Why High Risk Pools (Still) Won’t Work

By Jean P. Hall
The Commonwealth Fund, February 13, 2015

As the new Congress convenes and the Supreme Court prepares to hear arguments in the King v. Burwell case challenging tax subsidies for insurance purchased through the federally facilitated marketplaces, proposals to repeal and replace the Affordable Care Act (ACA) are resurfacing. Many of these rely on high-risk health insurance pools to cover people with preexisting health conditions.

In fact, the risk pools are suggested as a viable alternative to the ACA’s ban on preexisting condition exclusions in the individual market and the marketplaces. My recent analysis of high-risk pools, however, explains why these entities simply are not a realistic alternative to coverage requirements under the ACA. In a nutshell, high-risk pools:

1. are prohibitively expensive to administer,
2. are prohibitively expensive for consumers to purchase, and
3. offer much less than optimal coverage, often with annual and lifetime limits, coverage gaps, and very high premiums and deductibles.

Recent proposals to replace ACA reforms with high-risk pools focus on using state-based programs, but historical experience with 35 state-based high-risk pools and more recent experience with the national Pre-Existing Condition Insurance Plan (PCIP) illustrate the problems with this approach. Even though state-based high-risk pools charged premiums of up to 250 percent of those charged to healthy beneficiaries in the individual insurance market, premium revenues paid just 53 percent, on average, of program costs. In addition to these high premiums, enrollees in state-based high-risk pools faced annual deductibles as high as $25,000 and annual coverage limits as low as $75,000. Past research indicated that high costs and limited benefits associated with high-risk pool coverage resulted in delayed or forgone care and adverse outcomes for enrollees. Many also accrued medical debt despite having insurance.

For these reasons, use of high-risk pools in lieu of marketplace and Medicaid expansion coverage would result in greater state and federal costs, fewer people with preexisting conditions able to obtain coverage, and coverage that fails to meet the often greater needs of people with chronic conditions.

http://www.commonwealthfund.org/publications/blog/2015/feb/why-high-risk-pools-still-will-not-work

Brief: Why a National High-Risk Insurance Pool Is Not a Workable Alternative to the Marketplace

http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/dec/1792_hall_highrisk_pools.pdf

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Comment:

By Don McCanne, MD

Those who wish to repeal or at least drastically reduce the provisions of the Affordable Care Act realize that they must come up with a replacement.

Most of the proposals would grant much greater flexibility to insurance products while reducing regulatory oversight. The problem that creates is that individuals with high medical expenses tend to be shut out of the insurance market. To ensure coverage for these individuals, high-risk insurance pools have been proposed.

This article and the brief that it is based on explain why high-risk pools are not a satisfactory solution. The premiums are unaffordable, and the pared-down benefits are unsatisfactory. These over-priced plans do not provide the financial protection that patients with chronic disorders need.

Even with the Affordable Care Act, enrollment in the temporary high-risk pools had to be closed early because they proved to be too expensive, threatening depletion of the allotted funds. They provide poor coverage at a very high cost.

With a single payer system this problem disappears. Funding is based on ability to pay, through the tax system, and not on the basis of anticipated medical expenses. Everyone receives the care they need, regardless of their health status. The fragmented plans supported by the repeal and replace people cannot do that.

Report Back from the 4th Annual Students for a National Health Program (SNaHP) Summit

The 4th annual SNaHP summit took place on Saturday, February 14, 2015, on the medical campus of the University of Illinois-Chicago. More than 170 medical and health professional students from over 50 schools gathered to discuss single payer, develop their activism and advocacy skills, and create a national strategy for achieving Medicare for All. There were students from states that had never been represented before including, among others, Alabama, Florida, Tennessee, and North Carolina. The fact that so many students, more than double the number that attended the prior year, flocked to Chicago on Valentine’s Day is a testament to the growing commitment of health professional students to achieving equitable and universal access to health care. Click on the link below to view presentations and photos from the conference. 

https://www.pnhp.org/student-summit

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Guest Comment: 

By Scott Goldberg, MS3 

I had the honor of delivering the opening address – entitled “Where We’ve Been and Why We’ll Win – at the 4th annual SNaHP summit. The talk focused on the century-long struggle for national health insurance, what we can learn from these efforts, and why students are well-positioned to spark a broad, social movement for single payer. Here is an excerpt from the speech:

“Now, I’m not disillusioned by the 100-plus year history of failing to achieve national health insurance. In fact, there are important lessons that can inform our efforts and that give me hope that we will be successful where those before us were not.

