PNHP

GAO finds CMS negligent in risk adjustment for Medicare Advantage plans

GAO finds CMS negligent in risk adjustment for Medicare Advantage plans

Medicare Advantage: Substantial Excess Payments Underscore Need for CMS to Improve Accuracy of Risk Score Adjustments

United States Government Accountability Office (GAO)
Report to Congressional Requesters, January 31, 2013
What GAO Found
GAO found that the cumulative impact of coding differences on risk scores increased from 2010 through 2012 and was greater than the Centers for Medicare & Medicaid Services’ (CMS) risk score adjustment of 3.4 percent for each of the 3 years. In updating the analysis from its January 2012 report, GAO estimated that cumulative Medicare Advantage (MA) risk scores in 2010 were 4.2 percent higher than they likely would have been if the same beneficiaries had been enrolled continuously in Medicare fee-for-service (FFS). For 2011, GAO estimated that differences in diagnostic coding resulted in risk scores that were 4.6 to 5.3 percent higher than they likely would have been if the same beneficiaries had been continuously enrolled in FFS. This upward trend continued for 2012, with estimated risk scores 4.9 to 6.4 percent higher.
CMS’s adjustment to risk scores for 2010 through 2012 to account for diagnostic coding differences was too low, resulting in estimated excess payments to MA plans of at least $3.2 billion. CMS’s annual 3.4 percent reduction in risk scores is equivalent to $2.8 billion in 2010, $3.0 billion in 2011 and $3.2 billion in 2012. According to GAO’s estimates, the amount of the excess payments to MA plans after accounting for CMS’s adjustments was $0.6 billion in 2010, between $1.1 billion and $1.6 billion in 2011, and between $1.5 billion and $2.9 billion in 2012. Cumulatively across the 3 years, this equals excess payments of between $3.2 billion and $5.1 billion.
For 2013, CMS continues to use the risk score adjustment of 3.4 percent it used in 2010, 2011, and 2012. To conduct its data-based analysis, CMS officials reported that they used the same methodology used in 2010, but they incorporated more recent data.
CMS officials stated that they believed there was policy discretion with respect to the most appropriate adjustment factor but did not identify the specific source of their authority to consider factors other than the required data analysis when determining the adjustment amount. While CMS did not change its risk score adjustment methodology for 2013, agency officials said they may revisit their methodology for future years.
Concluding Observations
Risk adjustment is important to ensure that payments to MA plans adequately account for differences in beneficiaries’ health status and to maintain plans’ financial incentive to enroll and care for beneficiaries regardless of their health status. Our work confirms that differences in diagnostic coding caused risk scores for MA beneficiaries to be higher than those for comparable beneficiaries in Medicare FFS in 2010, 2011, and 2012. CMS’s decision to use a 3.4 percent adjustment to risk scores for 2010 through 2012 instead of the higher adjustments called for by our analysis resulted in excess payments to MA plans. The existence of such excess payments indicates that CMS’s adjustment does not accurately account for differences in treatment and diagnostic coding between MA plans and Medicare FFS—the stated goal of the statute that required CMS to develop a diagnostic coding adjustment. In our January 2012 report, we recommended that CMS take steps to improve the accuracy of the adjustment to account for excess payments due to differences in diagnostic coding. We noted that CMS could, for example, account for additional beneficiary characteristics, include the most recent data available, identify and account for all the years of coding differences that could affect the payment year for which an adjustment is made, and incorporate the trend of the impact of coding differences on risk scores. CMS’s adjustment for 2013 is the same as it used in 2010, 2011, and 2012. However, given our finding that this adjustment was too low and resulted in estimated excess payments to MA plans of at least $3.2 billion, we continue to believe that it is important for CMS to implement our recommendation that it update its methodology to more accurately account for differences in diagnostic coding.
http://www.gao.gov/assets/660/651712.pdf
And…

Medicare Advantage remains strong

U. S. Department of Health & Human Services (HHS), September 19, 2012
“Thanks to the Affordable Care Act, the Medicare Advantage and Prescription Drug programs have been strengthened and continue to improve for beneficiaries,” said (HHS Secretary Kathleen) Sebelius.
For the third year in a row, the Centers for Medicare & Medicaid Services (CMS) used authority provided by the Affordable Care Act to protect beneficiaries from significant increases in costs or cuts in benefits.
http://www.hhs.gov/news/press/2012pres/09/20120919a.html

The private Medicare Advantage plans, offered as an option to traditional Medicare, have been cheating taxpayers by selectively enrolling healthier, lower-cost patients, though being paid at full rates, and more recently by coding patients as having more complicated conditions in order to qualify for higher, risk-adjusted payments. The GAO now provides us with further evidence that Secretary Sebelius and HHS/CMS have been complicit in this fraud.
The Affordable Care Act included provisions to reduce the overpayments to the private Medicare Advantage plans. This GAO report shows that HHS/CMS ignored GAO’s recommendations to improve their risk adjustment methodology, recommendations that should have reduced overpayments due to the embellished diagnostic codes being submitted by the Medicare Advantage plans. HHS/CMS refused to improve the accuracy of their adjustments, which has already resulted in overpayments to these private plans of between $3.2 billion and $5.1 billion.
Why would they do this? Secretary Sebelius has repeatedly touted the Medicare Advantage plans, and has made efforts to expand enrollment in them, even though they cost the taxpayers more money. Overpaying them allows the plans to offer greater benefits in order to entice individuals to enroll. This is leading to further privatization of Medicare, opening up opportunities for Paul Ryan and other members of Congress to push future Medicare beneficiaries into his “premium support” proposal – a voucher plan to privatize Medicare.
Although the Medicare Advantage programs are more expensive, the intent is to expand enrollment and then make a simple change – convert the financing to a defined contribution (premium support), shifting more of the costs to Medicare beneficiaries through higher premiums and then through greater cost sharing (higher deductibles, etc.) to keep the premiums from skyrocketing beyond the means of most seniors.
President Obama has said that he is quite willing to put Medicare on the table as part of the austerity program being advanced by the budget hawks. Secretary Sebelius is advising him on “strengthening” Medicare. Be afraid. Be very afraid.

HHS approves private plans for Arkansas Medicaid patients

Arkansas’s unusual plan to expand Medicaid

By Sarah Kliff
The Washington Post, February 28, 2013

The Medicaid expansion has emboldened Republican governors to strike all sorts of deals with the Obama administration. They’re willing to make the program larger, the thinking tends to go, only if they can make it more conservative in the process.

