PNHP

UNITE HERE report on ACA and worsening inequality

UNITE HERE report on ACA and worsening inequality

The Irony of ObamaCare: Making Inequality Worse

UNITE HERE, March 7, 2014

The promise of Obamacare was the right one and the hope for extending healthcare coverage to the un- and under-insured a step in the right direction. Yet the unintended consequences will hit the average, hard-working American where it hurts: in the wallet. Currently a national dialogue is emerging by all political parties on the issue of income inequality. That is a debate worth having. The White House and Congressional Democrats are “resetting” the domestic agenda following the negative fallout from the rollout of the ACA. They plan to shift focus from health care to bread and butter issues of income inequality that have eroded the American paycheck for decades.

Ironically, the Administration’s own signature healthcare victory poses one of the most immediate challenges to redressing inequality. Yes, the Affordable Care Act will help many more Americans gain some health insurance coverage, a significant step forward for equality. At the same time, without smart fixes, the ACA threatens the middle class with higher premiums, loss of hours, and a shift to part-time work and less comprehensive coverage.

*  Transferring A Trillion Dollars in Wealth: Most of the ACA’s $965 billion in subsidies will go directly to commercial insurance companies, one of the largest transfers of public wealth to private hands ever. Since the ACA passed, the average stock price of the big for-profit health insurers doubled, their top executives were paid more than a half billion dollars in cash and stock options, and in the past 2 years, the top 10 insurers have spent $25 billion on mergers and acquisitions.

*  Strangling Fair Competition: Before reform, different types of health plans were regulated under different bodies of law. The Obama Administration has blocked many non-profit health funds from competing for the law’s proposed trillion dollars in subsidies by refusing to set fair regulations for different types of plans. The unbalanced playing field will give employers of people covered by these plans powerful incentives to drop coverage.

*  Moving to Part Time Work: The Administration’s experts say employers won’t follow the incentives and drop coverage. But they also told the nation that employers would not cut workers’ hours to get below the 30-hour per week threshold for “full time” work, even as 388 employers announced hours cuts since early 2012.

*  Cutting People’s Pay: If employers follow the incentives in the law, they will push families onto the exchanges to buy coverage. This will force low-wage service industry employees to spend $2.00, $3.00 or even $5.00 an hour of their pay to buy similar coverage.

Conclusion

For two years, labor unions and employer partners have patiently explained to the Obama Administration and Congress the potential damage that the ACA poses to these unique, successful non-profit health plans.

Having already made efforts to accommodate businesses, churches and congressional staff, it is ironic that the Administration is now highlighting issues of economic inequality without acting to preserve health plans that have been achieving the goals of the ACA for decades. Without a smart fix, the ACA will heighten the inequality that the Administration seeks to reduce.

We take seriously the promise that “if you like your health plan, you can keep it. Period.” UNITE HERE members like their health plans. UNITE HERE’s plans are ready to compete with the corporate giants of the health insurance industry if Washington will simply create a level playing field.

http://cdn.ralstonreports.com/system/assets/drupal/ObamaCaretoAFL_FINAL.pdf

UNITE HERE is a union of service workers in hotels and other industries. Many of their members are insured through non-profit Taft-Hartley plans with joint union-management governance structures. This report shows how the Affordable Care Act can have a negative impact on the health care coverage and hours of employment of union members, in effect making inequality worse.

Some of their legitimate complaints:

*  Employers are not required to make available health insurance to employees who work less than 30 hours per week. Although the Obama administration denies that this will cause employers to reduce the hours that many of their employees work, it is already happening. Obviously that reduces the employees’ net incomes and may disqualify them from receiving insurance coverage.

*  Employers do not have to provide any health coverage at all if they do not have more than 50 employees. Many employers are taking measures to stay below the 50 full-time employee threshold.

*  Employer penalties for not providing coverage are far smaller than the employer costs of their health benefit programs. It is likely that many employers will elect to pay the penalties rather than support a health plan. Yet it is unlikely that employers will increase wages enough to compensate for the lack of an employee health benefit program.

*  Most UNITE HERE union members have wages low enough to qualify for subsidies to help pay for plans obtained through the state or federal insurance exchanges. Yet those subsidies cannot be used for employees in the UNITE HERE Taft-Hartley plans. (They do indirectly receive the tax benefit of deductibility for employer-sponsored plans, but at their income levels, this benefit may be negligible.)

*  More expensive plans will be subject to a 40 percent excise tax. The UNITE HERE Taft-Hartley plans may be subject to this tax, not because the benefits are too generous, but rather because health care costs are so high and because many of the employees in the service industry union are older with greater health care costs. This excise tax is borne by the employee through higher premiums and forgone wage increases.

*  All plans, including Taft-Hartley plans, pay taxes that are used to ease the financial transition of private plans offered on the exchanges. Though the union members ultimately pay these taxes, they receive none of the benefits since Taft-Hartley plans do not qualify for transitional financial support.

*  Self-funded plans, such as these Taft-Hartley plans, are prohibited from being offered to the public and thus cannot benefit from market competition as the exchange plans can.

*  ACA generously subsidizes private health plans with some of those funds going to overpaid executives and wealthy shareholders, thereby contributing to worsening inequality.

Although UNITE HERE calls for Congress and the president to level the playing field through legislation and rule making, a far better solution would be to establish a single payer national health program.

Under an improved Medicare for all, UNITE HERE union members would receive more generous benefits, with first dollar coverage, and with a net cost to them in taxes that would be significantly less than what they are currently paying in premiums and forgone wages. A single payer system would be more effective in reducing inequality than would tweaking the Taft-Hartley plans.

Maine Medical Association survey shows 64 percent support single payer

Membership survey shows strong support for a Medicare for All, single-payer approach to reform

By the editors
Maine Medicine Weekly Update, March 10, 2014

A recent survey of Maine Medical Association (MMA) members showed an increase in the percentage of members supporting a single-payer approach to health system reform. The survey, completed by more than 450 respondents, included the following question:

“When considering the topic of health care reform, would you prefer to make improvements to the current public/private system or a single-payer system such as a ‘Medicare for all’ approach?”

