Summary: A chief health officer and pediatrician at Indiana University speaks plain and powerful truth about growing insurance cost-sharing – it’s designed to reward insurers, to the health and financial detriment of the insured.

What’s Wrong With Health Insurance? Deductibles Are Ridiculous, for Starters, New York Times, July 7, 2022, by Aaron E. Carroll

More than 100 million Americans have medical debt, according to a recent Kaiser Health News-NPR investigation. And about a quarter of American adults with this debt owe more than $5,000.

The Affordable Care Act was supposed to improve access to health insurance, and it did. Unfortunately, it has not done enough to protect people from rising out-of-pocket expenses in the form of deductibles, co-pays and co-insurance.

This moral-hazard argument assumes that patients are rational consumers, and it assumes that cost-sharing in the form of deductibles and co-pays makes them better shoppers. Research shows this is not the case.

People are not smart shoppers or rational spenders when it comes to health care. When you make people pay more, they consume less care, even if it’s for lifesaving treatment.

The average deductible on a silver-level plan on the A.C.A. exchanges rose to $4,500 in 2021.

Those who receive insurance from their employers aren’t much better off than those who buy on the A.C.A. marketplaces. The average deductible for insurance offered by large companies in the United States was more than $1,200.

Those are only the deductibles. After they are paid, people must still cover co-pays and co-insurance until they hit the out-of-pocket maximums. The good news is that the A.C.A. limits these in plans sold in the exchanges. The bad news is that they’re astronomical: $8,700 for an individual and $17,400 for a family. A large majority of Americans don’t have that kind of money sitting in accounts, certainly not after paying an average of about $5,000 in premiums each year for a benchmark individual silver plan.

The purpose of insurance is to protect people from financial ruin if they face unexpected medical expenses. Reducing the amount that they need to pay from six figures to five is necessary, but not sufficient. It’s not enough to give people insurance.

Aaron E. Carroll is the chief health officer for and a distinguished professor of pediatrics at Indiana University.

Comment:

By Don McCanne, M.D.

For many decades we’ve recognized we have a very serious problem. We have a very expensive health care system which exposes far too many to significant medical debt because our fragmented, dysfunctional health insurance system has been inadequate to provide the financial protection that patients need.

It seems obvious that we need to provide as a solution a system that provides health care access to the patient – all patients – without exposing them to medical debt. But instead of looking for a solution that takes care of the problems of patients, we have been looking for solutions that take care of the problems of the insurer.

Thus we have perpetuated the moral-hazard argument: make the patient feel the financial pain of the health care they are about to consume so that costs to the insurer will be reduced by eliminating superfluous care. Well, we know what that does: it results in skipped necessary care and impaired health outcomes, even death, and it results in medical debt because of the direct charges the insurer passes on to the patient – both the opposite of what a health care financing system should be achieving.

Dr. Carroll’s proposed solutions would modify current health care financing, e.g., by offering better insurance for the chronically ill and reference pricing for drugs and procedures. His solutions are piecemeal, subject to gaming, and inadequate.

Suppose all of these decades we had been looking for solutions that took care of our target –patients – rather than a marketplace intermediary – insurers, what would these solutions look like? Well, they would provide health care access to absolutely everyone without burdening them with medical debt. Instead of reducing spending by erecting financial barriers to patient care, we would reduce spending by eliminating this very expensive, administratively complex insurance industry and its investors.

For decades we’ve known that a publicly administered single payer system is what we clearly need, yet we have continued to privatize even our existing public programs such as Medicare and Medicaid to the benefit of private equity rather than to the benefit of patients.

So why do we keep electing legislators and an administration that take care of the superfluous, dysfunctional, egregiously wasteful insurance industry when we want them instead to take care of the health care needs of the people?

http://healthjusticemonitor.org…

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Summary: A news article reports on Congressional hearings on problems with Medicare Advantage. An academic article describes big challenges and valuable public benefits lost if traditional Medicare is replaced by Medicare Advantage. Our apologies for a longer-than-usual post … too many Medicare Advantage failings to review!