First, the AMA has opposed single payer since 1917. But while the AMA could honestly say it represented the voice of doctors, it no longer can. Only about 20 percent of physicians are members. This provides an opening, for another physician organization to step into the void that speaks on behalf of what is just and right for patients. You may see where I’m going with this – but this is where Physicians for a National Health Program comes in. PNHP is the only physician organization dedicated to the sole purpose of transforming American health care by passing NHI. And the organization can only grow. If there are 800,000 active doctors in this country, then about 2.5% of them are members of PNHP. This means we, as students and future doctors, have a lot of work to do to get our colleagues to sign up. We should be doing this on a daily basis. Think about all the time you spend with fellow students, residents and even attendings. Think about how many times the issue of insurance comes up and you want to scream out: “If we had single payer, this would not be an issue!” Now, every time that thought comes to mind, do something about it. Mention single payer and encourage those around you to sign up for PNHP. These conversations are not, at the core, political. They are essential to the foundations of our profession, and we must normalize them. I want you to recruit at least one new colleague to PNHP each month. It’s a modest ask, but if everyone here does it we’ll have nearly 2,000 new members in a year. Then, we can start to envision a future where PNHP will usurp the AMA as the organization that speaks on behalf of doctors.

While the AMA might have been a major barrier to NHI in the 20th century, our biggest barriers now are private health insurance companies and Big Pharma. You all know that we are facing one of the most well-financed and formidable opponents in American history. Both have fought tooth and nail against single payer with their army of lobbyists and have contributed heavily to candidates for public office to protect their position and maximize their profits. It is no secret that they spent $173 million to defeat the public option, which amounted to about a million dollars a day during the debate over health reform. So when we talk about single payer, we must talk about the massive profits reaped at the expense of patient care. The neoliberal corporate agenda has infiltrated health care and we must vigilantly fight back against the idea that health care is a commodity and, instead, declare that health care is a public good that all Americans, regardless of race or class, should have access to.

But I am not discouraged by our well-resourced foes for three reasons. One, their arsenal of smear tactics is dwindling. The fear of “socialized medicine” is waning. Communism coming to America is an outdated notion. Two, these companies are universally despised. A recent poll demonstrated that almost all Americans believe that private insurance companies are the biggest problem in our system. So there’s our message right there – we must get rid of private insurance companies to have real health reform. Three, ultimately, the system cannot function without us. If we remain silent, we will only allow these companies to continue to reap massive benefits at the expense of our patients and our professional code of ethics. If we, as health care providers, are united in opposition, we will not be defeated.

You may believe that after 100 years of struggle we will never achieve single payer. But let me tell you why we will win and what we have to do to get there.

I want you to look around you. Our movement is growing exponentially. There are now 35 student PNHP chapters, with 10 new ones in the last year alone. There are 19,602 PNHP members, 731 of whom are students. The second SNaHP summit had 40 students, the third had 80, and the fourth has 160. I emphasize this growth because, historically, students have been the stimulus and source for broader activism. Just recently in Chile, following three years of nationwide student protests, the country will make college tuition-free and are paying for it with a 27% tax on corporations. Look at the civil rights movement in the US. It was the Student Nonviolent Coordinating Committee (SNCC) that spearheaded the civil rights movement. The Freedom Riders, not all, but the majority were young people and students. Over time, it grew and became a mass popular movement and achieved historic things. We don’t know the names of the leaders of SNCC, but that is the point with movements. We know the name of Martin Luther King Jr, but who do you think organized the marches, the talks, the sit-ins? Members of SNCC did. They did the heavy lifting of organizing, going door to door, and putting their lives on the line. Our movement does not need a figurehead. It needs unified direct action.

