PNHP

Now just try to make the plans work

Now just try to make the plans work

Newly Insured, Many Now Face Learning Curve

By Abby Goodnough
The New York Times, August 2, 2014

Advocates of the Affordable Care Act, focused until now on persuading people to buy health insurance, have moved to a crucial new phase: making sure the eight million Americans who did so understand their often complicated policies and use them properly.

The political stakes are high, as support for the health care law will hinge at least partly on whether people have good experiences with their new coverage.

Many people who signed up for private coverage through the new marketplaces had never had health insurance, and even the basics — like what a premium is and why getting a primary care doctor is better than relying on the emergency room — are beyond their experience. Others have a sense of how insurance works but find the details of the marketplace plans confusing, especially if they signed up without the help of someone who understood them.

Insurers, too, are trying to help ease their new members’ confusion. Independence Blue Cross, which enrolled 165,000 people in its marketplace plans, has representatives traveling the Philadelphia region this summer in a tractor-trailer, the Independence Express, and offering educational seminars. Independence also has tried to reach all of the new members by phone to welcome them and “make sure they understand what they bought,” said Paula Sunshine, the company’s vice president of consumer sales and marketing.

The company knew going in that the learning curve would be steep. It held focus groups last year with nearly 2,000 people and found, for example, that virtually none knew what coinsurance was.

In one sign of widespread confusion, a recent Kaiser Family Foundation survey of programs that helped people apply for marketplace coverage found that 90 percent had already been re-contacted by consumers with post-enrollment questions.

http://www.nytimes.com/2014/08/03/us/newly-insured-by-health-law-millions-face-a-learning-curve.html

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Comment:

By Don McCanne, M.D.

If health care reform had worked the way it should have, today anyone could get the health care that he or she needed without having to worry about how to pay for it. What are we seeing instead? Just trying to enroll in health care coverage has been a very difficult process for many, and tens of millions will still remain uninsured. And today’s article shows how problematic the next step is – trying to put your coverage to use.

Some of the problems have already been widely publicized. Newer plans, especially those in the exchanges, have low actuarial values (i.e., very high deductibles and other excessive cost sharing). Cost sharing can make care unaffordable for those with modest incomes. Plans are now using narrow- and ultra-narrow networks of hospitals and health care professionals which limit patients’ choices in their health care, often preventing access to the most appropriate physicians and hospitals. We are now seeing tiered levels of specialized services and pharmaceuticals in which patients are financially penalized if they use specialists or drugs in the higher, more expensive tiers even if they are clearly preferred for medical reasons. The penalty is assessed by the insurers strictly to dissuade patients from using more expensive care even though it may be better care. Patients are also having difficulties determining not only whether specific providers are in or out of their networks, but also which tier they are in and what that means. Furthermore, the provider enrollment in these networks is quite unstable, not to mention the instability that arises when the patient must change plans and therefore change networks. This says nothing about the problems patients face when they try to get an appointment and find that there are no openings, or find that the distances are too far – directly due to the insurance innovation that promises a higher volume of patients to fewer physicians so that insurers can get greater discounts, even though overloading their practices. The list goes on and on with administrative excesses that are designed to enhance the business performance of the insurance products at a cost to the patients that they should be serving.

It should not have been this way. A single payer national health program would have automatically enrolled everyone; it would have included all providers, and it would have been financed through equitable taxes, making it affordable for everyone.

Although this New York Times article presents the problem as a need to teach individuals the complexities of using these newer insurance products, the problem is actually the complexities themselves and the tremendous injustices that ensue.

The remainder of this comment is composed of more excerpts from the NYT article. The experience of Salwa Shabazz should enrage us and drive us to demand health care justice for all. Her case shows us the compelling need for comprehensive structural reform of our health care financing system.

The following are excerpts from the NYT article (link above):

Last week, Salwa Shabazz arrived at the office of a public health network here with a bag full of paperwork about her new health insurance — and an unhappy look on her face. She had chosen her plan by phone in March, speaking to a customer service representative at the federal insurance marketplace. Now she had problems and questions, so many questions.

“I’ve had one doctor appointment since I got this insurance, and I had to pay $60,” Ms. Shabazz told Daniel Flynn, a counselor with the health network, the Health Federation of Philadelphia. “I don’t have $60.”

Mr. Flynn spent almost two hours going over her Independence Blue Cross plan, which he explained had a “very complicated” network that grouped doctors and hospitals into three tiers. Ms. Shabazz, who has epilepsy, had not understood when she chose the plan that her doctors were in the most expensive tier.

“None of that was explained when I signed up,” she said. “This is the first I’m hearing it.”

Independence Blue Cross has focused on making sure people understand the tiered-network plan that Ms. Shabazz chose, which was popular because of its relatively low price but also particularly hard to understand. Ms. Shabazz, 38, paid only about $32 a month in premiums, with federal subsidies of $218 covering the rest. But she could not afford the $60 co-payments to see her specialists on her annual income of $19,000.

Her financial situation worsened when she had to quit her job at the Pennsylvania Liquor Control Board in June because of the epilepsy, she said. She had called the federal marketplace to report her change in income, and had received a letter that she handed to Mr. Flynn, hoping he could explain it. The news, he said, was not good: With no more paychecks, she had fallen into the so-called coverage gap, earning too little to keep qualifying for the subsidies that made her premiums affordable, but likely still not qualifying for Medicaid because Pennsylvania has not expanded that program, as 26 states have under the Affordable Care Act.