The most interesting deal though may be coming out of a state with a Democratic governor: Arkansas. There, Gov. Mike Beebe must get 75 percent of his legislature to sign off on any funds necessary for the Medicaid expansion — a tough sell when Republicans control both the state House and Senate.

What the legislature could be sold on, they told the governor, was this: Using billions in federal Medicaid dollars to buy private health insurance coverage for the state’s lowest income populations.

To the surprise of many — Beebe included — Health and Human Services has given that plan the go-ahead.

Keep in mind, this is really different from what Florida did. There, Gov. Rick Scott received a waiver to move nearly all of the state Medicaid recipients into a Medicaid health plan, run by a private company, to manage their care.

What Arkansas is doing is using Medicaid dollars and sending people to the private health insurance exchanges, where they will shop for a plan like millions of other Americans expected to receive subsidies.

A  private insurance plan tends to be more expensive than Medicaid. The Congressional Budget Office estimates the difference between the two, for an individual, is $3,000.

Right now, that doesn’t matter for Arkansas: The federal government will pay 100 percent of the costs for the Medicaid expansion up until 2017. But after that, the match drops to 10 percent — and then the price tag for coverage does have an effect on the Arkansas budget.

I asked (Beebe spokesman Matt) DeCample why buy the more expensive health plans, which will ultimately cost their state, and the federal government, more money.

“These policies are going to be pricier than strictly through Medicaid expansion,” he replied, “But this is the kind of option that our legislature asked us to look for. Our primary hope is that, we can do this, and this is one way to pursue it.”

http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/28/arkansass-different-plan-to-expand-medicaid/

Comment:

By Don McCanne, M.D.

Did I get this right? Health and Human Services has granted Arkansas a waiver to allow Medicaid dollars to be used to purchase private health plans in the state insurance exchange, even though they are much more expensive (and have more limited benefits than Medicaid). And they are doing this only so that state legislators can brag about using private insurers for a public program.

Insanity.

Winning Medicare for All? 'I Like Our Chances'

Despite insights, Time magazine's cover story falls short on remedy

By James Kahn
CommonDreams.org, February 28, 2013
 
In his recent Time magazine article, Steven Brill paints a vivid and rather depressing picture of the perverse malfunctioning of our health care system – overpriced and technology-addicted – and he acknowledges some of the advantages of Medicare.

Sadly, however, he shies away from an endorsement of the obvious solution: an improved Medicare for all, i.e. single-payer national health insurance.

I’ll come back to that a little later. However, let me first say that Brill masterfully illuminates much of what’s wrong with U.S. health care.

Take, for example, the “chargemaster” list: an archival, bizarrely hyper-inflated price list in each hospital based on some long-lost secret formulas and automatically inflated over time.

As a physician and health policy researcher, I’ve long known about the massive charges offered to non-contract payers (read: individuals not covered by a public or private insurer), charges that are completely meaningless for costing studies because they’re almost never paid in full and don’t represent the real resources used to provide care. However, what Brill lays out brilliantly (pun intended) is the following:

•    Some very poor (lower-middle income) people actually do pay the sky-high chargemaster rates.
•    There is a cottage industry (growing, I’m sure, if nothing else due to this article) to help those hapless souls negotiate steep discounts on these ridiculous bills.
•    Hospital administrators either refuse to discuss the chargemaster list or offer up the most heinous, transparently nonsensical justifications for using it.
•    Perhaps worst of all, the CEOs of large not-for-profit providers are paid literally millions of dollars (OK, not tens of millions like big for-profit companies, but still …), thereby introducing into a supposedly public-good-oriented setting the compensation (and marketing) tone of for-profit industry.
•    When these not-for-profits list their “charity” care they value it at the price levels in the chargemaster, even though the cost to produce those services is less than 10 percent of the chargemaster price.

In these and other instances, Brill performs an outstanding public service. However, he regrettably stops short (or his editors stopped him short) of explaining why a single-payer health care system is the only effective remedy for the mess we find ourselves in today. This despite the fact that much of what he says would lead you directly to that conclusion.

He goes so far as to quote others, including John Gunn, Sloan-Kettering’s chief operating officer, who says, “If you could figure out a way to pay doctors better and separately fund research … adequately, I could see where a single-payer approach would be the most logical solution. … It would certainly be a lot more efficient than hospitals like ours having hundreds of people sitting around filling out dozens of different kinds of bills for dozens of insurance companies.”

Yet Brill characterizes single payer, the most logical solution, as “unrealistic” and fraught with the danger of government overreach and intrusion, summarily dismissing it. Need we mention insurance-company overreach and intrusion in the doctor-patient relationship? Need we note the freedom of Medicare beneficiaries to choose their own doctor and hospital, something that would also characterize a single-payer system?

Incidentally, Brill sharply undervalues the government role in paying for health care. He says that the federal government pays $800 billion per year out of our $2.8 trillion health bill, with the remainder mainly picked up by private insurers and individuals.

The $800 billion federal spending on Medicare and the federal portion of Medicaid is right. However, when you add in other federal programs, the state portion of Medicaid, other state and local programs, health insurance for government employees, and tax subsidies, the total government contribution is over 60 percent of total health spending, and rising. Our government already spends enough to pay for universal single payer!

Single-payer health reform is clearly the answer. We need to create the meme and the momentum and the aura of inevitability to do the right thing — despite the opposition of individuals and organizations with massive vested financial interests in the private health industry. They can be overcome.

Think Lincoln and the 13th amendment. As he said (or at least Daniel Day-Lewis said in the movie), regarding prospects of passing the amendment out of Congress, despite doom-saying by his advisers — “I like our chances” (slight smile).

I like our chances on single payer because it’s now so obvious how irremediably broken our system is, and the house of cards will eventually fall. It’s all about perseverance and timing.

James G. Kahn, M.D., M.P.H., is a professor at the Philip R. Lee Institute for Health Policy Studies, Global Health Services, and the Department of Epidemiology and Biostatistics, all at the University of California, San Francisco. He is also past president of the California chapter of Physicians for a National Health Program.