As Noam Chomsky has said: ‘Direct action carries the message forward in a very dramatic fashion. Direct action means putting yourself on the line. It indicates a depth of commitment and clarification of the issues, which often stirs other people to do something.’ Achieving single payer will require resistance and civil disobedience. All the great movements in history have. Look again at the civil rights movement. Institutional segregation had been going on for hundreds of years, but what sparked the movement? A couple of incidents of direct action. Rosa Parks insisting on sitting in the front of the bus. Black students sitting at a lunch counter in Greensboro. Without these actions, the movement would probably never have happened. You can make as many speeches as you like but they will never have the effect of those actions. And while the movement started with students, it became broad-based and diverse. Just like the movement for single payer, we must reach out to and build ties with labor unions (over 600 have already endorsed HR 676), civic and faith-based movements, and even small businesses. While businesses may seem like natural allies of the private insurance companies, many of them feel the strain of paying to insure their employees and would clearly benefit from government-run health insurance.

In closing, Americans are literally dying for equitable, universal health care access. And so I know that deep down you feel, as I do, that the time has come for direct action. The question is – when do we get started? Here’s one idea – Medicare’s 50th birthday is coming up and a nationwide coordinated action would be a powerful first step.

When I talk to people about single payer, I often hear: “Oh yeah, I support single payer but it will never happen in this country.” I tell them that people once thought the abolition of slavery and women’s suffrage could never be won – that these were “unrealistic” dreams. And yet both of these “unrealistic” dreams were ultimately won. While moderates were advocating for incremental change, the activists pushed for revolutionary change and were successful. What seemed impossible yesterday is something we accept as a given today. So next time someone says single payer will never happen, tell them this: “If you believe it won’t happen, it never will. But if you believe that the only way it will happen is to actually do something about it, then I am sure you will make the only choice that a moral and principled person would, and that is to join me in this struggle.”

Thank you.”

Scott Goldberg is a medical student at the University of Chicago Pritzker School of Medicine and a member of the board of directors of Physicians for a National Health Program.

In The Debate About Cost And Efficacy, PCSK9 Inhibitors May Be The Biggest Challenge Yet

By William Shrank, Alan Lotvin, Surya Singh, and Troyen Brennan
Health Affairs Blog, February 17, 2015

Health care reform is intended to lower costs, but they are still rising, albeit less steeply than in the past. Moderation is not however the case in the area of specialty pharmacy. The medications to treat Hepatitis C are the most cited examples of a general inflationary trend, but the pipeline of expensive medications is extensive.

Yet, policymakers and payers appear unwilling to undertake significant cost controls on medication pricing. Indeed the controversy over the $84,000 price tag for Sovaldi (sofosbuvir) has largely faded, suggesting a certain resiliency in our system’s ability to absorb costs.

We believe that resiliency is about to be challenged in a manner unlike we have seen in the past, at least in the area of pharmaceuticals. A number of pharmaceutical manufacturers are developing a new class of medication to manage high cholesterol — the PCSK9 (proprotein convertase subtilisin/kexin 9) enzyme inhibitors.

The PCSK9 inhibitors will be specialty medications and likely priced as such. While we will not know exact pricing until the first generation of these medications is approved for use by the Food and Drug Administration sometime in mid-2015, estimates of annual pricing for these injectable drugs are in the range of $7,000 – $12,000. Given the number of people potentially eligible for treatment with the PCSK9 inhibitors will number in the millions, the potential overall expenditures by payers are huge.

As this is chronic therapy, PCSK9 sales could be expected to persist and grow over time, and will likely be the highest selling class of medications in history. Plus, as a biologic agent, there will not be a simple pathway to cheaper generics in a 10-15 year timeframe. Even in a system that costs $4 trillion per year, a single therapy adding $100-200 billion in costs annually is extraordinary.

Managed pharmacy care, indeed the health care system, has never seen a challenge like this to our resilience in absorbing costs. Payors, the employers, and health insurers, will first be shocked, then expect action. Action will take the form of compliance with clinical guidelines, and careful managed care oversight.

But in addition, perhaps the costs of PCSK9 inhibitors will push us to develop some consensus about the pricing of new specialty medications, as part of a more thoughtful discussion about the use of scarce resources on behalf of patients.

(The authors are from CVS Caremark and CVS Health.)

http://healthaffairs.org/blog/2015/02/17/in-the-debate-about-cost-and-efficacy-pcsk9-inhibitors-may-be-the-biggest-challenge-yet/

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President Obama’s Precision Medicine Initiative

The White House, January 30, 2015

Building on President Obama’s announcement in his State of the Union Address, today the Administration is unveiling details about the Precision Medicine Initiative, a bold new research effort to revolutionize how we improve health and treat disease.  Launched with a $215 million investment in the President’s 2016 Budget, the Precision Medicine Initiative will pioneer a new model of patient-powered research that promises to accelerate biomedical discoveries and provide clinicians with new tools, knowledge, and therapies to select which treatments will work best for which patients.