“You’ll probably have to cancel your plan,” he said.

Ms. Shabazz’s mother, Waheedah Shabazz-El, who had accompanied her to the appointment, shook her head as her daughter wiped away tears. “There are so many layers to this,” Ms. Shabazz-El said.

Closing comment by Don McCanne:  We are not powerless. Let’s demand single payer, and not let up until we get it.

What does California’s 4.2% premium increase mean?

Obamacare premiums to rise a modest 4.2% in 2015

By Stuart Pfeifer, Chad Terhune, Soumya Karlamangla
Los Angeles Times, July 31, 2014

Defying an industry trend of double-digit rate hikes, California officials said the more than 1.2 million consumers in the state-run Obamacare insurance exchange can expect modest price increases of 4.2% on average next year.

“We have changed the trend in healthcare costs,” said Peter Lee, Covered California’s executive director. “This is good news for Californians.”

State officials and insurers credited the strong turnout during the first six-month enrollment window that ended in April for helping to keep 2015 rates in check. But others cautioned it’s still too early to gauge the health law’s impact, suggesting several factors may be temporarily holding rates down in the individual market.

“We don’t really know what the real cost of Obamacare is yet because insurance companies are heavily subsidized for the first three years” of the law’s implementation, said Robert Laszewski, a healthcare consultant in Virginia who has closely tracked the overhaul. “The insurance companies essentially can’t lose money.”

California Insurance Commissioner Dave Jones said the modest uptick in premiums was a positive sign, but he said insurers were likely motivated by a November ballot initiative, Proposition 45, that would give his office new authority to regulate health insurance rates.

“This is merely a pause in the double-digit rate increases we’ve seen historically,” Jones said.

Consumer Watchdog, the Santa Monica advocacy group pushing Proposition 45, said insurers held back this year to avoid that kind of voter backlash.

WellPoint Inc., Anthem Blue Cross’ parent company, Kaiser and other insurers have contributed more than $25 million to defeat the ballot measure.

http://www.latimes.com/business/la-fi-obamacare-2015-rates-20140801-story.html

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Comment:

By Don McCanne, M.D.

Before we discuss some of the possible reasons that the 2015 increase in premiums for California’s ACA exchange were held down to 4.2 percent, we should mention the bad news that is not being covered by the media. We are celebrating an artificially low increase that is still twice the rate of inflation – 2.1 percent (Consumer Price Index, June 2014 – Bureau of Labor Statistics), as workers continue to fall behind over the last three decades of increasing income inequality.

Although ACA enthusiasts are touting success in controlling health insurance premiums, there are many reasons why their celebration is premature, but two stand out.

Proposition 45, which will be on the November ballot, would provide authority to California’s insurance commissioner to regulate health insurance premiums. The last thing the insurers want to do is to anger voters with high rate increases just before this election. The insurers have already contributed over $25 million to defeat this measure.

The other important reason is that the insurers are still protected by reinsurance and insurance rate corridors. In fact, the Obama administration adjusted this coverage to be sure that the insurers were fully protected again next year should they not receive enough premium revenue to meet their expenses. They can’t lose! Of course they are going to come in with low bids when they are under the threat of voter revolt.

And what about the next year when they no longer have protection against losses? We already know the routine. “The patients enrolled in our plans were older and sicker while the younger, healthier individuals were covered by plans at work, or bought the cheap catastrophic plans, and the new drugs that cost tens of thousands of dollars or more placed a strain on our budgets, and our contingency reserves were depleted with the market crash of 2015, and we’ve lost our rate flexibility with the termination of government reinsurance, and…” Well, you know.

Although there are many other uncertainties as the implementation of ACA plays out, one certainty that we can rely on is that insurers will be requesting much larger premium increases for 2017, possibly double digits. That would not be happening under a single payer national health program.

Victor Fuchs on the solution for high health care costs in U.S

Why Do Other Rich Nations Spend So Much Less on Healthcare?

By Victor R. Fuchs
The Atlantic, July 23, 2014

Despite the news last week that America’s healthcare spending will not be rising at the sky-high rate that was once predicted, the fact remains that the U.S. far outspends its peer nations when it comes to healthcare costs per capita. This year the United States will spend almost 18 percent of the gross domestic product (GDP) on healthcare.

Why does the United States spend so much more?

The biggest reason is that U.S. healthcare delivers a more expensive mix of services. For example, a much larger proportion of physician visits in the U.S. are to specialists who get higher fees and usually order more high-tech diagnostic and therapeutic procedures than primary care physicians.

A second important reason for higher healthcare spending in the U.S. is higher prices for inputs such as drugs and the services of specialist physicians. The prices of branded prescription drugs in the U.S. are, on average, about double those in other countries. The fees of specialist physicians are typically two to three times as high as in other countries. The lower prices and fees abroad are achieved by negotiation and controls by governments who typically pay for about 75 percent of all medical care. Government in the U.S. pays about 50 percent, which would still confer considerable bargaining power, but the government is kept from exerting it by legislation and a Congress sensitive to interest-group lobbying.

The third and last important reason for higher spending in the U.S. is high administrative costs of insurance. Many of our peer countries have lower administrative costs through more coordination, standardization, and in some countries a single national system or several regional healthcare-insurance systems, even when the provision of care is primarily a private-sector responsibility.

The complexity of private-sector insurance is not in the public interest. Each company offers many plans that differ in coverage, deductibles, co-pays, premiums, and other features that make it difficult for buyers to compare the prices of different policies.