HHS approves private plans for Arkansas Medicaid patients

Arkansas’s unusual plan to expand Medicaid

By Sarah Kliff
The Washington Post, February 28, 2013
The Medicaid expansion has emboldened Republican governors to strike all sorts of deals with the Obama administration. They’re willing to make the program larger, the thinking tends to go, only if they can make it more conservative in the process.
The most interesting deal though may be coming out of a state with a Democratic governor: Arkansas. There, Gov. Mike Beebe must get 75 percent of his legislature to sign off on any funds necessary for the Medicaid expansion — a tough sell when Republicans control both the state House and Senate.
What the legislature could be sold on, they told the governor, was this: Using billions in federal Medicaid dollars to buy private health insurance coverage for the state’s lowest income populations.
To the surprise of many — Beebe included — Health and Human Services has given that plan the go-ahead.
Keep in mind, this is really different from what Florida did. There, Gov. Rick Scott received a waiver to move nearly all of the state Medicaid recipients into a Medicaid health plan, run by a private company, to manage their care.
What Arkansas is doing is using Medicaid dollars and sending people to the private health insurance exchanges, where they will shop for a plan like millions of other Americans expected to receive subsidies.
A  private insurance plan tends to be more expensive than Medicaid. The Congressional Budget Office estimates the difference between the two, for an individual, is $3,000.
Right now, that doesn’t matter for Arkansas: The federal government will pay 100 percent of the costs for the Medicaid expansion up until 2017. But after that, the match drops to 10 percent — and then the price tag for coverage does have an effect on the Arkansas budget.
I asked (Beebe spokesman Matt) DeCample why buy the more expensive health plans, which will ultimately cost their state, and the federal government, more money.
“These policies are going to be pricier than strictly through Medicaid expansion,” he replied, “But this is the kind of option that our legislature asked us to look for. Our primary hope is that, we can do this, and this is one way to pursue it.”
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/28/arkansass-dif…

Did I get this right? Health and Human Services has granted Arkansas a waiver to allow Medicaid dollars to be used to purchase private health plans in the state insurance exchange, even though they are much more expensive (and have more limited benefits than Medicaid). And they are doing this only so that state legislators can brag about using private insurers for a public program.
Insanity.

4 things to know about Medicare's overhead costs

By Bob Herman
Becker’s Hospital Review, Feb. 27, 2013

Many statistics and numbers are thrown around when health care policymakers and leaders discuss Medicare’s administrative costs, but an article set to appear in June’s Journal of Health Politics, Policy and Law attempts to alleviate the confusion associated with Medicare’s overhead costs.

Kip Sullivan, JD, part of the Minnesota Chapter of Physicians for a National Health Program, wrote the article to examine the debate over Medicare’s administrative expenditures and how CMS’ figures should be used.

Here are four things to know, based on the article.

1. There are two different measures of Medicare’s administrative costs. One figure comes from the Medicare Board of Trustees’ annual report, while the other comes from CMS’ National Health Expenditure Accounts. According to the latest trustees’ report, Medicare’s overhead represented 1.4 percent of its total expenditures. According to the latest NHEA, Medicare’s overheard was 6 percent of expenditures.

2. The discrepancy between the two figures is due to Medicare Parts C and D. Mr. Sullivan wrote that the difference between the trustees’ measure of overhead and the NHEA measure “is due almost entirely to the fact” that the NHEA figure includes administrative expenses incurred by health insurers that participate in Medicare Advantage (Part C) and Medicare’s prescription drug program (Part D). In essence, the overhead associated with the private insurers involved with Medicare raise the program’s overhead by almost 5 percent, or $24 billion in 2010.

3. All groups across the political spectrum have been confused about, or misused, Medicare’s administrative costs. According to the article, conservative think tanks, liberal authors, health insurance lobbyists and others have all misrepresented Medicare’s administrative costs.

4. The Medicare Board of Trustees and NHEA figures are comprehensive. Some have criticized the government’s definition of Medicare’s overhead, but Mr. Sullivan writes that both governmental figures include other expenditures incurred by CMS, the IRS, Social Security and others to administer Medicare. When it comes to “traditional” Medicare, the trustees’ measure is the more accurate one, according to the report.

http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/4-things-to-know-about-medicares-overhead-costs.html

Census report on employment-based health insurance

Employment-Based Health Insurance: 2010

By Hubert Janicki
United States Census Bureau, February 2012
 
• The likelihood of employment-based coverage declined from 64.4 percent (± 0.5) in 1997 to 56.5 percent (± 0.5) in 2010.
 
• In 2010, 71.1 percent (± 0.5) of employed individuals aged 15 and older worked for an employer that offered health insurance benefits to any of its employees.

• 42.9 percent (± 1.8) of individuals who did not complete high school worked for an employer that offered health insurance to any of its employees, compared with 78.9 (± 0.5) percent for individuals with a college degree.
 
• Of workers aged 45 to 64, 75.7 percent (± 0.7) worked for an employer that offered health insurance benefits, compared with 60.0 percent (± 1.4) for workers aged 19 to 25.
 
• Among married couples with only one member employed in a firm that offers health insurance benefits, 68.7 (± 1.7) percent provided coverage for the spouse.

http://www.census.gov/prod/2013pubs/p70-134.pdf

Comment:

By Don McCanne, M.D.

The Affordable Care Act was designed to avoid disruption of employer-sponsored health plans since employer plans covered the largest number of individuals and employer contributions to their health plans provided the largest source of health care funding in the United States.

Taking advantage of these funds that were already in place was a natural for those writing the legislation, especially since the expansion of Medicaid and the introduction of health exchange plans would require additional federal funds at a time when considerable concern is being expressed over our current government expenditures (even if the concern should be primarily about inadequate revenues instead).

This Census Bureau report adds to the data which show that employer offers of health care coverage continue to decline. It is uncertain what impact the Affordable Care Act will have on this trend since employers will face conflicting incentives for continuing coverage. It certainly will be tempting for them to discontinue their coverage, enabling their employees to enroll in the government subsidized exchange plans or Medicaid.

The impact of these subsidies will have to be weighed against the loss of deductibility for employer-sponsored plans, though that theoretically should be neutral to the employer as forgone wages for health benefits are then paid to the employees, and it would be the employees who would have a higher tax obligation. (Do you believe that the behavior of employers actually would follow the common wisdom of the economists in this matter?) Also, larger employers would have to weigh the impact of the assessment (penalty, tax, or whatever) for not providing coverage to their qualified employees.

There is a wide range of opinions on this matter, but it is likely that there will be little tendency to increase the numbers of individuals with employer-sponsored coverage. In contrast, it is more likely that other employers will follow the lead of those who early on decide against providing coverage as they play games with the rules that determine whether there would be penalties or how much they would be.