Sixty-four and three-tenths percent (64.3%) of respondents indicated that they preferred the single-payer option compared to the alternative “Improvements to the current public/private system,” which garnered support from 35.7% of those respondents who answered the question. The nearly two-thirds who indicated the single-payer preference represents an increase from the previous membership survey in 2008, in which just over half (52.3%) indicated preference for the single-payer option while 47.7% preferred improvements to the current system.

The question presented was worded precisely the same in each of the surveys.

In the recent survey, conducted in January, there was little to no difference in response to the question based upon age, geographic location, or MMA membership status. There was, however, a significant difference based upon specialty, with primary care physicians and psychiatrists tending to more heavily favor the single-payer option than physicians in other medical specialties. Respondents from practices that were owned by the physicians themselves were less likely to prefer the single-payer option and more likely to prefer improving the current system.  

The survey had a total of 462 respondents of whom 85% were physicians and 15% were medical students. 87% of the respondents were MMA members. The respondents make up approximately 13% of MMA members. The survey was conducted by Crescendo Consulting Group in Portland on behalf of MMA as part of the Payment Reform grant awarded by the Maine Health Access Foundation. The survey was also requested by a group of members who presented a Resolution at the 2013 Annual Meeting asking for the survey to be updated from 2008.

More details of the survey will be placed on the Association’s website at www.mainemed.com by the end of this week.

While the survey demonstrates strong support for a single-payer system by those members who responded to the survey, MMA’s formal policy position on health system reform, developed originally in 2003 and updated in 2010, is in support of universal coverage for all Mainers to be achieved through a combination of public and private health plans.

Physicians For A National Health Program Have Organizational Meeting

The Chattanoogan, March 7, 2014

An organizational meeting for a new Southeast Tennessee chapter of Physicians for a National Health Program was held Thursday evening at Foodworks.  

Founded in 1987, PNHP believes that access to high-quality health care is a right of all people and should be provided equitably as a public service rather than bought and sold as a commodity. It advocates for a universal, comprehensive single-payer national health program and has more than 19,000 members and chapters across the U.S.

Attendees included a physician-in-training, medical educators, and practicing and senior physicians. They discussed organizational matters, future meetings and the development of a speaker’s bureau for local presentations.  

More information about PNHP, including resources supporting the need for a national health program, can be obtained at www.pnhp.org.  For local information, contact Dr. Laura Helfman at riverdoc@blomand.net.

http://www.chattanoogan.com/2014/3/7/271307/Physicians-For-A-National-Health.aspx

ACA won’t control health care costs

By Henry J. Waters III
Columbia (Mo.) Daily Tribune, March 8, 2014

Recently a group of physicians sponsored a visit by a University of Massachusetts professor of economics who goes about the country touting the advantages of single-payer health care, using numbers as his forte. Gerald Friedman appeared at the University of Missouri School of Medicine at the behest of the Missouri chapter of the Physicians for a National Health Program.

His thesis: the Affordable Care Act, otherwise known as Obamacare, does a lot of good things but does not control costs. The answer is a single-payer system in which the government acts as insurer.

I have made the same argument here based on the obvious premise health insurance can operate most efficiently and inexpensively only if the risk pool includes the entire population. We are seeing problems inherent in the hybrid ACA approach. For political reasons, elements of the old system are being preserved while tomorrow’s fix is held at bay.

We know the better model. Often referred to as Medicare for all, the best new system will operate like the familiar and popular Medicare system, expanded to include people of all ages and means.

Models in other nations show continuing roles for private insurance companies but not as designers of universal coverage. Indeed, universal coverage is contrary to the economic principles of private health insurance, which profits by maximizing revenue and minimizing costs. The role of government in a national health system is the opposite, resulting in more effective care at lower overall cost, which Friedman regards as a hugely important economic boon.

In years past, physicians and other health care providers have not wanted to lose the fee-for-service system, but growing numbers now look forward to a more rational system. They are tired of private insurance hassles and recognize fee-for-service to put profit over best-care practices. Of course, they should be well compensated, but with a nationally managed system, providers can be incentivized to emphasize wellness and health outcomes rather than proliferation of services and procedures.

As Friedman points out, the substantial money saved in a single-payer system can go back into the economy. Health care costs can be reduced by billions. He cited numerous examples of lower costs and superior health outcomes in other countries.

“Get the profit out of health care, and everybody wins,” he says.

Well, not everybody. Sellers of insurance, drugs and other health care products and services have profited through the years with the disappearing system. You can’t blame them for working the territory and wanting the status quo to last, but by now evidence is clear the United States should join the other developed countries of the world with a better system. Examples are everywhere, including in our own country.

Let’s call it Medicare if we don’t like “single-payer,” but let’s get on with it.

Henry J. Waters III is editor at the Columbia Daily Tribune.

http://www.columbiatribune.com/opinion/the_tribunes_view/aca/article_d1a23bf0-a679-11e3-8c21-10604b9f6eda.html?comments=focus

Lawmaker who supports private health insurance should look into single-payer system

By Bob Balhiser
The Missoulian (Mont.), Letters, March 9, 2014

I was amused to read Joe Balyeat’s (March 3) guest column explaining why Obamacare is doomed to fail. He attempts to make his point by extolling the virtues of private health insurers who, as I see it, are largely responsible for the fact that Americans pay the highest costs for health care of any developed country in the world.

The fact is that we in the U.S. pay about 18 percent of our Gross Domestic Product for health-related costs, while all other advanced countries pay an average of 11 percent GDP. Put another way, that 7 percent difference in GDP in our economy amounts to nearly $1 trillion in annual costs that go to parasites in our health care system. Two of the most egregious of these parasites are the private health insurers that Balyeat defends, and big pharmaceutical companies; trial lawyers also push up system expenses by forcing doctors to practice costly defensive medicine.

Few developed countries are saddled with private health insurers, but those that are have tightly controlled and regulated systems that force insurers to compete aggressively with one another for customers. Many other developed countries have some variation of “single payer” systems that would be a lot like having Medicare For All. Americans could save about $ 1 trillion ($1,000,000,000,000) annually in health care costs with Medicare For All.

I’d like to see Balyeat consider these facts and explain why a “single payer” system would not be far better and more economical than one that relies on the private health insurers he seems to so admire.

Bob Balhiser resides in Helena.