If we turn the question around and ask why healthcare costs so much less in other high-income countries, the answer nearly always points to a larger, stronger role for government. Governments usually eliminate much of the high administrative costs of insurance, obtain lower prices for inputs, and influence the mix of healthcare outputs by arranging for large supplies of primary-care physicians and hospital beds while keeping tight control on the number of specialist physicians and expensive technology. In the United States, the political system creates many “choke points” for diverse interest groups to block or modify government’s role in these areas.

For those who would like to limit government control, there is an alternative route to more efficient healthcare through “managed competition,” proposed by Alain Enthoven, a Stanford University Business School Professor, more than 25 years ago. It is based on integrated group practice, which brings the insurance function, physicians, hospital, drugs, and other elements of care into a single organization that takes responsibility for the health of a defined population for an annual risk-adjusted per capita payment. Examples include the Group Health Cooperative of Puget Sound in Seattle and the Kaiser Permanente organizations in California.

With regard to healthcare, the United States is at a crossroads. Whether the Affordable Care Act will significantly control costs is uncertain; its main thrust is to reduce the number of uninsured. The alternatives seem to be a larger role for government or a larger role for managed competition in the private sector. Even if the latter route is pursued, government is the only logical choice if the country wants to have universal coverage. There are two necessary and sufficient conditions to cover everyone for health insurance: Subsidies for the poor and the sick and compulsory participation by everyone. Only government can create those conditions.

http://www.theatlantic.com/business/archive/2014/07/why-do-other-rich-nations-spend-so-much-less-on-healthcare/374576/

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Comment:

By Don McCanne, MD

Highly respected Stanford economist Victor Fuchs has long supported private solutions to universal coverage, such as Alain Enthoven’s managed competition. Although there is much to be said for establishing integrated health care delivery systems within the community, the logistics of providing all care through competing integrated delivery systems have proven to be insurmountable, as witness the managed care revolution that reduced this concept to competition between inefficient, expensive and intrusive third party insurer money managers.

Fuchs now notes that “the complexity of private-sector insurance is not in the public interest.” He acknowledges the crucial role of government in other nations. He states that we are now at a crossroads between “a larger role for government or a larger role for managed competition in the private sector.” Even if private managed competition is selected, “government is the only logical choice if the country wants to have universal coverage.”

But look at the government requirement he would impose if the private managed competition option were selected: “Subsidies for the poor and the sick and compulsory participation by everyone.” We already have that in the Affordable Care Act, and yet we will be left with 31 million uninsured.

At least Fuchs is right when he says, “Only government can create those conditions.” But the vehicle has to be functional. That’s why we need to do it through a single payer national health program. We can still have our integrated health care delivery systems that Arnold Relman also supported, but in addition we will need the other components that make the system work efficiently for all of us.

Happy Birthday, Medicare — the best form of health insurance

By Jackie Wolf
Daily Hampshire Gazette, July 31, 2014

AMHERST, Mass. — There is a joke that goes: What’s so good about turning 65? Answer: Insurance agents stop calling. I would like to suggest a variation on that joke: What’s so good about turning 65? For almost all people in the United States, the good news is they are eligible for Medicare.

The good news is they no longer, each year, have to read through charts and tables of private insurance company policies with different benefit levels, different deductibles, different co-pays and different premiums to find an affordable policy. When you are eligible for Medicare, you really have a great deal more peace of mind and health care security.

For almost 50 years, Medicare has provided millions of Americans with health insurance — in fact, approximately 37 million people in 2012 in all 50 states. It is a tested, proven United States model of good, government-run health insurance. Medicare operates efficiently and effectively paying 97 cents of every dollar on direct health care services. Medicare provides doctors and researchers with volumes of data on medical procedures and outcomes searching for the best approaches to treat and cure disease and illness. Medicare also covers an annual physical for all enrollees as well as fitness programs.

Compare those facts to the reality of the private insurance market. I challenge you to find any private insurance company that spends 97 cents of every dollar collected on direct health care services. With their high executive salaries, high budgets for marketing and advertising, and hundreds of denial-of-claims clerks, private insurers struggle to meet the mandated level of paying out 90 cents for every dollar collected on health care services.

Marilyn Tavernner, administrator for the Centers for Medicare and Medicaid Services is paid an annual salary of $143, 800. Compare that to the salary of Andrew Dreyfus, CEO of the Blue Cross Blue Shield of Massachusetts, who earned $1.1 million in 2011 (and that does not include benefits to which he is entitled). Remember: Blue Cross Blue Shield is a non-profit. In addition, the 17 directors of Blue Cross Blue Shield of Massachusetts are paid $47,000 to $54,500 each to show up for 10 meetings a year.

Private health insurers spend so much on marketing and advertising because they are looking for healthy people. They want to attract younger, active people and sell them policies – that’s called “cherry picking” — while avoiding, and, if possible, getting rid of older, sick people — that’s called “lemon dropping.” Many Massachusetts residents are speaking out for single payer for Massachusetts — or Improved Medicare for All Massachusetts.

They are tired of the fact that their health insurance is tied to their employment. They are tired of the fact that their employers have a say in what benefits are available. They are tired of filling out pages of paperwork to file claims for benefits they have paid for. And they are tired of all the bills for premiums, co-pays and co-insurance.