Also employers will likely continue with the current trends to shift more health care costs to their employees, with the alleged premise that it would make them better health care shoppers. They really don’t care about their employees’ shopping habits. Employers are adopting these plans for one reason only. High deductibles and other innovations reduce their costs – the employers’ costs – for these plans, with the trade off of increasing costs for employees who actually need health care.

It seems clear that more people will either be pushed into the underfunded Medicaid program or the underinsurance plans of the exchanges, or they simply will go uninsured.

The Affordable Care Act isn’t fixing our system, and employers understandably are losing their enthusiasm for filling the gaping void in the adequacy and allocation of our inefficient private health plans. You would think that employers would be ready to get on board with an improved Medicare that covers everyone. It would certainly get rid of one big headache for them.

Saving on health care at the cost of people's health

Health care spending in the U.S. has slowed because fewer people can afford health services

By Margaret Flowers, M.D.
Al-Jazeera, Feb. 27, 2013

In his recent State of the Union speech, President Obama remarked in one short sentence that “Already, the Affordable Care Act [ACA] is helping to slow the growth of health care costs.” That was the extent of his comments on the historic health care bill he signed into law in March 2010 after more than a year of pushing health reform through Congress. It is true that total health care spending in the U.S. has slowed, but it does not have much to do with the ACA. Instead, it is another symptom of the ailing market-based health system in the U.S. which is causing poor health outcomes and growing inequality.

The U.S. is unique among industrialised nations when it comes to health care. All other wealthy nations have some type of national universal health system that is publicly financed. The U.S. relies primarily on a market-based health care system in which most private health insurance is tied to employment. There are public programs, Medicaid, for those who are in extreme poverty, but these are subject to state-balanced budget pressures and struggle to meet the needs of their populations. And there is a public-private system for people 65 years of age and older, Medicare, that is financed through taxes at the federal level. Overall, health coverage is private except for many people who do not qualify for public programs and find private health insurance unaffordable.

Privatized health system: A failed experiment

The U.S. health system is a failed experiment. Since the 1980s when the U.S. moved aggressively to privatise the financing and delivery of health care, the cost of care, health disparities and the number of people without insurance have climbed. The U.S. spends more per capita on health care than any other country and has excellent health facilities, but in the U.S., patients receive the amount of health services they can afford rather than what they need.

In fact, health care spending per capita in the U.S. is two and a half times what the average OECD (Organisation for Economic Co-operation and Development) nation spends. Total health spending constitutes a greater piece of the Gross Domestic Product (GPD), currently at 17.9 percent, than the OECD average of 9.5 percent. Yet, nearly 50 million people in the U.S. have no insurance at all. And tens of millions more are under-insured, meaning they have insurance but suffer significant financial barriers to care and face bankruptcy in the event of a serious accident or illness.

U.S. health care law leaves millions without coverage

A study using data from 2007 found that 62 percent of all personal bankruptcies were due to medical illness and costs and nearly 80 percent of those who experienced medical bankruptcy had some sort of health insurance. In the U.S. it is not uncommon for communities to hold fundraisers when someone is diagnosed with cancer or other significant health conditions. It is also not uncommon for parents to forgo care when they have a terminal illness and die prematurely rather than leaving their family behind with no home or other assets.

In a 2009 study, it was estimated that there are 45,000 excess deaths among uninsured adults in the U.S. each year due to lack of access to care. That adds up to more than 120 adults each day. And uninsured children are more likely to die as well. The total number of preventable deaths is probably higher. Another study estimated that there would be over 100,000 fewer preventable deaths in the U.S. each year if we had a high-functioning health system like France, Australia or Japan.

Considering the amount of money invested in health care, the U.S. reaps a poor return in health outcomes. A recent report by the Institute of Medicine indicates that life expectancy in the U.S. for both men and women is falling. And the U.S. fares poorly in a number of categories such as infant mortality, chronic diseases, disability and violent and drug-related injuries. The report points to a number of causative factors such as the lack of a universal health care system and lack of a social safety net. It also points out the severe degree of wealth inequality in the U.S. and the social effects on health that coincide with that such as lack of education, drug abuse and violence.

Wealth inequality in the U.S. is worsening. The most recent U.S. Census Bureau data show that one in three people in the US are living in poverty or are low income. The Gini index which measures inequality grew for the first time since 1993, by 1.6 percent, pointing to rising inequality. This is not surprising. Following the economic crisis of 2008, the purported recovery has only been realised by the wealthiest 1 percent who received 121 percent of the income gains due to falling income in the bottom 99 percent. In real terms, what this means is that two-thirds of US families do not have a safety net to see them through personal emergencies. And the U.S. may be entering a double-dip recession.

Rising out-of-pocket costs lead to self-rationing

The majority of families in the U.S. routinely have to make financial choices about necessities. When it comes to keeping their homes, putting food on the table and meeting their children’s needs, seeking health services is a low priority unless it is an emergency. This results in self-rationing, and it is the cruelest form of rationing because it is not based on the needs of the population but on ability to pay.

Over the three years following the economic crisis of 2008, total health care spending slowed in the U.S. to just below 4 percent each year, down from around 6 percent each year. This decrease in spending began before the ACA was passed and continues at the same pace, so far being unaffected by the ACA. Rather, the decrease in spending is the result of greater shifting of health care costs onto individuals who are unable to afford it and so are using fewer services.

Since 2008, there has been a steady decline in the number of people who are seeing their doctor. One reason is that people lost their jobs and with that their employer-sponsored health insurance. But even those who have private health insurance have been making fewer physician visits. That trend started to revers
e in 2012, but only for preventative health services, because the ACA requires greater coverage for those. Of concern is what these patients will do if a serious health condition is diagnosed because in the U.S., having health insurance does not guarantee that necessary care will be covered and most people face significant deductibles that they must pay before their benefits begin. So, the effect of more preventative care on actual health outcomes remains to be seen.

There is a debate currently over whether we are in a temporary downturn in the use of health services and health spending or whether this is the new normal. I argue that unless there are significant changes in the financing of health care, we are reaching a new normal in the U.S. of under-insurance. There has been a consistent trend of rising costs of health insurance premiums and pharmaceuticals while a greater proportion of the burden is being shifted onto the individual.

A root cause of this trend is that private health insurance corporations are first and foremost responsible to their investors to provide income. This is achieved by charging high prices for insurance premiums and avoiding payment for health services. A new tool to accomplish this, called Consumer-Driven Health Plans (CDHPs), entered the market about 10 years ago.