When Health Costs Harm Your Credit

By Elisabeth Rosenthal
The New York Times, March 8, 2014

Like most people, I am generally vigilant about paying my bills — credit cards, mortgage, cellphone and so on. But medical bills have a different trajectory. I (usually) open the envelopes and peruse the amalgam of codes and charges. I sigh or swear. And set them aside for when I have time to clarify the confusion: An out-of-network charge from a doctor I know is in-network? An un-itemized laboratory bill from a doctor I’ve never heard of? A bill for a huge charge before my insurer has paid its yet unknown portion of a hospital’s unknowable fee?

I would never countenance the phrase “60 days past due” on my Visa card statement. But medical bills? Well… with the complex negotiations that determine my ultimate payment, it often takes months to understand what I actually owe.

Unfortunately, I may be playing a dangerous game. Mounting evidence shows that chaos in medical billing is not just affecting our health care but dinging the financial reputation of many Americans: While the bills themselves frequently take months to sort out, medical debts can be reported rapidly to credit agencies, and often without notification. And even small unpaid bills can severely damage credit ratings.

A mortgage initiator in Texas, Rodney Anderson of Supreme Lending, recently looked at the credit records of 5,000 applicants and found that 40 percent had medical debt in collection, with the average around $400; even worse, most applicants were unaware of their debt. Richard Cordray, director of the federal Consumer Financial Protection Bureau, has noted that half of all accounts reported by collection agencies now come from medical bills, and the credit record of one in five Americans is affected.

A single medical bill reported to a credit agency can easily become a “millstone around your neck” said Mark Rukavina, principal at Community Health Advisors, a health care advisory service. He added: “It will take a long time to make that right, even once the bill is paid. I’ve had mortgage brokers call me and say ‘I have these people with great credit. They’ve refinanced before, but now they’ve got this medical bill and even though they’ve paid it off, I can’t get them a good rate.’ ”

Part of the problem is that there are few standards governing medical debts: One billing office might give you — or your insurer — 60 days to pay before pursuing collection. Another might allow you to pay off a bill slowly over a year. Many will sell the debt to collection companies, which typically take a cut of the proceeds and decide when or whether to report unpaid debt to credit agencies.

The problem is accelerating for several reasons. Charges are rising. Insurance policies are requiring more patient outlays in the form of higher deductibles and co-payments. More important, perhaps, is that while doctors’ practices traditionally worked out deals for patients who had trouble paying, today many doctors work for large professionally managed groups and hospital systems whose bills are generated far away, by computer.

Both Congress and the protection bureau have been trying to better insulate patient credit scores from the inefficiencies of our market-based medical system. Various proposals have been considered to differentiate medical debt from other forms; it could be erased once it has been paid off or not reported to credit agencies at all, for example. So far, the credit industry has fought successfully against such efforts, noting that they could allow some genuine scofflaws to evade legitimate charges. But it’s also good business, since health care bills are now the largest source of business for collection companies, according to consumer protection agency officials.

Having spent the last year reporting a series on American health costs, I’ve heard plenty about credit casualties.

Gene Cavallo, 61, a New Mexico businessman who put his children through college, had always paid his bills promptly and had an excellent credit rating, until he required surgical excision of a melanoma on his shin two years ago. The more than 60 bills generated for the surgery and six months of follow-up visits — arriving sporadically and ranging from 18 cents to $17,000 — came to $110,000; his insurance covered about $70,000.

When various providers asked him to pay the remaining $40,000, he requested itemized bills and balked at some of the “ridiculously inflated prices,” such as $85 for tweezers and $20 for a box of tissues. He argued the bills point by point, and ultimately agreed to pay $25,000.

But during the negotiations some of the debt was sent to collection. Two years later, he no longer answers the daily robocalls from collection agencies and has had a couple of credit cards canceled because his score has fallen. “It was a scary thing to do because I own a business and dabble in real estate, so the ability to borrow has always been important to me. And now I have no ability, I assume, to borrow for any reason.”

Michael S., who declined to give his full name so as to protect his reputation with business clients, had to declare bankruptcy in Wisconsin more than five years ago after a fraught year in which his toddler was evaluated for what proved to be a benign neurological condition that required no treatment: “You’d get bills for several different doctors’ groups and for tests and M.R.I.s and you don’t know what they are. I was having trouble figuring out who we owed what. And then, if it goes to collection, then suddenly they’re saying we need this paid now.”

With medical expenses, unlike most other purchases, you generally don’t know the price the hospital will charge in advance. And the subsequent bills and insurance statements — so-called explanations of benefits — are often layered in obfuscation and pressure tactics.

Consider Chris Sullivan of Pennsylvania, whose $2,770 bill for an echocardiogram offered a “prompt payment” discount of 20 percent if he wrote a check within 21 days — meaning a discount for not asking questions on a bill for a test he was told would be under $300.

Another “explanation of benefits” statement notified Joe Cotugno of New York City that his two-day hospital stay for a hip replacement was billed at $99,469.70 (doctors’ fees not included). Cigna paid $68,420.53 after knocking off some $28,000 and requiring Mr. Cotugno to pay $3,018.41. So, it informed him, “You saved 96 percent.” Huh?

The Consumer Financial Protection Bureau has been studying the impact of medical billing on credit scores since 2012, acknowledging that unpaid medical bills in collection “frequently end up on consumer credit reports,” as an outgrowth of “very complex and confusing systems of figuring out who owes what after a medical procedure.” Mr. Cordray, the bureau’s director, said it would take appropriate action if harmful practices were identified.

Bills in Congress that would regulate the practices have been stalled for years. The Medical Debt Relief Act was passed by the House in 2010, but never made it to a Senate vote. After a modified version of the bill failed to pass again last year, another act was recently introduced in the Senate and House.

Meanwhile, patients are right to worry. When Matt Meyer, who owns a saddle-fitting company in New Hampshire, set up a monthly payment plan after some surgery, he was distressed to notice that the invoices came from a debt collector. “I had no idea this was considered debt,” he said, and wondered: “Are they reporting that” to a credit agency?

Good question.

Elisabeth Rosenthal is a reporter for The New York Times who is writing a series about the cost of health care, “Paying Till It Hurts.”

Medical bills and credit reports

When Health Costs Harm Your Credit

By Elisabeth Rosenthal
The New York Times, March 8, 2014

Mounting evidence shows that chaos in medical billing is not just affecting our health care but dinging the financial reputation of many Americans: While the bills themselves frequently take months to sort out, medical debts can be reported rapidly to credit agencies, and often without notification. And even small unpaid bills can severely damage credit ratings.