Physicians are, likewise, getting fed up dealing with the private health insurance market. Just this past week, I was talking with a graduate student whose mother is a psychiatrist. He told me his mother spends approximately 20 percent of her time filling out paperwork to get payment from the multitude of insurance companies. And that doesn’t cover the time she spends on the phone challenging the denials of treatments for her patients. It’s frustrating, discouraging and wrong.

We don’t need private insurance companies as middlemen. A state single payer health care plan — an improved Medicare for All Massachusetts plan (Senate bill S515) would insure all residents and guarantee quality, affordable care to all. Let’s look to the model of Medicare and enjoy health care security from cradle to grave. Happy Birthday Medicare!

Jackie Wolf is chair of the League of Women Voters of Amherst Health Care Committee.

http://www.gazettenet.com/home/12957847-95/jackie-wolf-happy-birthday-medicare-the-best-form-of-health-insurance

Improve health care by building on Medicare’s success

By Erica Heiman, M.D.
The Sacramento Bee, July 31, 2014

Lately, I have been diagnosing a lot of high blood pressure and diabetes. Patients who have never received medical care are now pouring into the county-funded Sacramento Primary Care Clinic, which provides care to low-income and other underserved patients.

The Affordable Care Act has expanded access to 8 million more Americans. Although Sacramento County has always tried to ensure high-quality care to indigent patients, Obamacare has opened our doors even wider.

Often, these new patients are unaware they have a condition that requires treatment because it has never caused them any trouble. But these conditions, if untreated, lead to increased risk of heart attack, stroke and other serious complications.

In short, it’s important for everyone to have a doctor. If hypertension and high cholesterol are detected early and treated, the risks down the road are dramatically reduced. That’s why I love primary care; it may be difficult to see the benefits from day to day, but in the long run, they are vast.

Medicare entered its 50th year on Wednesday. Signed into law by Lyndon B. Johnson in 1965, its goal was to alleviate “the threat of financial doom” faced by aging Americans and their families. Since the 1960s, Medicare has steadily expanded, currently providing coverage to more than 50 million elderly and disabled Americans. Medicare is far from perfect – but it has succeeded in reducing poverty among its beneficiaries and in reducing health disparities.

Opponents often assert that Medicare is wasteful and should be cut. Aside from the political infeasibility of this, given how popular it is, it’s actually inaccurate: Medicare’s operational costs are estimated at about 2 percent, far below that of most private insurance companies. According to recent studies, Medicare’s growth rate is actually lower than projected and lower than cost increases in the private sector.

Proposed changes to Medicare have recently focused on granting vouchers for Medicare-like insurance plans run by the private sector. These plans receive lower approval ratings from their beneficiaries than traditional Medicare. Other proposals would increase the age of eligibility for Medicare, which may save the federal government money in the short term, but would result in higher costs to employers, individuals and Medicaid. In the longer term, this would be much more likely to look nice on a written budget projection than to provide meaningful benefit to the American people.

To rein in skyrocketing costs in health care, the answer isn’t cutting Medicare. It’s expanding and reforming it to create an improved “Medicare for All.”

Eliminating private insurance companies would eliminate their high overhead costs and the hefty salaries their CEOs earn. It would allow more bargaining on pharmaceutical prices so patients would have more affordable choices. Health care delivery would still be done by private-sector hospitals and clinics, and the number of options would likely expand for the average American, as current insurance plans restrict to “in-plan providers” who can be difficult to find and hard to schedule with.

I’m appreciative of the expansion in coverage that the ACA has allowed, but we still have a ways to go. There are still 13 percent of Americans without health insurance. Many of my patients who just enrolled in Medi-Cal are having trouble getting specialty care because their plans have not negotiated contracts with specialists in their areas. This is frustrating for the patients – who have to spend anxious days, weeks and months waiting for a call from the orthopedist’s office – and for primary care clinicians like me, who would like nothing more than to know that our patients will be well cared for without the efforts of an army of case managers.

The answer to health care costs that are 2.5 times higher than the industrial nation average (and yet fail to produce higher-quality care and more favorable morbidity and mortality indicators) is Medicare for All.

As I celebrate Medicare’s birthday and its successes, I look forward to the day when every American will access the same high-quality care that those over 65 now enjoy.

Erica Heiman is a resident physician at the University of California, Davis, Medical Center and a member of Physicians for a National Health Program.

http://www.sacbee.com/2014/07/31/6594125/viewpoints-improve-health-care.html#storylink=cpy

We All Need Health Care Now

National Health Insurance Saves Money in the Long Run

By Peter Conn
Santa Barbara (Calif.) Independent, July 30, 2014

Happy birthday, Medicare, which celebrates 49 years of service today. In a 1995 essay in the journal Health Affairs, Robert Ball wrote that those who helped develop Medicare saw it as a first step toward universal national health insurance. Covering only seniors was a fallback position because that is all that could be expected to pass Congress at the time. Sound familiar?

Medicare is not perfect, but political fights over ideology and special interest profits have blocked improvements that would increase efficiency and effectiveness. Otherwise by now we would have national health insurance, have better outcomes, have no uninsured nor financial barriers to care, and would be spending much less on administrative overhead, like the rest of the industrialized world.

The Medicare Advantage program — your Medicare dollars given to private insurers who of course need to make a profit — promised reduced cost and expanded coverage, but instead increased costs (15 percent more costly to the Medicare fund than traditional Medicare) and decreased choice of physicians.

Part D, subsidized drug prices but prohibited negotiating prices or importation, thus keeping prices artificially high.