Publicly the CDHPs were promoted as common sense plans that would prevent overuse of health services by putting more financial responsibility in the hands of patients who were then expected to make wiser decisions about how to spend their dollars on health care. This was called “having skin in the game.” But in reality, CDHPs have only created greater financial barriers to care and increased the number of people who experience medical bankruptcy while private insurance corporations’ profits have soared.

Studies show that patients are not able to discriminate well between necessary and unnecessary care, and so they avoid both. The consequence of avoiding or delaying necessary care is that conditions are then more difficult and expensive to treat and have worse outcomes, unless of course the outcome is death which leads to overall cost savings. And a recent study described the toll that cost-sharing takes on families, writing: “We found that high levels of cost sharing precipitated considerable anxiety and substantial debt problems, as well as disruptions of medical care.”

U.S. health law increases under-insurance

The ACA will increase the number of people who have insurance, but most will have CDHPs with low levels of coverage. The highest quality health plans have traditionally been those that are employee benefits. But under the ACA fewer employers are planning to offer health benefits. Some will drop coverage altogether and pay a fine instead, which ends up costing less. Other employers are shifting more positions to less than full time or to consultants in order to avoid providing health benefits. And other employers are planning to offer funds for their employees to purchase their insurance individually. More than half of the plans purchased in the individual market are lower benefit plans.

Beginning in 2014, states are required under the ACA to create health insurance exchanges where individuals will purchase health insurance or face a penalty for being uninsured. The exchanges will sell tiers of plans, ranging from those that will pay for 90 percent of covered health services (Platinum) to those that only cover 60 percent (Bronze), and insurance lobbyists are pushing for even lower coverage. Federal subsidies will be available for people whose income is below a certain level and for whom premiums would cost more than 9.5 percent of their income, but these subsidies will only apply to the “Silver Plans” which pay for 70 percent of covered services which is grossly insufficient.

I emphasise covered services because one way that insurance companies avoid paying for care is to say that a service is not covered. And it was recently revealed that the 9.5 percent cut off only applies to individual coverage. This means that if a person’s individual coverage is less than 9.5 percent but family coverage is higher, they do not qualify for the subsidy. The IRS will not charge the employee a penalty for their uninsured spouse and children.

The ACA has only added more complexity and bureaucracy to an already overly complex and bureaucratic health care system in the U.S. Over a third of health care spending goes to administration and marketing for the multitude of health plans. And this will grow under the ACA due to the costs of the new exchanges, the new regulations for insurers that must be enforced and the new tax penalty that will be assessed for those who do not purchase insurance. In fact, the state of California which is suffering huge budget difficulties and is struggling to fund health care, just received a $674 million federal grant to market and administer its state exchange. Imagine what that would mean if instead those dollars were invested in new health facilities or payment for health care.

Discussing U.S. health care reform

The rise in administrative costs, as well as the failure to include proven cost controls, will lead to the ultimate failure of the ACA. In the meantime, as prices rise and coverage shrinks, we can expect increased self-rationing. This may mean a slower rise in overall health care spending, but at what cost to the population. More people will find themselves unable to afford necessary care. This will lead to greater suffering, greater disability and more people dying from preventable causes. This will be the new normal in the U.S.

Future of global health systems: Public or private?

There is another path. The U.S. could recognise the failure of its market-based health system and instead adopt evidence-based health reform. The U.S. could join the rest of the civilised world and create a universal, lifelong, comprehensive and publicly financed health system. In the U.S., we call this Single Payer (meaning the health system is financed by the government through taxes) or Medicare for All.

Current health spending in the U.S. is sufficient to cover a single-payer system. And the majority of people and health professionals support this approach. The major barrier is corporate influence over the U.S. political process. Health insurance, pharmaceutical and private hospital corporations spend millions to lobby and elect legislators who are favourable to their interests. Legislative staffers are often hired from these industries and lobbyists for the industries are often former legislative staffers. For example, staffers and lobbyists were very successful in making certain that the ACA would protect their profits.

It is not likely that the U.S. will move to Single Payer unless a strong grassroots movement demands it. And corporate forces, including corporate political parties, do what they can to prevent this. During the health reform process, tens of millions of dollars were given to grassroots groups and labor to support the ACA and the White House made sure that they complied with the Democrat’s messaging. Now, these same groups are allying with the health insurance corporations to promote the purchase of their products.

Instead of learning from the rest of the world, the U.S. is pushing its failed market-based system on other countries. The new Trans-Pacific Partnership is expected to degrade top health systems in Australia and Japan. The president announced in his State of the Union address that he is pushing a new and similar trade agreement on the European Union. And, unfortunately, many EU nations are privatising their systems due to pressure from international financiers despite popular protests.

We are at a crossroads globally. There is a long-term body of strong evidence that publicly financed universal health care systems improve health and control costs. But as transnational corporations gain greater power, they will expand their reach throughout the globe in order to profit from those who have the means to pay for care. What will be the human cost of this path? As one colleague said about the current environment: “If you aren’t exploitable, you’re expendable.”

Margaret Flowers, MD, served as congressional fellow for Physicians for a National Health Program and is on the board of Healthcare-Now. She is co-director of It’s Our Economy and co-host of Clearing the FOG Radio Show.

http://www.aljazeera.com/indepth/opinion/2013/02/201322671734465929.html

Woolhandler, Himmelstein and Relman on the right path for Medicare

Sunday Dialogue: The Future of Medicare

The New York Times, February 23, 2013

Readers weigh in on problems with the health care program:

Canada’s Medicare program — phased in at the same time as the American version — shows how we can make Medicare simpler and thriftier, while simultaneously upgrading its coverage. Canada’s program covers all Canadians (not just the elderly) under a single public program in each province, and bans co-payments and deductibles.

Patients can choose any doctor and hospital. Cutting out private insurers and the complexity and fragmentation they impose has simplified paperwork for patients, doctors and hospitals. Administrative costs are roughly half United States levels, saving more than $1,000 per capita.

Over all, Medicare spending on the elderly has grown three times faster in the United States than in Canada since 1980, while life expectancy (for the elderly, as for all age groups) has grown faster in Canada. If American Medicare costs had risen at Canadian rates, we’d have saved more than $2 trillion by now, and Medicare’s trust fund would show a healthy surplus.