(HJM bolding for key points)

Government Watchdogs Attack Medicare Advantage for Denying Care and Overcharging, KHN, June 29, 2022, by Fred Schulte

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel Tuesday.

Witnesses sharply criticized the fast-growing health plans at a hearing held by the Energy and Commerce subcommittee on oversight and investigations. They cited a slew of critical audits and other reports that described plans denying access to health care …

Rep. Diana DeGette (D-Colo.), chair of the subcommittee, said seniors should not be “required to jump through numerous hoops” to gain access to health care.

The watchdogs also recommended imposing limits on home-based “health assessments,” arguing these visits can artificially inflate payments to plans without offering patients appropriate care. …

Bliss said seniors “may not be aware that they may face greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare.”

Leslie Gordon, of the Government Accountability Office, the watchdog arm of Congress, said seniors in their last year of life had dropped out of Medicare Advantage plans at twice the rate of other patients leaving the plans.

Rep. Frank Pallone Jr. (D-N.J.), who chairs the influential Energy and Commerce Committee, said he was “deeply concerned” to hear that some patients are facing “unwarranted barriers” to getting care.

James Mathews, who directs the Medicare Payment Advisory Commission, which advises Congress on Medicare policy, said Medicare Advantage could lower costs and improve medical care but “is not meeting this potential” despite its wide acceptance among seniors.

Notably absent from the hearing witness list was anyone from CMS, which runs the $350 billion-a-year program.

[CMS] officials clearly knew years ago that some health plans were abusing the payment system to boost profits yet for years ran the program as what one CMS official called an “honor system.”

CMS aimed to change things starting in 2007, when it rolled out an audit plan called “Risk Adjustment Data Validation,” or RADV. Health plans were directed to send CMS medical records that documented the health status of each patient and return payments when they couldn’t.

The results were disastrous, showing that 35 of 37 plans picked for audit had been overpaid, sometimes by thousands of dollars per patient. Common conditions that were overstated or unable to be verified ranged from diabetes with chronic complications to major depression.

Yet CMS still has not completed audits dating as far back as 2011, through which officials had expected to recoup more than $600 million in overpayments caused by unverified diagnoses.

Medicare Advantage Enrollment Growth Implications for the US Health Care System, JAMA, June 28, 2022, by Gretchen Jacobson & David Blumenthal

Medicare Advantage will be the dominant source of Medicare coverage by 2025. This development creates significant challenges ….

[T]he need to find new ways to set Medicare Advantage payment rates. Currently, Medicare Advantage plans in local markets are paid to cover Medicare benefits based on the average costs of providing those same benefits to patients in traditional Medicare within the same market. Yet, basing payments on the costs of covering remaining enrollees in traditional Medicare will be less appropriate as these individuals become less and less representative of the Medicare population…

[P]otential loss of the vital role that traditional Medicare has had in shaping the health care system generally. Traditional Medicare has led the way in developing quality standards and measures that have been widely applied and in transparently sharing results with the public.

[T]raditional Medicare claims data provide the only nationwide source of consistent, comparable information on patterns of care throughout the country. … have enabled important observations about variability in care within and across geographic areas, and have informed policies to reduce variation, reduce unnecessary spending, and improve the quality of care.

[T]raditional Medicare has helped support rural health care centers and fund graduate medical education. …

[Q]uality and utilization data that traditional Medicare has accumulated on individual clinicians and health care centers are not currently accessible for those same entities serving patients enrolled in Medicare Advantage plans. … Medicare Advantage organizations and their clinicians and health centers are not reimbursed based on encounter data, and thus do not have the same incentives to submit complete and accurate information.

A Medicare Advantage–dominated system also raises questions about how Medicare would work through private plans to achieve the many other public purposes that Medicare has served. Traditional Medicare’s increased payments for clinicians and health care centers in rural areas have helped to maintain access to care for rural populations.