And now, instead of folding Medicare, Medicaid, employer-provided insurance, and individual insurance into one Medicare-for-all plan, we have added Obamacare, which multiplies the administrative complexity and inefficiency of both public and private insurance plans. It still leaves over 30 million people without health insurance with an indefinite wait time for all but emergency room care.

Don’t misunderstand the above as a call for repealing Obamacare, which has provided affordable coverage to millions more people. My point is that if we could get beyond the ideological fighting, beyond corporate desire for ever-increasing profits and look only at efficiency and effectiveness, we could have national health insurance for everyone at no additional cost and save money now and in the long run.

Logically, fiscal conservatives should embrace a reform such as Medicare for all because, factually, it would save all of us money — government, individuals, and businesses. But it is hard to even get some progressive politicians who think Medicare for all is a good idea to champion it for fear of conservative backlash. The time is not right, some say.

Logic and facts may not be in fashion, but the time is right to organize, organize, organize. So if you think Medicare for all is a good idea, support one of the many groups backing the idea. When the parade of supporters gets big enough, the politicians will scramble to get to the front.

In the end, it is up to individuals, businesses, medical professionals, and organizations of all types to act. The movement exists. You need to join it to make it succeed.

Peter Conn is outreach coordinator of Health Care for All — Santa Barbara.

http://www.independent.com/news/2014/jul/30/we-all-need-health-care-now/

Who are those remaining uninsured?

Where are California’s Uninsured Now? Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey

By Bianca DiLulio, Jamie Firth, Larry Levitt, Gary Claxton, Rachel Garfield and Mollyann Brodie
Kaiser Family Foundation, July 30, 2014

Of those Californians who were uninsured prior to open enrollment, 58 percent now report having health insurance, which translates to about 3.4 million previously uninsured adult Californians who have gained coverage, and 42 percent say they remain uninsured. The most common source of coverage was Medi-Cal with 25 percent of previously uninsured Californians reporting they are now covered by Medi-Cal. An additional 9 percent of California’s previously uninsured say they enrolled in a plan through Covered California, resulting in about a third reporting new coverage from the two sources most directly tied to the ACA. Twelve percent say they obtained coverage through an employer and 5 percent report enrolling in non-group plans outside of the Covered California Marketplace; some enrollment in these types of coverage may have been motivated by the ACA’s requirement to purchase insurance and some may be the result of normal movement within the marketplace.

Section 3: The Remaining Uninsured

Who Remained Uninsured?

As many previously uninsured Californians gained coverage, 42 percent remained uninsured. Many of the remaining uninsured have tenuous links to health insurance posing challenges for future enrollment efforts. Forty-five percent of the remaining uninsured reported in the baseline survey that they had been without health insurance for two or more years and an additional 37 percent said they have never had insurance. Hispanics make up 62 percent of the remaining uninsured and nearly half of them (29 percent) are undocumented Hispanics who are not eligible for Medi-Cal or assistance through Covered California. About 4 in 10 (39 percent) report family income that put them in the group likely eligible for Medi-Cal and another quarter (24 percent) are likely eligible for financial assistance through Covered California. These shares reflect the demographics of people who were uninsured prior to the first ACA open enrollment period and did not get coverage during the open enrollment period. Others may have been covered prior to open enrollment but now uninsured – a group not captured by this survey.

Why Did They Remain Uninsured?

Why did 42 percent of California’s uninsured prior to open enrollment remain without coverage? Most of the remaining uninsured seem to value insurance, with majorities saying it is something they need (71 percent) and that it is worth the costs (59 percent). Still roughly 3 in 10 of the remaining uninsured say they can get by without insurance (28 percent) or don’t feel coverage is worth the price (33 percent), including 4 in 10 (40 percent) of those who are likely eligible for coverage through Covered California or Medi-Cal due to their self-reported income level and immigration status.

The cost of insurance (whether perceived or actual) remains a barrier. When asked in their own words why they didn’t get coverage, one-third (34 percent) point to costs as the reason. Fifteen percent say they don’t qualify or don’t think they do, including 9 percent who say they can’t enroll or are worried about signing up because of their immigration status. Other reasons the remaining uninsured give for not signing up for coverage include not having yet tried or being too busy (9 percent), not having enough information about enrolling (9 percent), having tried but not being successful (8 percent), and not wanting or needing coverage (7 percent). A few (6 percent) say they didn’t get insurance because of issues associated with the application process, including three percent who say they are still awaiting contact or approval – a finding that is perhaps related to the large backlog of about 900,000 Medi-Cal applicants waiting for counties across the state to process their applications.

California’s Undocumented Uninsured

In California, undocumented immigrants make up about a fifth of those who were uninsured before the ACA expansions kicked in, and under the law, they are not eligible for Medi-Cal or subsidies through the exchange. As a group they are largely aware of these restrictions – 63 percent say they are not eligible for Medi-Cal and 70 percent say they don’t qualify for financial assistance through Covered California. Half say the mandate doesn’t apply to them and most (60 percent) correctly respond that they won’t have to pay a fine for not having coverage.

While the ACA restricts access to health benefits for undocumented immigrants under the law, there is still keen interest in coverage among this group. Since last summer about a third (35 percent) of California’s undocumented uninsured say they obtained coverage and of those who remain uninsured, half say they intend to get coverage later this year. In fact, the remaining undocumented uninsured are more apt to say they place a high value on insurance than other remaining uninsured Californians; nearly three quarters (73 percent) of the undocumented uninsured say health insurance is worth the cost and 85 percent say it is something they need, each 20 percentage points higher than the share for other remaining uninsured Californians.