Public-private partnerships:

The Obama Administration will forge strong partnerships with existing research cohorts, patient groups, and the private sector to develop the infrastructure that will be needed to expand cancer genomics, and to launch a voluntary million-person cohort.  The Administration will call on academic medical centers, researchers, foundations, privacy experts, medical ethicists, and medical product innovators to lay the foundation for this effort, including developing new approaches to patient participation and empowerment.

http://www.whitehouse.gov/the-press-office/2015/01/30/fact-sheet-president-obama-s-precision-medicine-initiative

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Comment:

By Don McCanne, MD

In the United States, innovation and research in health care have been well rewarded… too well rewarded. The hepatitis C drugs, and now the PCSK9 inhibitors for high cholesterol are cases in point.

Our obsession with letting the market perform its miracles has led to a culture in which we accept and even expect the medical entrepreneurs to be rewarded with the maximum prices that the market will bear. In fact, prices have been pushed up well beyond what any normal functioning market would bear simply because the new products are able to bury their prices in the risk pools established by the private insurers and the pharmacy benefit managers.

Prices are so outrageous that now even the pharmacy benefit managers are complaining, as in the article by Shrank, et al. It is interesting that they suggest, as a solution, “careful managed care oversight.” Yet it is the intermediary “care managers” that have permitted this outrage. Besides, the private insurers are using these high prices to their advantage by placing these drugs in tiers that shift much of the costs to patients, thereby chasing away patients that would have higher health care costs.

President Obama’s Precision Medicine Initiative, as proposed, should have us all concerned. He calls for public-private partnerships that include medical product innovators. You can be assured that these biomedical innovators have already plotted to share in this lucrative market, knowing that their products will be introduced with prices in the stratosphere after they complete the nuisance stage of developing the products for the market. 

The government already plays a role in taxpayer financed research. The public has a vested interest in these products and the government should be protecting our interest. When markets go awry it is the government that has the responsibility to step in and right the wrongs. Since the private insurers and pharmacy benefit managers have served us so poorly, we should replace them with our own public program – a single payer national health program. That would end our culture of developing new products that have outrageously high prices built in as an essential component.

Out of Pocket, Out of Control

By The Editors
Bloomberg View, February 16, 2015

Obamacare’s goal to expand access to health care has been only half a success: More Americans have insurance, but a rise in cost sharing means fewer can use it. Copayments — those predetermined charges you pay at the doctor’s office — are a big part of the problem. In recent years, they’ve risen to the point where they no longer work as they’re meant to. 

In theory, charging moderate fees to see a doctor or get a procedure gives people an incentive to consider whether they really need it. Done carefully, copays can thus reduce unnecessary spending, benefiting everyone.

That means the charges have to be just large enough to influence people’s decisions, and not so big as to keep people from getting the care they need. Yet copays have been going up significantly. In the past five years, the average price to see a primary care doctor has risen 20 percent. For a specialist it’s gone up 29 percent, and for outpatient surgery it’s up 43 percent. And that’s just for employer-sponsored insurance; on average, those covered through the Affordable Care Act’s exchanges face even higher expenses.

No wonder 22 percent of people now say the cost of getting care has led them to delay treatment for a serious condition. That’s the highest percentage since Gallup started asking in 2001. Another poll found that as many as 16 million adults with chronic conditions have avoided the doctor because of out-of-pocket costs.

The wisdom of copayments also relies on the notion that consumers understand the incentives the payments are supposed to impose. Yet almost two-thirds of Americans don’t know what costs they face for using an emergency room or a walk-in clinic, a recent survey found.

When copayments grow too big and confusing to be effective cost controls, they merely shift an ever-greater share of insurance costs away from premiums. And this undermines the basic purpose of insurance, which is to spread the risk of unforeseen costs across populations and over time — among not just the minority who need care, but also everyone covered by the plan. Unlike premiums, out-of-pocket payments concentrate spending on the few who get sick.

