Health Insurance Exchanges May Be Too Small to Succeed

By Dana P. Goldman, Michael Chernew and Anupam Jena
The New York Times, November 23, 2012
With the re-election of President Obama, the Affordable Care Act is back on track for being carried out in 2014. Central to its success will be the creation of health-insurance exchanges in each state. Beneficiaries will be able to go to a Web site and shop for health insurance, with the government subsidizing the premiums of those whose qualify. By encouraging competition among insurers in an open marketplace, the health care law aims to wring some savings out of the insurance industry to keep premiums affordable.
Certainly, it is hard to be against competition. Economic theory is clear about its indispensable benefits. But not all health care markets are composed of rational, well-informed buyers and sellers engaged in commerce. Some have a limited number of service providers; in others, patients are not well informed about the services they are buying; and in still others, the quality of the service offerings vary from provider to provider. So the question is: What effect does insurer competition have in a marketplace with so many imperfections?
The evidence is mixed, but some of it points to a counterintuitive result: more competition among insurers may lead to higher reimbursements and health care spending, particularly when the provider market – physicians, hospitals, pharmaceuticals and medical device suppliers – is not very competitive.
In imperfect health care markets, competition can be counterproductive. The larger an insurer’s share of the market, the more aggressively it can negotiate prices with providers, hospitals and drug manufacturers. Smaller hospitals and provider groups, known as “price takers” by economists, either accept the big insurer’s reimbursement rates or forgo the opportunity to offer competing services. The monopsony power of a single or a few large insurers can thus lead to lower prices. For example, Glenn Melnick and Vivian Wu have shown that hospital prices in markets with the most powerful insurers are 12 percent lower than in more competitive insurance markets.
So health insurance exchanges are probably welcome news for hospitals, physicians, and pharmaceutical and medical device companies throughout the United States. If health insurance exchanges divide up the market among many insurers, thereby diluting their power, reimbursement rates may actually increase, which could lead to higher premiums for consumers.
There is some evidence on how insurer market power affects premiums. Leemore Dafny, Mark Duggan, and Subramaniam Ramanarayanan have found that greater concentration resulting from an insurance merger is associated with a modest increase in premiums — suggesting that concentration may not help consumers so much — although they did report a reduction in physician earnings on average. Over all, however, the evidence is limited and mixed.
Greater competition in the insurance industry — either through health insurance exchanges or other measures — may not lower insurance premiums. Weakening insurers’ bargaining power could instead translate into higher costs for all of us in the form of higher premiums.
In financial markets, we ask if banks are too big to fail. When it comes to health care, perhaps we should ask if insurers are too small to succeed.

It is true that very large insurers within the exchanges can use their monopsony power (controlling the market as exclusive buyers) by demanding lower prices for health care services, but only for their own plans. Most health care costs will still be covered by employer-sponsored plans, Medicare, Medicaid and other programs. Thus plans offered by the exchanges cannot have much impact on our total national health expenditures.
Another difficulty with the monopsony power of private insurers is that when they are investor owned (WellPoint, UnitedHealth, Aetna, etc.), their first priority must be to use their leverage to benefit their investors. That results in insurance innovations that often are not particularly transparent, but have adverse consequences for the patients they insure. The private sector exercising power as a monopsony can be as evil as a monopoly.
In contrast, a public monopsony can be very beneficial in getting prices right – high enough to ensure adequate capacity in the delivery system, yet low enough to ensure value in health care.
The ultimate beneficent monopsony would be a single public program covering absolutely everyone (“single payer”). We could achieve this easily by improving Medicare and then making it universal. Health policy studies have proven that this would not only cover everyone, but it would finally bring us that elusive goal of health care reform – bending the cost curve to sustainable levels.
http://economix.blogs.nytimes.com/2012/11/23/health-insurance-exchanges-…

HealthCare.gov (HHS)
November 20, 2012

On November 20, 2012, the Department of Health and Human Services (HHS) published a proposed rule that helps consumers shop for and compare non-grandfathered private health insurance options in the individual and small group markets by promoting consistency across plans, and protecting consumers by ensuring that plans cover a core package of items and services.

Specifically, this rule outlines health insurance issuer standards related to the coverage of essential health benefits (EHB) and the determination of actuarial value (AV), while providing significant flexibility to states to shape how EHB are defined.

The Affordable Care Act sets forth that EHB be equal in scope to benefits offered by a “typical employer plan.”  To meet this requirement in every state, the proposed rule defines EHB based on a state-specific benchmark plan, including the largest small group health plan in the state. The rule proposes that states select a benchmark plan from among several options identified in the proposed rule, and that all plans that cover EHB must offer benefits that are substantially equal to the benefits offered by the benchmark plan. This approach balances consumers’ desires for an affordable and comprehensive benefit package, our legal requirement to reflect the current marketplace, and issuer flexibility to offer innovative benefit designs and a choice of health plans.

http://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.html

And…

AHIP Statement on ACA Implementation

America’s Health Insurance Plans (AHIP)
November 20, 2012

America’s Health Insurance Plans (AHIP) President and CEO Karen Ignagni released the following statement on proposed rules released today by the U.S. Department of Health and Human Services on implementation of the Affordable Care Act (ACA):

“As implementation of the ACA moves forward, the focus needs to be on affordability for consumers and employers.