Where are California’s Uninsured Now? Wave 2 of the Kaiser Family Foundation California Longitudinal Panel Survey

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Comment:

By Don McCanne, MD

California’s aggressive efforts to implement the provisions of the Affordable Care Act resulted in 58 percent of the previously uninsured now having coverage – about 3.4 million individuals. While this certainly gives cause for celebration, it must be tempered by the knowledge that 42 percent of the previously uninsured are still uninsured. Who are these people and why are they not insured?

The excerpts above provide a brief answer, though much more is available in the comprehensive report at the link above. In very general terms, as these authors note, many of the remaining uninsured “have tenuous links to health insurance posing challenges for future enrollment efforts.” The roughly 2.5 million previously uninsured who still remain uninsured will provide much greater challenges in trying to get them enrolled in some form of coverage, and a great many of them will still remain uninsured.

A comment should be made about California’s undocumented residents. They tend to be blamed by some for California’s high numbers of uninsured. Actually they constituted only about one-fifth of the uninsured before implementation of ACA. Although they are not eligible for Medi-Cal (Medicaid) nor for subsidies under Covered California (ACA insurance exchange), 35 percent obtained coverage on their own and another 50 percent intend to later this year. They have, in fact, been more responsible in this regard than have other uninsured Californians who were not enrolled in Medi-Cal or Covered California.

California’s efforts have been exemplary, and those involved in the ACA implementation are to be commended. Yet it is likely that one or two million people will remain uninsured. That’s not acceptable, and it is not California’s fault. California, and the entire nation for that matter, has an irreparably flawed health care financing infrastructure with which to work. It is obvious what we need to do. We need to replace this flawed system with a single payer national health program covering everyone, including the undocumented. The sooner the better.

Medicare’s 49th birthday: What is to be done?

By Danny Ash, M4
KevinMD.com, July 30, 2014

At a crowded townhall meeting in 1959, an elderly woman stepped up to the microphone and spoke to a panel of senators. “I am not worried for my son’s time,” she began. “He is 35, and I am sure he will face a better future when his time comes to retire. But what is to be done for those of us who need help right now?”

This was one of a series of grassroots hearings held by a Senate subcommittee between 1959 and 1961. The senators visited 38 American cities in all, inviting the elderly to come and speak of the troubles they faced in their everyday lives. And come they did, tens of thousands of them, packing halls from San Francisco to Miami.

As the transcripts show, these men and women had much on their minds, with concerns ranging from housing, to unemployment, to pensions. But there was one topic that dominated the hearings: health care.

“Here are the doctor and hospital bills for my wife’s latest illness,” said one man brandishing a sheaf of papers. “They come to more than $2,000. I’ve paid them and my savings are all gone now. What shall we do the next time one of us gets sick?”

These stories and others like them galvanized the nation into action, and on this day in 1965, Lyndon B. Johnson signed Medicare into law. In 1965 only 46% of seniors had hospital insurance; in 1970, that number was 97%. In those five years, the death rate for seniors over 85 dropped by 20%. Subsequent modifications expanded eligibility to include Americans with certain chronic diseases, as well as those too disabled to work. With the benefit of hindsight, most Americans now agree that Medicare has been a massive success, and the program has withstood repeated attempts to abolish or curtail its benefits.

Yet Medicare, and its sister program Medicaid, did not completely solve the problem of health care finance, especially for those under 65. As costs have continued to rise, it has become more and more difficult for Americans to get the care they need. Before the Affordable Care Act (ACA), there were more than 47 million of us without any health insurance, including me.

I couldn’t afford private insurance, and as a healthy young man, I hoped I wouldn’t need it. When I injured my right hand, the pain was excruciating. For days I could barely move my fingers, and my forearm looked like a banana well past its expiration date. But worst of all was the uncertainty. Had I broken a bone, torn a tendon? In any case, I knew I couldn’t afford to see a doctor. Federal law requires emergency departments to treat all patients regardless of their ability to pay, but uninsured patients still get stuck with the bill. I bought a $10 splint at a drug store and hoped for the best.

Thankfully, my injury eventually healed. But now, as a fourth year medical student, I have already seen many patients who faced the same dilemma and were not so lucky. One, who had gashed his leg in a fall, came to the hospital only after he had developed a rampant wound infection that required surgical treatment and could easily have left him wheelchair-bound. A woman who came in to a clinic with near-critical high blood pressure told me she hadn’t been able to afford her medications, so she had been taking a pill a week to make them last.

Should I pay my rent, or should I buy my water pill? Do I fix my car, or do I see someone about my shortness of breath? These are decisions nobody should have to make — and yet, these are the decisions many face every day. Medicare, Medicaid, and now the ACA have all been steps in the right direction, but affordable and high-quality health care is still out of reach for millions of Americans.

It is time to finish the job. It is time to acknowledge that health care is a human right, that no man, woman, or child can engage in the pursuit of happiness while under the threat of illness or death. The time for half-measures and quick fixes has passed. We need universal health care, Medicare for all.

On this day, the 49th birthday of Medicare, let us reflect on how much we have accomplished, and what still remains to be done. In 1959 an old woman asked, “What is to be done for those of us who need help right now?” It is my fervent hope that we will soon have an answer to her question.