Canada has disposed of almost all out-of-pocket costs for doctor and hospital services since 1984 — and still spends half as much per person on health care as the U.S. does. While Canadians are more likely to see a doctor in any given year, they’re less likely than Americans to wind up in the hospital.

Rather than ban copayments entirely, however, the U.S. could make better use of their ability to steer people away from high-cost, low-value care.

The government should also look at extending copay subsidies to lower-income beneficiaries on employer plans and lowering the cap on out-of-pocket costs.

http://www.bloombergview.com/articles/2015-02-16/after-obamacare-health-care-reform-needs-to-curb-costs

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Comment:

By Don McCanne, MD

It is reassuring when we see representatives of the business community shining light on the deficiencies in our system of health care financing. In this article, the editors of Bloomberg View explain that higher out-of-pocket spending shifts costs away from premiums, which are designed to spread the risk, and instead concentrates spending on those who get sick. As they state, this undermines the basic purpose of insurance.

As they explain. “Canada has disposed of almost all out-of-pocket costs for doctor and hospital services since 1984 — and still spends half as much per person on health care as the U.S. does.”

However, the Bloomberg editors, like most of the policy community, as a principle of faith insist that we must still have modest copayments as an incentive to deter low-value care. As if the administrative waste of managing deductibles, copayments, and coinsurance were not already enough, they would add further to these administrative excesses by applying income-indexed subsidies to the copayments of employer-sponsored plans, just as has been done with the ACA exchange plans.

Canada has shown us that the policies inherent in their single payer system are far more effective in controlling excess spending than are our feeble, market-based policies such as cost sharing. The differences in the health spending trajectories of the two nations are proof enough; Canada has bent the cost curve and we have not. Cost sharing has hardly had even a negligible impact in our total spending.

We do know that cost sharing can impair access to necessary care and create financial hardships for some. Since it hasn’t controlled costs and single payer would, we should make the change to a single payer national health program with first dollar coverage. That would pool risks and improve access without creating burdens for anyone, except maybe a transitional burden for those in the insurance industry who would have to find more gainful employment.

A Five-Year Assessment of the Affordable Care Act

By John P. Geyman
International Journal of Health Services, February 10, 2015

Abstract

The Affordable Care Act (ACA) was enacted in 2010 as the signature domestic achievement of the Obama presidency. It was intended to contain costs and achieve near-universal access to affordable health care of improved quality. Now, five years later, it is time to assess its track record. This article compares the goals and claims of the ACA with its actual experience in the areas of access, costs, affordability, and quality of care. Based on the evidence, one has to conclude that containment of health care costs is nowhere in sight, that more than 37 million Americans will still be uninsured when the ACA is fully implemented in 2019, that many more millions will be underinsured, and that profiteering will still dominate the culture of U.S. health care. More fundamental reform will be needed. The country still needs to confront the challenge that our for-profit health insurance industry, together with enormous bureaucratic waste and widespread investor ownership throughout our market-based system, are themselves barriers to health care reform. Here we consider the lessons we can take away from the ACA’s first five years and lay out the economic, social/political, and moral arguments for replacing it with single-payer national health insurance.

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Will the ACA be different, and if so, in what ways? And if it won’t work, what next? These are the questions we will deal with in this article, drawing from my just-published book, How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans. The goals of this article are three-fold: (a) to compare the goals and claims for the ACA with its actual experience in the areas of access, costs, affordability, and quality of U.S. health care; (b) to summarize lessons we can already take away from its first five years; and (c) to briefly consider economic, social/political, and moral arguments for replacing the ACA with NHI.

http://joh.sagepub.com/content/early/2015/01/24/0020731414568505.abstract

Full Text (PDF – 17 pages): http://joh.sagepub.com/content/early/2015/01/24/0020731414568505.full.pdf

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Comment:

By Don McCanne, MD

In this paper, John Geyman summarizes the content of his important new book, “How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans.” It is already clear that the Affordable Care Act has not and will not provide adequate repairs to our fragmented and dysfunctional health care system. Rather than inflicting more suffering by continuing this flawed experiment in health policy, we should immediately begin the transition to a system that will work – a single payer national health program.

Both this IJHS article and his book serve as important resources in educating the nation on why this transition should be initiated as soon as possible. They should be distributed widely.

The book is available through the PNHP website here.