A mortgage initiator in Texas, Rodney Anderson of Supreme Lending, recently looked at the credit records of 5,000 applicants and found that 40 percent had medical debt in collection, with the average around $400; even worse, most applicants were unaware of their debt. Richard Cordray, director of the federal Consumer Financial Protection Bureau, has noted that half of all accounts reported by collection agencies now come from medical bills, and the credit record of one in five Americans is affected.

The problem is accelerating for several reasons. Charges are rising. Insurance policies are requiring more patient outlays in the form of higher deductibles and co-payments. More important, perhaps, is that while doctors’ practices traditionally worked out deals for patients who had trouble paying, today many doctors work for large professionally managed groups and hospital systems whose bills are generated far away, by computer.

Comment:

By Don McCanne

Our fragmented, dysfunctional system of paying medical bills is having a major impact on personal credit ratings. Half of all accounts reported by collection agencies now come from medical bills. The credit record of one-fifth of Americans is affected, and many of us are unaware of it. Are people so broke that they can’t pay their medical bills, or is something else going on here?

There are two major factors at play here. One is that with flat wages and increasing household costs, many people do have problems paying all of their essential bills, and medical bills are moved to the bottom of the stack. When payment of medical bills is postponed, or perhaps not paid at all, they are commonly sent to collection agencies, eventually appearing on the debtor’s credit report. Now that high deductibles are being used more to shift costs from payers (employers or government) to patients, this phenomenon is much more common.

The other factor is how people with good incomes who are meticulous with management of their personal finances end up with dinged credit reports because of medical bills. It is often due to the administrative complexity of the system we have of paying medical bills through private insurers who make payments based on whether the providers are in or out of network, on whether or not the products or services being billed are even covered by the plans, and on how much the deductible and coinsurance are and what charges can be credited against the deductible.

Typically the individual receives an explanation of benefits which is difficult to decipher often because some of these questions still remain unanswered. Billings may start to come in from various health care providers but without adequate explanation. When the patient inquires as to why the amount was not applied to the deductible, or why the amount seems to be for out-of-network providers when this provider is in-network, or for whatever  reason, the patient is often given a temporizing response. When more statements are received that failed to address concerns such as the deductible, further efforts to correct the problem are often met with reassurance. When nothing further is heard, the patient assumes the matter was cleared up. Only later when a collection agency begins to harass them or when they find their credit report includes unpaid medical bills do they discover that the matter never was resolved.

Add in further complexities such as when a person has primary coverage perhaps through Medicare and secondary coverage through a Medigap plan, or a person had a change in coverage coinciding with the medical services provided, straightening out who is responsible for which portions of the charges can be a monumental task.

These highly responsible individuals with previously excellent credit records are understandably angry. They tend to look elsewhere for blame – the physician’s office or billing service, the hospital’s billing department, the insurer’s claim processors, the credit agency’s disregard of registered protests, or perhaps the employer who provided such a screwed up health plan.

Single payer advocates know where most of the blame really lies. It is with our political leaders who insist on perpetuating this highly inefficient, fragmented system of financing health care instead of enacting a single payer national health program. This botched up system of medical billing is only one manifestation of the profound administrative excesses that permeate our system. Ironically, all of this extra administrative detail in handling medical billings doesn’t even work well. You would think that if we are going to be paying much more in administrative costs so that the insurers could do a “better” job than a single government payer in handling our claims, we would be demanding much better performance from them. But no, keep the government out and blame everyone else.

In typical D.C. fashion, our legislators continue to look for solutions that would increase regulatory oversight to prevent unfair damage to the credit ratings of conscientious individuals, though the legislators are receiving expected push back from the credit industry. What we do not need is more administrative oversight piled on top of an administrative boondoggle. Instead we need to replace it with an efficient improved Medicare, with first dollar coverage, that covers everyone. Credit scores dinged by medical bills then would become a quaint historical oddity.

Medical bills and credit reports

When Health Costs Harm Your Credit

By Elisabeth Rosenthal
The New York Times, March 8, 2014

Mounting evidence shows that chaos in medical billing is not just affecting our health care but dinging the financial reputation of many Americans: While the bills themselves frequently take months to sort out, medical debts can be reported rapidly to credit agencies, and often without notification. And even small unpaid bills can severely damage credit ratings.

A mortgage initiator in Texas, Rodney Anderson of Supreme Lending, recently looked at the credit records of 5,000 applicants and found that 40 percent had medical debt in collection, with the average around $400; even worse, most applicants were unaware of their debt. Richard Cordray, director of the federal Consumer Financial Protection Bureau, has noted that half of all accounts reported by collection agencies now come from medical bills, and the credit record of one in five Americans is affected.

The problem is accelerating for several reasons. Charges are rising. Insurance policies are requiring more patient outlays in the form of higher deductibles and co-payments. More important, perhaps, is that while doctors’ practices traditionally worked out deals for patients who had trouble paying, today many doctors work for large professionally managed groups and hospital systems whose bills are generated far away, by computer.

http://www.nytimes.com/2014/03/09/sunday-review/when-health-costs-harm-y…

Our fragmented, dysfunctional system of paying medical bills is having a major impact on personal credit ratings. Half of all accounts reported by collection agencies now come from medical bills. The credit record of one-fifth of Americans is affected, and many of us are unaware of it. Are people so broke that they can’t pay their medical bills, or is something else going on here?

There are two major factors at play here. One is that with flat wages and increasing household costs, many people do have problems paying all of their essential bills, and medical bills are moved to the bottom of the stack. When payment of medical bills is postponed, or perhaps not paid at all, they are commonly sent to collection agencies, eventually appearing on the debtor’s credit report. Now that high deductibles are being used more to shift costs from payers (employers or government) to patients, this phenomenon is much more common.

The other factor is how people with good incomes who are meticulous with management of their personal finances end up with dinged credit reports because of medical bills. It is often due to the administrative complexity of the system we have of paying medical bills through private insurers who make payments based on whether the providers are in or out of network, on whether or not the products or services being billed are even covered by the plans, and on how much the deductible and coinsurance are and what charges can be credited against the deductible.