… looming challenges created by the impending transformation of Medicare into a system primarily consisting of competing for-profit health organizations. … [and] consider how to compensate for the vital information about the US health care system that could be lost with the decline of traditional Medicare. …

[C]onsider how to sustain Medicare’s record of innovation in payment and delivery system reform in a program in which the nature and results of innovation are increasingly the proprietary property of private entities. CMMI will have to develop methods to take full advantage of a much more modest traditional Medicare testing ground. Medicare also will have to consider whether and how to incentivize or encourage private organizations to share their most promising innovations— undertaken with public funds—so that Medicare can fulfill its obligations to all beneficiaries and, as a public program, to the health care system generally.

Comment:

By Jim Kahn, M.D., M.P.H.

Two unrelated reports on problems with Medicare Advantage, the private insurer side of Medicare:

KHN (Kaiser Health News) lists Medicare Advantage problems discussed in a Congressional hearing: care barriers and denials; excess home health assessments designed to inflate capitation payments; audits revealing widespread overpayment yet languishing >10 years; patients switching to traditional Medicare at the end of life when medical needs rise; Medicare Advantage failing to realize purported advantages; CMS missing in action (and from the hearing).

It’s a familiar story. Promise improved quality and lowered costs for CMS. Fail to achieve those goals (despite claims of success). Game the system to boost capitation payments and avoid meaningful oversight. These revelations aren’t news, indeed are noted regularly in HJM. Yet on and on it goes. CMS – the regulator asleep at the wheel – declined to testify (they can do that?).

The article by Jacobson & Blumenthal is more arcane – about how the traditional fully public fee-for-service part of Medicare has provided consistent national data on medical claims to help improve care and simple methods to adjust payments to support rural areas and medical education. They want CMS to somehow achieve the same abilities with Medicare Advantage, despite the variation and opacity implicit with a multitude of private insurance plans. There’s no indication it can ever happen.

Unfortunately, now traditional Medicare is pursuing a Medicare Advantage look-alike strategy. Engineered by CMS via the REACH program, for-profit ACO “entities” receive a capitated amount per patient. It will yield the same dynamics and vulnerabilities as Medicare Advantage. HJM has written often on this. CMS is catering to corporate interests.

In sum: myriad severe limitations associated with growing privatization of Medicare. There seems to be an implication around here somewhere … oh, I see it. Why don’t we transform Medicare into a fully public system, with no role for profit-seeking intermediaries, like it used to be? While we’re at it, let’s adopt the system universally, replacing private insurance, Medicaid, etc. Just like dozens of other countries. We could call it a “single payer.”

http://healthjusticemonitor.org…

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Summary: An important study in the United Kingdom finds that care contracting with for-profit companies sharply raises preventable mortality. Privatization with for-profit providers threatens health outcomes in the UK and, as we have argued before, in the US.

Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013–20: an observational study of NHS privatisation, The Lancet Public Health July 1, 2022, by Benjamin Goodair and Aaron Reeves

Summary:

Background: The effects of outsourcing health services to for-profit providers are contested, with some arguing that introducing such providers will improve performance through additional competition while others worry that this will lead to cost cutting and poorer outcomes for patients. We aimed to examine this debate by empirically evaluating the impact of outsourced spending to private providers, following the 2012 Health and Social Care Act, on treatable mortality rates and the quality of health-care services in England.

Methods: For this observational study, we used a novel database composed of … procurement contracts between April 1, 2013, and Feb 29, 2020 (n=645 674…), across 173 clinical commissioning groups (CCGs; regional health boards) in England … identifying [providers] as National Health Service (NHS) organisations, for-profit companies, or charities. We supplemented these data with rates of local mortality from causes that should be treatable by medical intervention, indicating the quality of health-care services. …

Findings: We found that an annual increase of one percentage point of outsourcing to the private for-profit sector corresponded with an annual increase in treatable [preventable] mortality of 0·38% (95% CI 0·22–0·55; p=0·0016) or 0·29 (95% CI 0·09–0·49; p=0·0041) deaths per 100 000 population in the following year. This finding was robust to matching on background characteristics, adjusting for possible confounding factors, and measurement error in our dataset. Changes to for-profit outsourcing since 2014 were associated with an additional 557 (95% CI 153–961) treatable deaths across the 173 CCGs.