Danny Ash is a medical student in Ohio.

http://www.kevinmd.com/blog/2014/07/medicares-49th-birthday-done.html

High cost of medications hurting health system

By David Potter, M.D.
Chico Enterprise-Record, July 29, 2014

I appreciated your article about Medicare for all Americans. I did want to expound a little bit about Tom Reed’s point about drug costs.

The high cost of medications in our health system is a huge problem. Ten percent or more of American patients don’t take important or life-saving medications because they can’t afford them. And some people take medications they can’t afford and experience bankruptcy at a rate unknown in other countries. For example, cancer patients in the United States are twice as likely as the general public to experience bankruptcy and a lot of that is due to the cost of cancer drugs.

By law, Medicare is not allowed to negotiate with drug companies to get the best price. And our prices are two to four times those in other countries. Interestingly, the VA is allowed to negotiate drug prices and their prices are half of those facing Medicare recipients.

Expanding Medicare to everyone would be a good way to ensure universal access to health care. In the meantime, allowing Medicare to negotiate prices with the drug companies would help lower the cost of medical care for people who are covered by Medicare already.

Dr. David Potter resides in Chico.

http://www.chicoer.com/letters/ci_26239762/letter-high-cost-medications-hurting-health-system

Medicare is worthy model to provide health care for all

By Jessica Schorr Saxe, M.D.
The Charlotte (N.C.) Observer, July 30, 2014

On July 30, 1965, President Lyndon Johnson signed Medicare into law, making 19 million Americans aged 65 and over eligible for health care coverage.

Given what you know about the federal government, how long do you think it took to implement?

Keep in mind that implementation involved identifying everyone over 65 for automatic enrollment in Medicare Part A (hospitalization) and identifying who would opt to enroll in (and pay for) Medicare Part B (office visits); enrolling the providers for Part A and the doctors and insurance companies for Part B; coordinating various government agencies; and developing policy.

Since there was no Internet, enrollment was accomplished by a quaint process using punch cards sent through the U.S. mail, supplemented by door-knocking.

Medicare was fully implemented on July 1, 1966 – 11 months after enactment – with 95 percent of eligible individuals signed up.

As we watch the cumbersome, protracted enactment of the Affordable Care Act, we should be aware that much of the problem is not the government, but the complications of dealing with insurance companies with their varying coverage, premiums, co-pays and networks, as well as their concerns about losing profits by paying for medical expenses.

While we laud the ACA for insuring the previously uninsured (and sometimes desperate), we should keep in mind those left behind: those still uninsured and often still desperate. As a doctor who sees low-income patients, I know many.

I recently saw a woman in her 40s who had had a stroke three months earlier. Her diabetes and blood pressure were seriously out of control. Because she had no insurance, she had not kept the primary care and neurology appointments made for her at her discharge from the hospital. She easily could have died waiting to seek medical care.

Another patient had suffered for years with a serious, yet treatable, skin condition. Why? After he lost his job, he lost his health insurance, and thus his dermatologist.

The public must look beyond the ACA to a system that will not leave so many locked out and suffering.

And when we do, we should start with Medicare as a framework, recognizing that:

  • Medicare operates more efficiently than private insurance, spending less than 2 percent on administration and overhead, whereas private insurance companies typically spend more than 12 percent, sometimes considerably more.
  • Participants in Medicare report greater health-care satisfaction than the privately insured.
  • Medicare costs have a slower rate of growth than costs under private insurance.
  • Medicare pays providers more quickly than private insurance.
  • Medicare has decreased poverty among the elderly.

And it achieves these successes while covering the aged and disabled – the sickest among us.

Is Medicare perfect? Hardly. But it is the best model the U.S. has, and it can be improved. Expanding Medicare to cover everyone – thus dispensing with the wasteful middleman, i.e. the insurance companies – would provide many benefits. It would save hundreds of billions of dollars a year in reduced administrative costs. It would have negotiating clout to rein in medical supply prices. It would give us the choice we want – not the choice of convoluted insurance plans, but the choice of doctors and hospitals.

And the issues agonizingly debated in Burwell v. Hobby Lobby of whether employers should have a say in the contraceptive decisions of their employees? Poof! The discussion would disappear because employers would no longer be involved in health insurance. That alone would save the nation from lawsuits and endless public debate.

Furthermore, letting employers out of the health care business would free them to spend their time on their own businesses and spare them worrying about whether their workforce can get needed health care. And it will make their businesses more competitive in the international marketplace.

We should celebrate the anniversary of Medicare’s enactment this year by moving toward improved and expanded Medicare for all, which will give us the access, quality, cost-control and choice that we deserve – and that our wealthy country can easily provide. Wouldn’t achieving that be cause to celebrate in its golden anniversary year of 2015?

Jessica Schorr Saxe is a family physician in Charlotte.

http://www.charlotteobserver.com/2014/07/30/5075944/medicare-is-worthy-model-to-provide.html#storylink=cpy

Happy birthday, Medicare

By Ed Weisbart, MD
St. Louis Post-Dispatch, July 30, 2014

Medicare is today entering its 50th year, and the need to expand it to all Americans has never been greater.

Private health insurers are putting more and more restrictions on which doctors and hospitals can take care of which patients. Premiums, co-pays, co-insurance and deductibles are rising, often sharply. And states like ours are picking and choosing which low-income people to save and which to let die.

We insist on clinging to the uniquely American model of private health insurance despite the fact that it costs us double what every other modern nation spends per person on care, that our life expectancy lags those nations’ by several years, and that it places each of us just one disease away from bankruptcy.