Typically the individual receives an explanation of benefits which is difficult to decipher often because some of these questions still remain unanswered. Billings may start to come in from various health care providers but without adequate explanation. When the patient inquires as to why the amount was not applied to the deductible, or why the amount seems to be for out-of-network providers when this provider is in-network, or for whatever  reason, the patient is often given a temporizing response. When more statements are received that failed to address concerns such as the deductible, further efforts to correct the problem are often met with reassurance. When nothing further is heard, the patient assumes the matter was cleared up. Only later when a collection agency begins to harass them or when they find their credit report includes unpaid medical bills do they discover that the matter never was resolved.

Add in further complexities such as when a person has primary coverage perhaps through Medicare and secondary coverage through a Medigap plan, or a person had a change in coverage coinciding with the medical services provided, straightening out who is responsible for which portions of the charges can be a monumental task.

These highly responsible individuals with previously excellent credit records are understandably angry. They tend to look elsewhere for blame – the physician’s office or billing service, the hospital’s billing department, the insurer’s claim processors, the credit agency’s disregard of registered protests, or perhaps the employer who provided such a screwed up health plan.

Single payer advocates know where most of the blame really lies. It is with our political leaders who insist on perpetuating this highly inefficient, fragmented system of financing health care instead of enacting a single payer national health program. This botched up system of medical billing is only one manifestation of the profound administrative excesses that permeate our system. Ironically, all of this extra administrative detail in handling medical billings doesn’t even work well. You would think that if we are going to be paying much more in administrative costs so that the insurers could do a “better” job than a single government payer in handling our claims, we would be demanding much better performance from them. But no, keep the government out and blame everyone else.

In typical D.C. fashion, our legislators continue to look for solutions that would increase regulatory oversight to prevent unfair damage to the credit ratings of conscientious individuals, though the legislators are receiving expected push back from the credit industry. What we do not need is more administrative oversight piled on top of an administrative boondoggle. Instead we need to replace it with an efficient improved Medicare, with first dollar coverage, that covers everyone. Credit scores dinged by medical bills then would become a quaint historical oddity.

Facing death – and hope

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, March 7, 2014

A man in his 90s became very ill and was brought to the hospital by ambulance. The emergency room physician called and asked me to admit the patient to the intensive care unit. I was upstairs in the hospital.

I briefly studied the electronic record before heading downstairs. I learned that the man suffered from dementia, advanced to the point that his primary care physician was unable to have any meaningful dialogue with him for several years. I also saw data to convince me that this man was critically ill.

In the emergency room the physician reviewed with me the things that he and the nurses had initiated but added that in the bigger picture that he thought the patient was dying. He mentioned that he had asked about “do not resuscitate status” but that the patient’s wife didn’t have an answer. She “wanted everything done.” He had explained the need for intensive care and called me.

As I evaluated the patient I found a man poorly responsive and generally very ill. He had cachexia, which means wasted muscles and body mass, in other words he was beginning to look like a skeleton. His mental status and vital signs suggested that critical care measures already initiated were appropriate. Given the patients advanced age and profound frailty, the emergency room physician was probably right, I thought, this patient appeared to be dying.

“I am so sorry to say this,” I told the patient’s wife. “When he couldn’t eat over the last few days, it was a sign that he was starting the very last chapter of his life.” As gently as I could, that death might be imminent, no matter what treatment we offered.

There was a pause.

“I like that other doctor better.”

The patient’s wife was referring to the emergency room doctor who had assured her that we would do “everything.” She was not ready to face her husband’s end, nor to hear the event spoken about.

I sat with her for a quiet moment. After years of supporting him in their own home, she would now be relegated to his bedside, watching the hospital staff perform his care. I listened to her recount the details of their usual day and wondered how I could best help her. Compared with their usual routine, the strangeness and stress of the experience seemed enormous.

As a hospital medicine physician and also a hospice and palliative medicine physician, I have experienced many moments like these. These silences illuminate our social acquaintance with – or perhaps our everyday distance from – the experience of illness and death and how our system fails its patients.

Three weeks ago we had a death in our own family. My father-in-law had suffered three cancers, the last one incurable, and he was fading away over his last months. In the end, when he collapsed, the ambulance was called and he too went to the intensive care unit for the last day of his life. My colleagues asked if his death was expected. It was, I suppose, but when it came, the social dislocation and stress were profound.

When it comes to serious illness, the infirmities that come with age, and the process of dying, our health system is unnecessarily inhumane. Over the recent decade, of those who die in the United States, the percentage who receive care in the ICU during the last year of life has risen from about 1 of every 5 to nearly 1 of every 3.

Facing a loved one’s death is overwhelming. Since the chances are very good that all of us will face death, it seems obvious we should be devoting our resources to building a system based upon caring for patients with the kind of dignity they deserve.

But to do so would take a profound change in direction for the whole nation. Instead we have health policy dominated by the financial interests of so many corporations, insurance companies, the pharmaceutical industry, profits from devices and all kinds of schemes to extract resources from caregiving.

The contradiction remains that with so many capable caregivers, such advanced medical science and technology and so much of our national budget at the ready, we could do so much better. And in that contradiction lies the hope.

Dr. Andrew Coates practices internal medicine in Upstate New York. He is president of Physicians for a National Health Program.

An audio recording of Dr. Coates’ remarks is available here.

You can find an archive of Dr. Coates’ broadcasts here: http://wamc.org/term/andrew-coates

Maryland should move toward single-payer

By Ron Meservey
The Baltimore Sun, Letters, March 6, 2014

The article, “Officials mull next steps for state exchange” (March 2) omitted the possibility of Maryland seeking help from the one state that is on a sensible path to a workable, universal health care system — Vermont.

The U.S. is the only developed country in the world that lacks universal health care. As a result, despite spending more per capita on health care than any other nation on Earth, we still have some 50 million Americans without health insurance, of whom some 50,000 die needlessly every year because they cannot afford the health care they need and medical debt is the leading cause of personal bankruptcy.

In terms of life expectancy and other quantifiable measures of public health, as a nation we rank somewhere between 35th and 40th in the world. Vermont is on course to set up a single-payer, publicly financed and privately delivered health care system similar to Canada’s Medicare that will cover everyone in the state with the same high standard of care and eliminate the useless, wasteful private insurance companies altogether.