“For health insurance exchanges and new insurance market rules to work, coverage needs to be affordable and there needs to be broad participation in the system.  While additional flexibility on essential health benefits (EHB) is a positive step, we remain concerned that many families and small businesses will be required to purchase coverage that is more costly than they have today.  It also is important to recognize that the new EHB requirements will coincide with the new restrictions in age rating rules that also go into effect on January 1, 2014.  Both of these provisions may incentivize young, healthy people to wait to purchase insurance until they are sick or injured, driving up costs for everyone with insurance.”

http://www.ahipcoverage.com/2012/11/20/ahip-statement-on-aca-implementation/

Comment:

By Don McCanne, MD

The Department of Health and Human Services has provided states with considerable flexibility in establishing essential health benefits (EHB) in the individual and small group insurance markets. The states will not have to require benefits that are typical of large employer health benefit programs, but rather the benefits will correspond to existing small group plans, as long as some services in each of ten required categories are included. These plans will be inadequate for those who require benefits that are not covered, not to mention the limitations of excess cost sharing and insufficient provider networks.

Yet the insurance lobby group, AHIP, complains that many families and small businesses would have to purchase coverage that is more costly than they have today. The reason that plans with the minimal essential benefits would be more costly is that the current individual and small group market is saturated with plans that are so substandard that they fail to provide adequate financial security in the face of medical need. With the new essential health benefits requirement, the insurance industry would lose the right to sell these highly profitable, but substandard plans. They will have to raise their standards to the level of mediocrity, as required by the new EHB rule.

Once again they state that “coverage needs to be affordable.” They have previously stated that health care costs need to be controlled, but, in the absence of any truly effective method of doing that, they need to be able to use innovative product design to keep their premiums competitive in the insurance market. The new EHB rule along with the actuarial value rule allows them the flexibility to be quite innovative. The bottom line is that in the conflict between affordable insurance premiums and adequate protection for patients, they will always choose to protect their market rather than protect patients.

The insurance industry understandably is interested in its own welfare. If that means compromising the adequacy of their plans, then so be it. But does that mean that we have to accept compromise in our health and in our financial security? We wouldn’t if we dismissed the private insurers and established our own improved Medicare program for everyone.

Essential Health Benefits, Actuarial Value, and Accreditation Standards: Ensuring Meaningful, Affordable Coverage

HealthCare.gov (HHS)
November 20, 2012
On November 20, 2012, the Department of Health and Human Services (HHS) published a proposed rule that helps consumers shop for and compare non-grandfathered private health insurance options in the individual and small group markets by promoting consistency across plans, and protecting consumers by ensuring that plans cover a core package of items and services.
Specifically, this rule outlines health insurance issuer standards related to the coverage of essential health benefits (EHB) and the determination of actuarial value (AV), while providing significant flexibility to states to shape how EHB are defined.
The Affordable Care Act sets forth that EHB be equal in scope to benefits offered by a “typical employer plan.”  To meet this requirement in every state, the proposed rule defines EHB based on a state-specific benchmark plan, including the largest small group health plan in the state. The rule proposes that states select a benchmark plan from among several options identified in the proposed rule, and that all plans that cover EHB must offer benefits that are substantially equal to the benefits offered by the benchmark plan. This approach balances consumers’ desires for an affordable and comprehensive benefit package, our legal requirement to reflect the current marketplace, and issuer flexibility to offer innovative benefit designs and a choice of health plans.
http://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.html
And…

AHIP Statement on ACA Implementation

America’s Health Insurance Plans (AHIP)
November 20, 2012
America’s Health Insurance Plans (AHIP) President and CEO Karen Ignagni released the following statement on proposed rules released today by the U.S. Department of Health and Human Services on implementation of the Affordable Care Act (ACA):
“As implementation of the ACA moves forward, the focus needs to be on affordability for consumers and employers.
“For health insurance exchanges and new insurance market rules to work, coverage needs to be affordable and there needs to be broad participation in the system.  While additional flexibility on essential health benefits (EHB) is a positive step, we remain concerned that many families and small businesses will be required to purchase coverage that is more costly than they have today.  It also is important to recognize that the new EHB requirements will coincide with the new restrictions in age rating rules that also go into effect on January 1, 2014.  Both of these provisions may incentivize young, healthy people to wait to purchase insurance until they are sick or injured, driving up costs for everyone with insurance.”
http://www.ahipcoverage.com/2012/11/20/ahip-statement-on-aca-implementat…