Why do we cling to it so feverishly?

Rabbi Susan Talve recently reminded me of a biblical story in which the slaves leaving Egypt tried 10 times to return home to slavery, to nearly nothing, instead of continuing on to the promised land. Why would they have done that?

Both answers are the same. No matter how rotten something may be, it’s human nature to resist giving it up for something new and tempting. Sometimes, that part of our nature does us great harm.

But here’s an important difference: Medicare is a nonprofit, social insurance program we have come to know very well. And as any senior or member of their family will tell you, they like it very much.

Medicare was enacted in 1965 because older Americans were dying needless, preventable deaths from not being able to afford health care. When they got sick, they would sell their homes and declare bankruptcy in a last-ditch effort for care. They were dying paupers after long lives of working hard toward the American dream.

Sound familiar? That’s exactly what’s happening today to Americans who have not yet reached Medicare age, despite the significant progress of the Affordable Care Act.

A 60-year-old husband and wife in Missouri with a combined household income of $62,200 today would pay a premium of $13,761 for a high-end Silver plan and still be faced with $12,700 out-of-pocket expenses, potentially consuming 42 percent of their household income on medical expenses.

And that doesn’t include anything more they might have to spend if they need to see a physician or go to a hospital that’s not in their plan’s network.

So despite the great news that millions more of us have insurance, medical bankruptcies will continue. More than 60 percent of those bankruptcies happen to people with insurance! We could end that problem if we improved Medicare and gave it to everyone.

Putting aside the fundamental issue of fairness, providing every American with improved Medicare is a wise investment for our nation.

Every one of the thousands of health insurance companies in this country uses legions of people who operate computer systems, analysts, sales people, and more, all dedicated to collecting premiums and minimizing payouts for claims — i.e. to fatten the company’s bottom line.

This paper-pushing and dollar-chasing affliction is everywhere. The average hospital in the U.S. employs more people in billing-associated jobs than it has hospital beds.

This level of bureaucratic waste diverts our nation’s resources and drives up the cost of doing business here. We would be wise to retrain those hardworking folks into positions that actually improve health.

Improving Medicare and providing it to all Americans would cost us less than what preserving our current system costs, and would give us powerful tools to control costs.

Today, Medicare’s 49th anniversary, let us stop clinging to the failed private insurance experiment and recommit ourselves to Medicare for All, the most fair and prudent solution.

Dr. Ed Weisbart is chairman for Physicians for a National Health Program-Missouri Chapter.

http://www.stltoday.com/news/opinion/columns/happy-birthday-medicare/article_db2d454f-d8b0-5e38-ae88-34b86565bc8c.html

Medicare’s success deserves celebration on its 49th birthday

By David Ball, RN, MHA
The Post and Courier (Charleston, SC), July 30, 2014 

Today is Medicare’s 49th anniversary, having become law in 1965 under President Lyndon B. Johnson. Before 1965, as many elderly became sick but too old to work, they simply became impoverished and died.

Despite its warts and room for improvement, Medicare remains more efficient than private health insurance. Its costs have risen more slowly, and yet it provides better access to care, better financial protection, and higher patient satisfaction.

In contrast to ideological disputes over the Affordable Care Act (Obamacare), Medicare offers 49 years of living proof that public, universal health coverage is superior to private insurance in every way.

Unlike the rollout of health care, government and state exchanges under the Affordable Care Act, Medicare was implemented smoothly and at low cost because the program is universal and didn’t juggle enrollment in hundreds of private insurance plans.

All industrialized nations, with the exception of the U.S. provide health care to their citizens. While we should take pride that seniors have wonderful health insurance in Medicare, we should be equally concerned that 40 million Americans under the age of 65 do not. This can be fixed without raising taxes.

The United States spends twice as much per capita as any other nation on health care. Despite the fact that we have the finest medical schools, research laboratories and hospitals in the world, they are of little value to patients who can’t pay for care.

With all we spend, we can afford to provide essential services to every American without imposing co-pays, deductions, caps or exclusions.

A bill in Congress, HR 676, would do just that. Titled the Improved Medicare for All Act, it would provide basic services, including preventative care, hospitalization, medications, mental health, and long-term care.

The Congressional Budget Office (CBO) determined it can be provided without raising taxes.

Universal health care would not only extend coverage to everyone below age 65, but it would improve coverage for seniors.

For example, Canada’s universal plan covers 79 percent of seniors’ costs compared with 51 percent covered by Medicare in the U.S.

Single payer also makes Medicare financially sustainable. Medicare would have saved $2 trillion if its costs had risen at Canadian rates since 1980.

While we can afford health care for all our citizens, we cannot afford the wasteful system we have today.

For-profit insurance companies suck a quarter of all health care premium dollars away from providing care and instead fuel a very healthy bottom line.

Medicare does what insurance companies do for a tenth of the cost.

If for-profit insurance companies disappeared tomorrow then those premium dollars could be put into our rural hospitals and clinics and not the pockets of insurance CEOs.

The way to improve Medicare is to drop the enrollment age from 65 to 0. Replace the paper pushing that for-profit insurance does at 71 percent efficiency with Medicare’s 98 percent efficiency.

Continue to deliver care privately – choose your own doctor and hospital, but fund it publicly – like police, fire departments and libraries.

http://www.postandcourier.com/article/20140730/PC1002/140739990/1025/