Interpretation: The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased in 2013–20. Private sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of health-care services.

Comment:

By Don McCanne, M.D.

Recently the founders of Physicians for a National Health Program and colleagues (including me) published an article in The Nation indicating why single payer Medicare for All is not enough and community ownership of the delivery system should be involved as well – a system like the British National Health Service. See our HJM post about that here.

In the meantime, our British friends have been experimenting with the alleged benefits of for-profit competition in health care, much as is promoted by the privatizers in our country – here privatizing both the delivery system and the payment/insurance system. Although we had plenty of data to show them the adverse consequences, nevertheless they proceeded with their studies and showed that their outsourcing of services to the private, for-profit sector significantly increased the rates of treatable mortality. Their experiment with privatizing health care killed patients.

(On a personal note, please excuse my repetition of a theme I have covered before. Having recently been exposed to a series of grand mal seizures which left me in a comatose state, I was placed in “hospice at home.” But fortunately having eventually partially recovered again, I felt like I had to take this opportunity to pound home once more real reform instead of being contented with incrementalism that takes such good care of private equity in health care but leaves millions of patients in need poorly served or not served at all. I know I won’t be around to see the reform we need, but maybe some of you will have your passion drive turned up to the level that we can get the job done. I know I can’t quit, so don’t you either.)

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Summary: Independence Day is about celebrating freedom. Let’s contemplate the freedoms we can achieve with universal health insurance.

Comment:

By Jim Kahn, M.D., M.P.H.

On this day in 1776 we declared independence from Great Britain. We asserted, and soon realized, our desire to be free of overseas control and exploitation – political, religious, and financial. Thus was the US founded in freedom (if initially only for white men).

Yet freedoms often conflict with each other, and with our communal goals. The freedom to vote runs up against a claimed freedom to establish local election rules. The freedom to do business conflicts with a commitment to workers, consumers, and the environment. Our independence relies in critical and complex ways on our interdependence. Individual freedom must be balanced with collective welfare.

In health, the balance is askew.

Freedom to profit financially is taken as paramount. Insurers, pharmaceutical companies, and many providers profit outrageously by charging high prices for services that are rationed or cost pennies to produce.

To that profit altar we sacrifice all the other freedoms that should prevail:

• Freedom to seek quality health care without impediment.
• Freedom to choose providers.
• Freedom to select therapies.
• Freedom from medical debt.
• Freedom from administrative barriers and hassles.

These health care freedoms are due to us all, regardless of economic status, race, gender, and citizenship.

We all deserve the freedom to enjoy the “free lunch” that is single payer: cheaper and better.

Freedom means placing community welfare over individual financial gain.

That’s the country I’m rooting for today, and every day.

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Summary: Today’s post by a visiting blogger reflects on recent policy think tank reports on medical debt, and bemoans the lack of attention to a much-needed major financing makeover.

Comment:

By Ana Malinow, M.D.

It always goes like this: excellent reporting and analysis from the best health policy think tanks detailing how the US health care system is failing, building up to a crescendo that surpasses credulity, followed by a conclusion full of banal suggestions as to how we can address these failures. The storyline never deviates.

Take the Urban Institute’s Which County Characteristics Predict Medical Debt? (covered yesterday in HJM), which maps the geographic distribution and drivers of medical debt, a problem unknown in other high-income countries. To our dismay, we find that “the county’s prevalence of chronic conditions is the strongest predictor of a county’s medical debt in collections.” That means, these human beings and their families, who should be worried about their health, are instead worried about their bills.

And the policy insights to address this unimaginable suffering? Let’s see: first, because many of the counties with the highest rates of medical debt are from states which didn’t expand Medicaid, let’s expand Medicaid, the country’s racialized, second-class health care system for the poor. Forget that these people with chronic illnesses will have to prove their poverty month after month to meet criteria.