A recent economic impact study found that such a system in Maryland could cover all Marylanders as the Affordable Care Act or “Obamacare” will not even when fully implemented. And it will do so at far less cost than either the ACA or our present non-system.

Ron Meservey resides in Columbia.

http://articles.baltimoresun.com/2014-03-06/news/bs-ed-exchange-letter-20140306_1_state-exchange-health-care-single-payer

Worse Than the Mob: The Insurance Industry Is Organized Crime

By William Rivers Pitt
Truthout, March 6, 2014

We got accountants playin’ God
and countin’ out the pills
Yeah, I know, that sucks – that your HMO
Ain’t doin’ what you thought it would do
But everybody’s gotta die sometime…

– Steve Earle

Nothing so thoroughly dominated the American political landscape over the last year more than the Republican assault on the Affordable Care Act, colloquially known now as “Obamacare.” The GOP’s eternal refrain that “Government is the problem” was used as a battering ram against the law, and House Republicans have voted to repeal or denude it exactly fifty times as of today. Ted Cruz and his cohort of wreckers shut down the government over it, and the Tea Party base broke out their Sharpies to make gloriously stupid protest signs that read “Government Keep Your Hands Off My Medicare.”

Amusing as all this was, the dark underbelly of it all is dangerously wrong. Yes, the ACA exchange website rollout was a train wreck, and yes, a small segment of the population has had problems with the new law. This is not in dispute. Websites can be fixed, however, and problems can be solved. None of this holds a candle to the awesome misery and financial pain inflicted upon the populace by the holy and sainted world of private business, known in this instance as the insurance industry.

My own saga with these broad-daylight thieves began in late summer, when I moved my family to New Hampshire. We were living in Boston before the move, and had health insurance through my wife’s employer. My wife has Multiple Sclerosis, and one of the big reasons we felt comfortable about moving was that, if she changed jobs after the move, she could not be denied health insurance due to her pre-existing condition, thanks to the ACA.

We made the move, and my wife’s employer transferred her to their location in Concord, more than an hour’s drive away from our new home. She worked full-time to keep the health insurance, but after three months of ten-hour days combined with almost three hours on the road getting to and from work, it became clear that the situation was untenable. She was exhausted all the time – fatigue is the #1 danger zone for people with MS; it leaves you wide open for an attack – and worse, she felt like she was missing out on raising our daughter because she was gone more than thirteen hours a day.

On top of that, winter was coming, and the last thing she wanted to deal with was driving one-lane roads at night in a snowstorm, which would have happened more than a dozen times given the severity of this winter. After careful consideration, she asked her employer to transfer her to a location only 20 minutes away from home. The price of that transfer: going from full-time to part-time, and losing our insurance.

We looked into the insurance available through my employer, but came to the conclusion – based on the information provided on the Healthcare.gov website – that going through the exchange was our best option. So we went to the website, and shopped for new insurance. The website was klunky, to be sure, but when I reached a point where it didn’t seem to be making sense any more, I called the 800-number provided and spent a couple of hours talking to a tremendously nice woman with a near-parody Wisconsin accent – “Ooh yah, dearie me” – who was amazingly helpful, and got me the rest of the way through the process. Given the fact of my wife’s MS, our process was particularly complicated, and this person did everything necessary to make sure we were taken care of.

That’s when my dealings with the government ended, and my dealings with the insurance industry began, and it has been downhill at speed ever since.

There is exactly one insurance company in New Hampshire peddling plans through the ACA: Anthem BlueCross BlueShield. After completing the enrollment process through the exchange, the next step was to deal directly with Anthem, which quickly came to be about as fruitful as trying to batter down a brick wall with my daughter’s teething ring. First it was two weeks of phone calls, involving serial hours listening to on-hold music that could easily have come straight out of a bad porn movie soundtrack, just to establish that Anthem actually recognized Multiple Sclerosis as a real disease. Then it was another week of porn-flick hold-music to get a straight answer on the location and availability of MS doctors that were “in the network,” and thus covered.

Every phone call yielded a different set of answers, a different phone number to call, which invariably led nowhere. The calls that finally yielded answers and useful information felt like luck-of-the-draw; we either got someone on the line who actually felt like working that day, or were simply fortunate that the person we spoke to actually picked the correct answer off their sheet of go-away pat responses. In the end, all of this took so long that we wound up shelling out nearly a thousand dollars to get COBRA coverage from my wife’s employer, just to make sure we had something over our heads. Finally, after almost a month of nonsense, we managed to get everything squared away, I cut Anthem a check, and we received insurance cards in the mail.

All was quiet for a while, until the beginning of last week, when my wife’s MS medication began to run low. Previously, and with no hassles, the process to acquire a refill for her prescription was to call the company that makes her medicine about a week before it ran out, place an order for a refill, and it would be delivered two days later. When we called the drug company at the beginning of last week, however, we hit a great big pothole: they could not do the refill until our new insurance company approved it.

My wife contacted Anthem a month ago to clear the way for this approval process. They required a statement from her neurologist in order for the prescription to be approved. That statement was acquired, and sent to Anthem, a month ago. According to every conversation we had with Anthem this week, however, the statement from her neurologist did not exist, and the process had to begin again from scratch.

And so it was phone calls to Anthem, and more phone calls, and hold music – between the two of us, my wife and I have logged enough hours on hold to fly to Neptune and back – and one answer with one phone call once we finally got someone on the line, another answer with another phone call once we finally got someone on the line, and all the while my wife’s stock of MS medicine dwindled, and dwindled, and dwindled.

Last Wednesday, fearing the worst, my wife began rationing her medicine: one dose a day instead of two. We made this very clear to the people at Anthem – I HAVE MS AND AM ALMOST OUT OF MEDICINE – but still, it was “Call this number” that went nowhere, “Call that number” that went nowhere, one answer, and then another, no two ever the same, the awful infinity of hold music, and then oops, we accidentally inverted the numbers on your prescription, we have to start over again, we will call you back, and then silence, and silence, and silence.

