weixel
The Hill, December 6, 2017

House Speaker Paul Ryan (R-Wis.) on Wednesday said House Republicans will aim to cut spending on Medicare, Medicaid and welfare programs next year as a way to trim the federal deficit.

“We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” Ryan said during an interview on Ross Kaminsky’s talk radio show.

Health-care entitlements such as Medicare and Medicaid “are the big drivers of debt,” Ryan said, “so we spend more time on the health-care entitlements, because that’s really where the problem lies, fiscally speaking.”

Ryan said he’s been speaking privately with President Trump, who is beginning to warm to the idea of slowing the spending growth in entitlements.

House and Senate Republicans are currently working on their plans for tax reform, which are estimated to add more than $1 trillion to the deficit. Democrats have voiced concerns that the legislation could lead to cuts to the social safety net.

Ryan is one of a growing number of GOP leaders who have mentioned the need for Congress to cut entitlement spending next year.

Sen. Marco Rubio (R-Fla.), last week, said “instituting structural changes to Social Security and Medicare for the future” will be the best way to reduce spending and generate economic growth.

Rep. Jeb Hensarling (R-Texas), chairman of the House Financial Services Committee, told Bloomberg TV that “the most important thing we can do with respect to the national debt, what we need to do, is obviously reform current entitlement programs for future generations.”

http://thehill.com…

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Comment:

By Don McCanne, M.D.

Talk about chutzpah. Speaker of the House Paul Ryan is going to reduce our nations’ debt by attacking Medicare and other social programs at the very time he is increasing the debt by reducing taxes on the very wealthy when the profound inequities in income and wealth instead mandate an increase in taxes on the wealthy. Hurting seniors and persons with disabilities with program cuts while adding to he coffers of the rich is the ultimate manifestation of chutzpah.

The traditional Medicare program has been suffering from neglect while the private Medicare Advantage plans have been pampered. Ryan and his colleagues intend to introduce premium support – a voucher that decreases in value over time. Premium support vouchers would be used to purchase private health plans that over time would shift more and more of the costs of health care to the Medicare beneficiaries themselves. Medicare already has excessive cost sharing that makes health care less affordable, and this would make it even worse. It also would give an opening to the very wealthy to abandon Medicare as they seek their own care through private payment. Losing the support of this politically powerful sector would likely mean that Medicare would be transformed into a chronically underfunded welfare program, worse than Medicaid since the benefits would be spartan as well.

Ryan and friends are using the current deficit to dictate tax policy and spending policy. Deficits are reduced by increasing revenues (taxes) and/or decreasing spending. On the spending side, our budget is already relatively austere, and further reductions would largely be harmful. On the revenue side, we need more tax income to reduce the deficit. So their solution? Increase tax revenue by reducing taxes on the wealthy?! But this is a fallacy that has been discredited time and time again – most recently by Kansas.

Tax cuts will increase the deficits which then they can use as an excuse to cut spending. Medicare and Social Security are targets for these cuts since they are such large programs. But Ryan is not waiting for the deficits to increase. He already knows that they will. So he is calling for cuts this coming year.

When tax rates are too low, future governments can adjust them. But the structural changes that they want for a privatized Medicare would be very difficult to patch in the future. Although eventually we will enact a well designed, single payer, improved Medicare for all program, in the interim, the damage that they could do to the existing Medicare program could be devastating for those with current health care needs.

The tax cut that they intend to enact before Christmas will expand deficits to the extent that a political opening will have been made for their premium support privatization program. It is imperative that we let Congress know immediately that they must block these unfair tax cuts for the rich. Then our members of Congress will need to stand firm to guard against the Medicare voucher scheme.

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