What else does the Urban Institute suggest? Consumer protections against surprise bills, even though the Kaiser Family Foundation just wrote that “surprise bills” represent just a fraction of the unexpected and large medical bills many Americans face. Oh, and yes, increase these poor people’s access to more credit, so they can become even more indebted.

What Urban Institute also finds, yet never elaborate upon, is that “counties with a higher share of the population ages 65 and older have lower rates of medical debts in collections.” That’s the age when people become eligible for Medicare – near universal coverage for the elderly. Not worth highlighting, apparently.

I can’t say with certainty what’s driving these very modest policy proposals rather than system-changing reform. I do know that Urban Institute funding is from mainstays of the current system. According to their 2020 Annual Report, that’s 35% federal government (including HHS and MedPAC), 34% foundations (including Merck, Walmart, Gates, Charles Koch Institute, and Walton Family), and 20% corporations (including JP Morgan Chase, Wells Fargo, Bank of America, Salesforce, AARP, Amazon, GM, Microsoft, QuickenLoans, Blue Shield Blue Cross Massachusetts, H&R Block, Lyft, National Associations of Realtors, etc).

And while we are on the subject of excellent reporting and analysis with lame conclusions, the Kaiser Family Foundation, in their recent publication on the burden of medical debt (covered in HJM) goes through excruciating detail describing who has medical debt: just about anyone in the US, but especially people with disabilities, those in worse health, those who live in poverty, Black Americans, people living in the South, and again, people living in Medicaid non-expansion states. At least the KFF has the integrity to write that “simply expanding coverage” will not solve the problem of medical debt in the US. But they refuse to connect the dots they so painstakingly displayed to major system change.

A national, single payer, universal, comprehensive, accessible, equitable health care system would abolish medical debt. Think about it. Why not just come out and say it?

Dr. Malinow is a pediatrician, former president of PNHP, and lead organizer for National Single Payer.

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Summary: Recently we reported on a national survey of medical debt. A new report uses credit bureau data to describe which local factors predict high levels of medical debt in collections. They are: being in the South, % of population with 4 or more chronic medical conditions, % low birth weight, % uninsured, % Black, low average income, and high medical spending.

Which County Characteristics Predict Medical Debt?, Urban Institute, June 15, 2022, by Fredric Blavin, et al.

Medical debt is a critical challenge to Americans’ financial stability and well-being. We use unique Urban Institute credit bureau data on more than 10 million consumers to investigate (1) where people are more likely to have medical debt in collections and (2) which county-level socioeconomic and health characteristics predict medical debt. We find that 79 out of the 100 counties with highest levels of medical debt in collections are in states that have not expanded Medicaid under the Affordable Care Act. These counties are mostly concentrated in Georgia, North Carolina, and Texas. We also find that a county’s prevalence of chronic conditions is the strongest predictor of medical debt in collections. In addition, counties with high shares of uninsured, low-income, or Black populations have higher rates of medical debt in collections. We offer a few insights on policies that can reduce medical debt, such as Medicaid expansion and consumer protections through the No Surprises Act.

Comment:

By Jim Kahn, M.D., M.P.H.

Black spots on the US map indicate that >30% of consumers have medical debt in collections. Not just medical debt, but in formal collections processes. Darker blue areas are at 20-30%.

Predictors include high rates of uninsurance, and related to that living in states with no ACA Medicaid expansion. Also the usual markers of vulnerability: % sick with multiple chronic conditions, % low birth weight, % low income, and % Black.

What is wrong with our country that we waste >$600 billion yearly on administrative complexity and profits for a fractured insurance system that torments the most vulnerable among us with financial problems related to getting medical care? We stand alone among wealthy countries in this cruelty.

Our health care financing system is a massive failure — inefficient, unkind, and deadly. No tweaks will fix its fundamental problems. How much clearer could that be?

We must find a way to transform today’s crises into a health system and country we can be proud of.

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Summary: Reflection seems the order of the day. US politics are in turmoil. Health insurance problems and the need for single payer are clearer than ever. How do we put it all together?