For those not in the know, Multiple Sclerosis is an auto-immune disease that causes the body’s own immune system to attack the brain. Think of the neurons in your brain as if they were stereo cables: copper wiring encased in a rubber sheath. With MS, the immune system chews through that rubber sheath and attacks the wiring, destroying it. The damage done is irreversible, and in the worst case can cause paralysis, blindness, weakness, loss of motor function in arms and legs, an inability to swallow, and permanent disabling pain. It is a filthy, wretched disease that does not even have the common decency to kill you after it is done torturing you; it leaves that to the other diseases that come galloping through the door after your body has been destroyed. The only thing keeping the beast at bay is my wife’s medication. When she has it, she is fine and strong, able to work and hold her child, able to live a normal life. When she does not have it, she is hedging Hell.

This was the cocked pistol at my wife’s head as we tried and failed all week to get Anthem to approve her prescription refill.

By Friday morning, we were frantic; she had one dose left, her MS symptoms were escalating rapidly because she had been rationing her medication for days, and if we didn’t get it done today, there could be no Saturday delivery of the medication, and we would be stuck with no medicine until after the weekend, and likely into the middle of the next week, if not beyond. Repeated calls to Anthem resulted in the same lather-rinse-repeat runaround, so in extremis, we reached out to her neurologist in Boston to see if he could help.

My wife’s neurologist is one of the best MS specialists in the city of Boston, which makes him one of the best MS specialists on the planet. He was appalled and astonished by what we had been dealing with, and took it upon himself to deal with Anthem himself…and after five hours on the phone with them, getting one different answer after another, he was finally told that approval for my wife’s medication had to be put before a review board, and would take at least 72 hours, and it wouldn’t happen until Monday at the earliest. In all the phone calls we’d made to Anthem regarding this prescription, not one person had told us about a review board. One of the best neurologists in practice was forced to surrender.

As a last-ditch Hail-Mary option, my wife’s neurologist told us to call the drug company directly; in extreme circumstances like ours, a lot of pharmaceutical companies will provide enough medication at no cost to serve as a bridge until a prescription is approved…but by then, it was after 5:00 p.m. on Friday, and when we called the company, we discovered they were closed for the weekend. It was over. My wife took no medicine on Saturday, and took her last remaining dose on Sunday night. She has not been on her medication since.

On Monday morning, a phone call to the drug company yielded immediate results: a month’s worth of medication was coming, and should arrive soon. Still, when my wife goes for her annual MRI, I expect to see a new brain lesion on the print-out of the scan, caused by this gap in her course of medication. We will name it “Anthem,” in honor of all the people who worked so diligently to make sure she could not get her medicine.

As of this writing on Wednesday night, we still have heard no word from Anthem as to the status of their suddenly-revealed approval process for my wife’s medication.

I believe down to my bones that what we have endured at the hands of these cretins has been entirely deliberate. No amount of incompetence or laziness can account for the appalling lack of response, the runaround, and the sudden appearance of this “approval process,” we have gotten from Anthem. They do not want to co-pay for my wife’s medication or for her disease in general, and are doing everything they can to avoid it. Period, end of file.

If you think this is a unique situation, a one-off that does not represent the general experience people have with the insurance industry, think again. I made mention of our situation on social media, and the testimonials I received in response were both astonishing and harrowing:

S.L.: As someone who worked for a big, local health insurance company, I can tell you that this sort of thing happens a LOT. And it’s one of the reasons I didn’t last too long, at that job. I felt like the biggest piece of poo, for having to follow “company guidelines” that royally screwed people over. I’d rather scrub toilets than to ever work in the health insurance field again.

J.R.: I have rheumatoid arthritis and have had nothing but hassles with BCBS denying coverage for blood work and medicines. In fact, I was on the Arkansas Risk Pool because I have a “pre-existing condition” and no other health insurance company would take me. But now that very same Risk Pool is not going to pay my office visits and labs from last year because…(wait for it) I have a pre-existing condition! Fuck all of them. I am sick of being punished for my chronic condition.

R.M.: As a mental health professional I’m convinced insurance companies will do ANYTHING to delay or avoid payment. Michael Moore understood that years back, providers bang heads against walls and get scared shitless we’ll be caught up in the outcomes of reckless disregard for what patients desperately need, and it’s the love of profit, pure and simple. The history of “insurance” in its many forms is book-worthy, from the black and poor families who used to save every penny for when the insurance man came around, often just so they’d get buried without ruining their families, to the people who literally sit and go over dental x-rays and challenge whether you really need that more expensive treatment when they’ve never laid eyes on you, to the many people who have been in your wife’s situation.

T.R.: Similar thing happening here with my lead-poisoned kiddo – waiting 4 months – sick 11 year old misses 9 weeks of school – waiting to see a specialist because he “isn’t in enough pain to expedite” and he can’t eat or breathe without pain – we finally get in to specialist on Wednesday (Pediatric GI) and she said – and I quote ” I don’t even need to examine him really – I’ve reviewed all the paperwork” WTF – sending us away with a referral to a pain clinic! Fuck – an 11 year old needs to be in debilitating pain for four months so he can see an idiot who refers him to a pain clinic !!!

G.S.: Our insurance company did the same thing with my migraine medicine, zomig. Told me I could only have 6 pills a month- which is awesome when your migraines come in clusters, multiple times a day, weeks on end. We ended up having to pay hundreds of dollars to get them. Doctor even called in an override to no avail.

K.B.: I have stories, many of them from my husband’s last 6 months of life in hospitals, or the ten years before as he slowly became more ill each year. What killed him? Mostly incompetence or willful disregard. Steve had been in the hospital since April 5 for a surgery to remove an aneurism that had been allowed to grow to nearly 23% of his body mass. A man that was 6’4″ and right at 225 pounds. On his birthday (June 10th) he was about 145 lbs unable to walk at all without two people holding him.

T.S.: Once, when the firm changed plans, I found that my insulin pens were covered by the new one, but the syringe tops were not. The pens are sitting there full of medicine, but you must tap the pen with a syringe top to get at it, obviously. These needle are fairly expensive, and as an item that must be changed for every shot, I could go through 6-10 a day. Of course I spent weeks on this, and ultimately someone approved my claim, seeing the obvious problem. But I always thought it was a deliberate bottom-line choice to begin with, and that I was lucky to get a fix at all.

A.S.: I had a wrangle with United Health Care last year over a denied claim. I had had an echocardiogram to determine if high blood pressure was causing damage to my heart, a procedure covered for that purpose. However, the code submitted by the provider’s office indicated that the echo was done to DIAGNOSE high blood pressure, for which it is not covered.