STEFFIE WOOLHANDLER
DAVID U. HIMMELSTEIN
New York, Feb. 20, 2013

The writers, internists and professors at the CUNY School of Public Health at Hunter College, co-founded Physicians for a National Health Program.

***

Medicare is headed for bankruptcy because it depends largely on open-ended fee-for-service payment of almost any services providers choose to deliver, at prices mainly determined by the providers. Compounding the problem, most providers act like independent businesses seeking to increase their income, regardless of whether they are for-profit or investor-owned.

An effective Medicare fix would require a new payment system that prospectively pays providers for comprehensive care at a rate set by a single public payer. It would also need a not-for-profit medical care system based on multispecialty doctor groups that pay physicians by salary, thus minimizing incentives to deliver duplicative or unnecessary care.

The new system would have to be mandatory for all citizens, including legislators, and it would have to be financed by a progressive, earmarked health care tax.

Obviously, such reform would be slow and difficult, but so would any other change that threatened vested interests. All reform will depend on an aroused public opinion.

ARNOLD S. RELMAN
Tucson, Feb. 21, 2013

The writer is professor emeritus of medicine and social medicine at Harvard Medical School and a former editor in chief of The New England Journal of Medicine.

http://www.nytimes.com/2013/02/24/opinion/sunday/sunday-dialogue-the-future-of-medicare.html?ref=opinion&pagewanted=all&_r=0

Comment:

By Don McCanne, M.D.

At a time when Congress and the Obama administration are contemplating a reduction in Medicare spending as a means of paring down our national budget deficit, it is important to remind the nation of the beneficial changes that we could be making to the Medicare program that would bring affordable, high quality care to everyone under a single payer Medicare budget that we could afford. The messages of Steffie Woolhandler, David Himmelstein and Arnold Relman need to drown out the messages of those who would send Medicare down the wrong path.

Market doesn't work for health

By James Binder, M.D.
The Charleston (W.Va.) Gazette, Feb. 27, 2013

A major shift is occurring in health and no one seems to be noticing. Computers have taken priority over patients. Wow! It doesn’t matter whether the patient is seen in the emergency room, a physician’s office or in a hospital, completing documentation on the computer is paramount. The patient better stay out of the way.

Is it impersonal? Of course. Is it a problem? Certainly. Over and over again, medical research has demonstrated that a physician’s ability to engage with the patient and create a strong therapeutic relationship is the best predictor of positive health outcomes.

How did we come to this point in health care? My belief is that the answer is clear and simple. We have allowed health-care decisions to be made by a fragmented business conglomerate in which profit is the chief motive. The marketplace has never and will never work for health care.

Private insurance companies spend 31 percent of the health dollar on advertising and an excessive bureaucracy, instead of for patient care. The idea that competition will lower costs has not worked despite 50 years of trying. When we become ill and vulnerable, which we all will at some point in our lives, we are not in a position to be discriminatory consumers in the marketplace. Even if we were, 50 percent of us live in areas, most often rural, where there is no choice.

To foster the transformation to electronic records, proponents of the marketplace approach told us that digital electronic records would improve the quality of health care and save money. They lobbied very hard to get legislation passed in 2009 supporting the use of electronic records in health care.

It did not save money for consumers. The cost of health care continues to skyrocket. It did bring windfall profits to a few strategically placed companies in the medical-industrial complex. The New York Times reported Feb. 19 that AllScripts doubled its sales from $548 million in 2009 to $1.44 billion in 2012.

With time, we are likely to learn more flexible ways of using computers so they don’t act as obstacles to a solid physician-patient alliance. The second problem may be more difficult to resolve. If we employ a fragmented, competitive marketplace model, companies will continue to create expensive electronic digital systems that do not communicate with each other. Their goal is to maximize the billing potential of hospital and other providers they serve. Solving this problem will require us to change our health-care financing method.

We could benefit from the use of digital electronic records if we followed the example of the Veterans Administration. It established an infrastructure in which each VA treating facility is able to assess medical records from any other VA medical provider, as well as from the Department of Defense. Clinicians have access to a patient’s diagnosis, medications and previous treatments in an instant.

In addition, the digital electronic program has been designed to assist primary-care clinicians as they provide comprehensive, preventive and evidence-based care. Electronic reminders address specific relevant health-care issues periodically and goals are tracked across time.

We could have similar unified and coordinated electronic medical records if we established a national program for financing health care. It is called single-payer health insurance.

For a discussion of single-payer, how it would operate, as well as learn about the Affordable Care Act, please join us at 7 p.m. April 25 at the University of Charleston. Participating in the discussion will be Andy Coates, M.D., president of Physicians for a National Health Program, and Perry Bryant, founder and executive director of West Virginians for Affordable Health Care.

Dr. Binder practices pediatrics at Cabin Creek Health Systems and is the author of “Pediatric Interviewing: A Practical Relationship-Based Approach” (2010) and “Primary Care Interviewing: Learning Through Role Play,” to be published by Springer in 2013.

http://wvgazette.com/Opinion/OpEdCommentaries/201302260098

Fighting for health care that doesn’t leave you broke & naked

A profile of Dr. Elizabeth Frost

By Jacob Wheeler
The Uptake (St. Paul, Minn.), Feb. 27, 2013

If Minnesota ever adopts a single-payer heath care system, the work of Dr. Elizabeth Frost will be remembered as one of the key reasons for its passage.

Together with her friend, Dr. Ann Settgast, Frost co-founded the Minnesota Chapter of Physicians for a National Health Program (PNHP) five years ago. The group holds rallies and speaks at hospitals across the state to recruit new members to its cause — and now boasts more than 1,000 members in Minnesota. Frost also has the ear of state lawmakers such as Sen. John Marty and Rep. David Bly, who hope to expand health care access in Minnesota.

“Single-payer” health care would make health care universal and ensure equal access to best treatment, expanding President Obama’s Affordable Care Act. Under single-payer, everyone would be entitled to the best available care, no matter the size of their wallet. Citizens could keep their health insurance coverage even if they lost or changed jobs, and be allowed to retain their preferred doctor or caregiver. By encouraging preventative care, proponents say a single-payer system would significantly lower costs (as much as $350 billion a year, they estimate). Perhaps most importantly, a single-payer system would end health insurance industry meddling. Patients could make decisions based on health needs, not on what a billing department dictates.