Talk World Radio: James G. Kahn on 300,000 U.S. COVID Deaths from Lack of Universal Healthcare (and other issues), 28 minutes

Comment:

By Jim Kahn, M.D., M.P.H.

Today we’re sharing an interview about our study on excess COVID deaths caused by high rates of uninsurance. We discussed a wide variety of issues in the framing of health insurance problems and reform.

Meantime, I’m contemplating next steps in the single payer movement, given recent momentous national political developments. More on that soon.

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Summary: Yesterday the Supreme Court reversed 50 years of abortion rights established by Roe v. Wade. This attack on reproductive rights and health is an integral part of a broader half-century undermining of our democratic system. The fights to save democracy and provide universal healthcare are linked.

Letters from an American, June 24, 2022, by Heather Cox Richardson

At yesterday’s hearing of the House Select Committee to Investigate the January 6th Attack on the U.S. Capitol, we heard overwhelming proof that former president Trump and his congressional supporters tried to overturn the will of the voters in the 2020 presidential election and steal control of our country to keep a minority in power.

Today, thanks to three justices nominated by Trump, the Supreme Court stripped a constitutional right from the American people, a right we have enjoyed for almost 50 years, a right that is considered a fundamental human right in most liberal democracies, and a right they indicated they would protect because it was settled law. Today’s Dobbs v. Jackson Women’s Health Organization decision overturned the 1973 Roe v. Wade decision that recognized a woman’s right to terminate a pregnancy. For the first time in our history, rather than conveying rights, the court has explicitly taken a constitutional right away from the American people.

These two extraordinary events are related. The current-day Republican Party has abandoned the idea of a democracy in which a majority of the people elect their government. Instead, its members have embraced minority rule.

The Dobbs decision marks the end of an era: the period in American history stretching from 1933 to 1981, the era in which the U.S. government worked to promote democracy. It tried to level the economic playing field between the rich and the poor by regulating business and working conditions. It provided a basic social safety net through programs like Social Security and Medicare …

Now the Republicans are engaged in the process of dismantling that government. …

[The Dobbs decision argued] that the right to determine abortion rights must be returned “to the people’s elected representatives” at the state level, even as states are restricting the right to vote. …

We are still waiting on another potentially explosive decision in West Virginia v. Environmental Protection Agency, in which the court will decide if Congress can delegate authority to government agencies as it has done since the 1930s. If the court says Congress can’t delegate authority, even if it waters that argument down, government regulation could become virtually impossible.

Comment:

By Jim Kahn, M.D., M.P.H.

Make no mistake about it, yesterday’s Supreme Court decision to reverse Roe v. Wade, clearly an attack on reproductive health and women’s rights, is also integral to a broader attack on democracy. It is latest development in a decades-long concerted effort to deconstruct the federal assertion and protection of rights that started in earnest with FDR 90 years ago, and to exploit our biased electoral system to empower a minority to implement that agenda. The latest twist, we are reminded in the January 6 Congressional hearings, is that the GOP is willing to use big lies and subversion of basic democratic processes to complete their slow coup. Heather Cox Richardson, as usual, sees all the connections. I encourage you to read her full post.

Single payer is profoundly pro-democratic, as I’ve repeatedly written in HJM. It is universal, equitable, economically leveling, and guided by representatives of the people not of corporate shareholders. Thus, the fight for universal healthcare and for real democracy have linked core values. I believe that mending our health care financing will help mend our fractured democracy. But are these two goals linked strategically? Does the fight for single payer bolster efforts to preserve democracy? Does preserving democracy tactically advance the single payer cause? My intuition says yes, but I don’t yet understand the integrated battle plan. I’ll revert on that.

I’ll close with a reminder that this is not just about governance and human rights, it’s also about life and death. Ample research demonstrates that restricting access to abortion raises maternal and even infant mortality. The new decision and subsequent state actions to restrict or ban abortion will cause many hundreds of added deaths per year. The evidence can be seen here, here, here, here, and here.

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