M.S.: You’ll never hear me say a good word about any health insurance company, not after the one I had in 2001 decided that the only kind of chemo they would pay for is one that gave me congestive heart failure seven years later.

L.S.: I got out of the hospital yesterday and did the pharmacy drive thru for my pain control script on the way home. Had to pay for it out of my own pocket because of some screw up at the insurance company. It is fucking Sat. morning and I have just been released after a few days in the hospital trying to stop an internal bleed someplace around my spleen. Trust me when I say pain control was not an optional thing. I paid the man for those drugs and cussed while I did it.

K.F.: Humana screwed me over by first denying coverage for emergency surgery (because I had not asked Mother May I & instead relied on a doctor telling me I needed surgery–silly me), then covering the expenses after I made a ruckus, then a YEAR LATER, deciding on their own that they didn’t have to pay after all, resulting in me getting calls from a collection agency threatening all kinds of nasty stuff.

L.D.K.: I had Aetna tell me they wouldn’t pay for an anti-fungal prescription for my toenail fungus……after multiple appeals and proof (biopsy results) that only this certain (expensive) medication would be affective in curing it…..but that they WOULD PAY to have all my toenails SURGICALLY REMOVED!

I.B.: Harvard Pilgrim Healthcare canceled my prescription for Provigil when I lost my job. They said that since I no longer “do productive work,” I no longer needed a medication that prevented me from sleeping all day. My doctor had to write them a letter explaining that without the medication, I wouldn’t be able to SEEK productive work, let alone ever HAVE productive work. We eventually got them to reinstate the prescription, but it took a couple months.

S.C.: My health insurance company tried to refuse to cover the brand of ADHD medication I need and force me to use one that contains a dye I’m allergic to.

A.W.: My dad’s been a doctor for 40+ years. From talking with him, the growing bureaucracy and endless paperwork that has come to typify interactions with the insurance companies makes actually doing the job of caring for the sick increasingly difficult. He also knows a few doctors who were charged with insurance fraud, for lying to the insurers in order to get patients the treatment they needed.

I could share a hundred more similar stories. The pattern is self-evident.

One person who wrote to me asked the pertinent question: why, given all the new customers the ACA will be funneling to the insurance companies, would the industry be so intransigent in its resistance to the law? Why would they keep deliberately screwing people even though their balance sheet is being flooded with new paying customers? The answer, I believe, lies in an article I wrote back in November:

According to the American Medical Association, more than 81 million people currently suffer from some form of cardiovascular disease.

According to the American Cancer Society, more than 11 million people currently suffer from some form of cancer.

According to the American Diabetes Association, almost 24 million people currently suffer from diabetes; the Centers for Disease Control estimate that half of all Americans could suffer from the disease by the year 2050.

The Centers for Disease Control estimate that some 50 million Americans suffer from arthritis, rheumatoid arthritis, gout, or lupus, 21 million of whom are disabled due to the condition.

According to the Alzheimer’s Association, more than five million Americans are currently afflicted with Alzheimer’s disease, a number that will shortly spike as our Boomer population grows older.

According to the National Multiple Sclerosis Society, some 400,000 Americans currently suffer from MS.

According to the National Parkinson’s Foundation, between 50,000 and 60,000 new cases of Parkinson’s are diagnosed in America each year.

The CDC estimates that close to a million people a year become infected with herpes.

More than a million Americans are infected with AIDS.

Some 79 million Americans are infected with the human papillomavirus (HPV), a disease that causes cancer in both women and men.

That, right there, is more than half the country.

That, right there, is the reason. Whatever other flaws may exist within the ACA, the one aspect of it that is a perfect good is the law’s mandate against people with pre-existing conditions being denied coverage, or getting wildly over-charged because of their condition. Before the law’s passage, this pool of customers – more than half the country, by the numbers – represented the insurance industry’s main cash cow, their profit engine…and when the ACA became law, they lost that, and are now seeking to make up the profit gap wherever and however they can.

The ban on insurance companies denying coverage for people with pre-existing conditions, or over-charging for that coverage, is comparable to telling the Mafia they can no longer take kick-backs from the businesses under their “protection.” In the movie Goodfellas, the main character, Henry Hill, succinctly lays out the Mob’s business philosophy regarding those who are struggling to make ends meet:

“Business bad? Fuck you, pay me. Oh, you had a fire? Fuck you, pay me. Place got hit by lightning, huh? Fuck you, pay me.”

In other words, they’re going to get paid one way or the other. If the insurance industry can’t screw you by charging triple rates for your pre-existing condition, they will get their pound of flesh some other way, like denying or delaying approval of an expensive prescription for a serious medical condition that will ruin your body and your life. But they are going to get that pound of flesh, and nothing is going to stop them.

Fuck you, pay me.

The Mafia has broken a lot of legs over the years, and put a lot of bodies in the ground, and extorted a lot of money from fearful people who have no choice but to obey, but the Mafia is left in deep shade by the insurance industry in America. The Republicans have spent oceans of time over the last few years yodeling about fictional “death panels” being a part of the ACA, but those “death panels” are all too real, and have existed for years in the guise of insurance companies that will drain your body of blood before refusing to approve coverage for a transfusion.

So, yeah, those who rant on about government being the problem with health care in America are cordially invited to take a flying fornication at a rolling doughnut on a gravel driveway in the rain. If you’re going to ding the government for anything, ding them – ding the Obama administration – for willfully abandoning the idea of single-payer universal care in favor of allowing the shameless muggers of the insurance industry to retain control of the process. They were awful before, and are worse now, because they are scratching as hard as they can to make up for the revenue they will be losing because they can no longer shaft sick people on the books.

Abandoning the concept of single-payer health care is the Original Sin of the Affordable Care Act. While I and the half of the country dealing with pre-existing conditions are grateful for the prohibition against denying coverage to people thus afflicted, that protection is next to useless when dealing with the shark tank that is the insurance industry. They have less morality than a Mafia leg-breaker, but far more power, and someone decided to keep them in charge of the process anyway.

The wrong people are running this show. Again.

http://truth-out.org/opinion/item/22279-william-rivers-pitt-worse-than-the-mob-the-insurance-industry-is-organized-crime