Frost, 39, is a Washington, D.C., native who went to medical school at Case Western Reserve in Cleveland and serves as a family physician at the Hennepin County Medical Center’s East Lake Clinic. She came to Minneapolis 11 years ago to live near her sister and her niece and nephew. One of the reasons she has stayed here is Minnesota’s focus on improving health care services which, while far from ideal, offer better access to care than many other states do. Frost, who refers to herself as “something of a do-gooder,” believes that her work as a physician extends beyond diagnosing defects or prescribing medicine.

Her tireless advocacy for single payer stems from her experience caring for her patients, and her concern that the present health system doesn’t offer adequate care.

“I had a patient who came to see me who was 64 years old and had chest pains,” Frost says when asked to illustrate the problem. “I recommended he go to the emergency room to get evaluated for his chest pains, and he refused because he didn’t have health insurance. He said ‘I’m gonna wait until I’m 65 to have this evaluated.’

“About a week later he went to the ER after having a massive heart attack. He died a few weeks later. If the Medicare age limit was 64 instead of 65, then that patient would be alive today.”

The frustration in Frost’s voice signals her impatience with a system in which patient outcomes often depend on arbitrary and unfair rules and requirements. She compares the current, broken system of health care to a skimpy hospital gown: The coverage looks fine, until you walk around and study it from behind.

Frost believes physicians have a duty to get involved in the health care debate that extends beyond caring for patients, a duty that should take them out of the clinic and into the public square: “Our goal is to figure out how to solve things on a grander scale,” she says. Physicians who heed their own advice, Frost and Settgast joined together to found the local branch of PNHP five years ago. Today, it has  over 1,000 members and supporters. Nationwide, Physicians for a National Health Program boasts 18,000 doctors.

Frost and Settgast organize an annual rally at the State Capitol to pressure lawmakers to push for single-payer health care in Minnesota. (This year’s rally was held Feb. 7.) Perhaps no lawmaker has been more allied with their work than Sen. John Marty a DFLer from Roseville, who consults closely with Frost and Settgast on organizing strategy and bill drafting. The two physicians helped Marty craft language for a single-payer bill that Marty introduced last month as SF18. The bill, which is unlikely to win approval this year, would “guarantee that health care is available and affordable for all Minnesotans.”

“Elizabeth is a perfect example of a doctor willing to advocate for the well-being of her patients,” says Marty. “Her advocacy to make sure they have access to health care is consistent with the work she does in her clinic.”

“I was impressed by her commitment to the issues, and commitment to really want to make change,” echoes Rep. David Bly, DFL-Northfield. “It’s really important that you have someone of her experience and stature step forward. I think they have had a tremendous impact in their effort to bring single payer to reality.”

When she’s not helping patients, speaking at hospitals to recruit new single-payer advocates or lobbying lawmakers, Frost often uses demonstrations to push her message that health insurance executives don’t deserve to profit while her patients suffer. Every winter she takes part in a Protest on Ice, a bit of political theater performed on the frozen surface of Lake Minnetonka in front of UnitedHealth CEO Stephen Hemsley’s house. Hemsley is one of the highest paid health industry executives in the country, taking home almost $50 million in 2011.

“That $50 million is our money,” said Frost. “He gets it off the backs of you and me.”

Frost’s message that adequate health care should be considered a basic right, not a privilege, resonates with lawmakers like Bly.

“You don’t have to go far to find (family or community) efforts to raise money to cover someone’s traumatic illness,” he said, referring to common fundraisers at homes or at Legion Halls to help pay for health crises such as a family’s cancer bills. “Those days have to be numbered. We have to get beyond that. Health care should be seen as a right. It’s a public good, like public schools or public safety.”

But is the public ready to support government-administered, single-payer health care of the kind advocated by Frost?

“If I could have a dollar for everyone who told me that single payer is not going to happen because it’s not politically viable, I would be a millionaire,” Frost admits. “(But) we all just need to close our eyes and jump. We need to get people in the streets demanding that health care is a human right.”

Single payer — in which the government pays all medical bills, has been adopted in Canada and already exists, in limited form in the shape of Medicare in the U.S. Still, it was viewed by many politicians as a radical option during the health care reform debates before Congress passed the Affordable Care Act (ACA). Nevertheless, single-payer advocates may already have made their impact on U.S. history. Frost believes that the arguments of single-payer health care advocates helped prompt conservative Supreme Court Chief Justice John Roberts to cast his crucial vote in the Court’s decision to uphold “ObamaCare.”

“I think that single-payer supporters might have been influential in him changing his mind to uphold the Affordable Care Act,” says Frost. “A lot of people that I work with were protesting against ACA on the steps of the Supreme Court — alongside members of the Tea Party — because they wanted the Court to overturn the Affordable Care Act in order to pave the way for single payer. The threat of single payer, the threat of the progressives, may have encouraged (Roberts) to change his mind and uphold ACA.”

Closer to home, Frost, Settgast and Physicians for a
National Health Program are using a more grassroots approach to push for single payer in Minnesota. With 14,000 doctors in the state, they believe they can have strength in numbers. PNHP gives talks in hospitals, clinics and churches to reach those potential allies. They have presented at the Mayo Clinic in Rochester as part of the Grand Rounds forum, in which doctors discuss a topic once a week. Frost estimates the group added 15-20 converts from the 200 people who attended last year’s Mayo speech.

Frost and Settgast also have a long-term hope that single payer will become more politically feasible, at least in Minnesota, in the next few years, perhaps as soon as 2015.

“We want to push for single payer passing in Minnesota in 2015,” says Frost. “Gov. (Mark) Dayton would be in his second term (if he wins re-election in 2014), and he’ll feel more liberal to push for something like this.”

It may seem like a stretch now. But don’t underestimate the effect that Frost, Settgast and the grassroots campaigning of Physicians for a National Health Program may be having on the debate. They are not going to quit anytime soon.

*****

Are You Covered? Click photo to see video about how Elizabeth Frost is fighting to cover you.
Editor’s Note: This is the second in an UpTake series of profiles on men and women whose names may not be widely familiar but whose leadership makes our neighborhoods, our cities, our states, better places. — Nick Coleman, Executive Editor

http://www.theuptake.org/2013/02/27/fighting-for-health-care-that-doesnt-leave-you-broke-naked-an-uptake-profile-elizabeth-frost/#more-60903

Woolhandler, Himmelstein and Relman on the right path for Medicare

Sunday Dialogue: The Future of Medicare

The New York Times, February 23, 2013
Readers weigh in on problems with the health care program:
Canada’s Medicare program — phased in at the same time as the American version — shows how we can make Medicare simpler and thriftier, while simultaneously upgrading its coverage. Canada’s program covers all Canadians (not just the elderly) under a single public program in each province, and bans co-payments and deductibles.
Patients can choose any doctor and hospital. Cutting out private insurers and the complexity and fragmentation they impose has simplified paperwork for patients, doctors and hospitals. Administrative costs are roughly half United States levels, saving more than $1,000 per capita.
Over all, Medicare spending on the elderly has grown three times faster in the United States than in Canada since 1980, while life expectancy (for the elderly, as for all age groups) has grown faster in Canada. If American Medicare costs had risen at Canadian rates, we’d have saved more than $2 trillion by now, and Medicare’s trust fund would show a healthy surplus.
STEFFIE WOOLHANDLER
DAVID U. HIMMELSTEIN
New York, Feb. 20, 2013
The writers, internists and professors at the CUNY School of Public Health at Hunter College, co-founded Physicians for a National Health Program.
***
Medicare is headed for bankruptcy because it depends largely on open-ended fee-for-service payment of almost any services providers choose to deliver, at prices mainly determined by the providers. Compounding the problem, most providers act like independent businesses seeking to increase their income, regardless of whether they are for-profit or investor-owned.
An effective Medicare fix would require a new payment system that prospectively pays providers for comprehensive care at a rate set by a single public payer. It would also need a not-for-profit medical care system based on multispecialty doctor groups that pay physicians by salary, thus minimizing incentives to deliver duplicative or unnecessary care.
The new system would have to be mandatory for all citizens, including legislators, and it would have to be financed by a progressive, earmarked health care tax.
Obviously, such reform would be slow and difficult, but so would any other change that threatened vested interests. All reform will depend on an aroused public opinion.
ARNOLD S. RELMAN
Tucson, Feb. 21, 2013
The writer is professor emeritus of medicine and social medicine at Harvard Medical School and a former editor in chief of The New England Journal of Medicine.
http://www.nytimes.com/2013/02/24/opinion/sunday/sunday-dialogue-the-fut…

At a time when Congress and the Obama administration are contemplating a reduction in Medicare spending as a means of paring down our national budget deficit, it is important to remind the nation of the beneficial changes that we could be making to the Medicare program that would bring affordable, high quality care to everyone under a single payer Medicare budget that we could afford. The messages of Steffie Woolhandler, David Himmelstein and Arnold Relman need to drown out the messages of those who would send Medicare down the wrong path.

Impending access crisis for low-income patients

States Can Cut Back on Medicaid Payments, Administration Says

By Robert Pear
The New York Times, February 25, 2013

The Obama administration said Monday that states could cut Medicaid payments to many doctors and other health care providers to hold down costs in the program, which insures 60 million low-income people and will soon cover many more under the new health care law.

The administration’s position, set forth in a federal appeals court in California, has broad national implications as it comes as the White House is trying to persuade states to expand Medicaid as part of the new law.

In a brief filed with the United States Court of Appeals for the Ninth Circuit, in San Francisco, federal officials defended a decision by California to cut Medicaid payments to many providers by 10 percent.

Kathleen Sebelius, the secretary of health and human services, approved the cuts in October 2011 after finding that beneficiaries would still have “adequate access” to the wide range of services covered by Medicaid.

The Obama administration urged judges to uphold those cuts, which are being challenged by patients, doctors, dentists, hospitals, pharmacists and other health care providers in California.

Health care providers said California’s payment rates were inadequate even before the cuts. They pointed to a federal study that said, “California stands out because of its very low Medicaid payment levels.”

In an interview, Gov. Jerry Brown of California, a Democrat, said the Medicaid cuts were essential to his efforts to dig the state out of a budget hole.

Federal law says Medicaid rates must be “sufficient to enlist enough providers” so that Medicaid beneficiaries have access to care at least to the same extent as the general population in the same geographic area.

Moreover, the administration said, Congress gave states “wide discretion” to set Medicaid rates, and courts should not second-guess decisions by Secretary Sebelius on the adequacy of rates.

“There is no general mandate under Medicaid to reimburse providers for all or substantially all of their costs,” the administration said.

http://www.nytimes.com/2013/02/26/us/politics/states-can-cut-back-on-medicaid-payments-administration-says.html?_r=0

And…

Healthcare overhaul may threaten California’s safety net

By Anna Gorman
Los Angeles Times, February 25, 2013

An estimated 3 million to 4 million Californians — about 10% of the state’s population — could remain uninsured even after the healthcare overhaul law takes full effect. The burden of their care will fall to public hospitals, county health centers and community clinics. And those institutions may be in jeopardy.

County health leaders and others say the national health law has had the unintended consequence of threatening the financial stability of the state’s safety net.

And under the federal law, some of the funding that goes to safety-net hospitals is also set to decrease.

Now, as the state scrambles to create the new healthcare infrastructure, Gov. Jerry Brown is proposing to take back another crucial pot of money that counties have depended on for more than two decades to care for the uninsured.

http://www.latimes.com/health/la-me-left-uninsured-20130226,0,3348028.story

Comment:

By Don McCanne, M.D.

California has been a leader in setting national trends in health care financing. Two developments should have low-income patients very concerned. California’s Medicaid program is critically underfunded, and the state is reducing payment rates by another ten percent. Also, the state is reducing funding for local safety-net institutions which provide critical access for low-income populations.

Perhaps the most alarming of all is the official response of the Obama administration (in an appeals court filing): “There is no general mandate under Medicaid to reimburse providers for all or substantially all of their costs.”

We have said over and over again that Medicaid, as a welfare program, will never have the political support to fund it adequately. The burden of the additional load of Medicaid patients will surely find the health care resources strained beyond the capacity of willing providers, especially when you consider that California already is not meeting the costs of providing care to this vulnerable population. And the 3 to 4 million Californians who will remain uninsured will need to rely on the safety-net institutions, though those institutions also are in jeopardy – again because of the lack of political support for welfare programs.

If California is successful with its cruel budget trimming, it can be anticipated that many more states will follow.

Here’s an amazing fact: Low income patients do not have the money to pay for health care. (What an intuitive stroke of genius!) What they need is an affordable system that removes financial barriers to care while ensuring adequate financing of our entire health care delivery system, thereby removing health system disincentives to providing essential care for this vulnerable population. Make that for all of us.