The Department of Health and Human Services has provided states with considerable flexibility in establishing essential health benefits (EHB) in the individual and small group insurance markets. The states will not have to require benefits that are typical of large employer health benefit programs, but rather the benefits will correspond to existing small group plans, as long as some services in each of ten required categories are included. These plans will be inadequate for those who require benefits that are not covered, not to mention the limitations of excess cost sharing and insufficient provider networks.
Yet the insurance lobby group, AHIP, complains that many families and small businesses would have to purchase coverage that is more costly than they have today. The reason that plans with the minimal essential benefits would be more costly is that the current individual and small group market is saturated with plans that are so substandard that they fail to provide adequate financial security in the face of medical need. With the new essential health benefits requirement, the insurance industry would lose the right to sell these highly profitable, but substandard plans. They will have to raise their standards to the level of mediocrity, as required by the new EHB rule.
Once again they state that “coverage needs to be affordable.” They have previously stated that health care costs need to be controlled, but, in the absence of any truly effective method of doing that, they need to be able to use innovative product design to keep their premiums competitive in the insurance market. The new EHB rule along with the actuarial value rule allows them the flexibility to be quite innovative. The bottom line is that in the conflict between affordable insurance premiums and adequate protection for patients, they will always choose to protect their market rather than protect patients.
The insurance industry understandably is interested in its own welfare. If that means compromising the adequacy of their plans, then so be it. But does that mean that we have to accept compromise in our health and in our financial security? We wouldn’t if we dismissed the private insurers and established our own improved Medicare program for everyone.

By Eric N. Momin, MD; Hadie Adams, MD; Russell T. Shinohara, PhD; Constantine Frangakis, PhD; Henry Brem, MD; Alfredo Quiñones-Hinojosa, MD
Archives of Surgery, November 2012

Among patients with brain tumors with no other major medical condition, uninsured patients (but not necessarily Medicaid recipients) have higher in-hospital mortality than privately insured patients, a disparity that was pronounced in teaching hospitals. These findings further reinforce prior data indicating insurance-related disparities in medical and surgical settings.

These insurance-related disparities might be explained by 1 of 3 possible mechanisms. Insurance status could influence health outcomes by affecting (1) a patient’s overall state of health, (2) the ability to access care (affecting the acuity of disease presentation), or (3) the quality of treatment that is provided.

Insurance-related disparities are not unique to the field of neurosurgery. Uninsured patients fare worse than privately insured patients in the settings of critical illness (higher chance of having life support withdrawn), ischemic or hemorrhagic stroke (higher mortality and neurologic impairment), myocardial infarction (higher mortality), and physical trauma (higher mortality). However, it is not clear that enrolling in a state-funded health plan would help the uninsured because Medicaid recipients also seem to experience a similar disparity in other settings, including pneumonia, appendicitis, abdominal aortic aneurysm repair, limb-threatening ischemia, and surgery for colorectal carcinoma. Of note, this Medicaid disparity was also present in our full cohort but was not convincingly present in the adjusted analysis of patients with no comorbid disease, especially in teaching hospitals.

http://archsurg.jamanetwork.com/article.aspx?articleid=1392156

Comment:

By Don McCanne, MD

Uninsured patients operated on for brain tumors have a higher in-hospital mortality than do insured patients. Regardless of the reasons why, this study adds to the abundance of studies that demonstrate that being uninsured can be bad for your health. Even patients with Medicaid may experience similar adverse outcomes.

The Affordable Care Act will leave 30 million uninsured, and it relies partially on Medicaid to expand coverage. Thus the Affordable Care Act may still be bad for the health of many of us.

We need a single program that provides all of us with high quality care – an improved Medicare for all. We should not put up with a deficient health care program that leaves some of us sick or even dead.

Postoperative Mortality After Surgery for Brain Tumors by Patient Insurance Status in the United States

By Eric N. Momin, MD; Hadie Adams, MD; Russell T. Shinohara, PhD; Constantine Frangakis, PhD; Henry Brem, MD; Alfredo Quiñones-Hinojosa, MD
Archives of Surgery, November 2012
Among patients with brain tumors with no other major medical condition, uninsured patients (but not necessarily Medicaid recipients) have higher in-hospital mortality than privately insured patients, a disparity that was pronounced in teaching hospitals. These findings further reinforce prior data indicating insurance-related disparities in medical and surgical settings.
These insurance-related disparities might be explained by 1 of 3 possible mechanisms. Insurance status could influence health outcomes by affecting (1) a patient’s overall state of health, (2) the ability to access care (affecting the acuity of disease presentation), or (3) the quality of treatment that is provided.
Insurance-related disparities are not unique to the field of neurosurgery. Uninsured patients fare worse than privately insured patients in the settings of critical illness (higher chance of having life support withdrawn), ischemic or hemorrhagic stroke (higher mortality and neurologic impairment), myocardial infarction (higher mortality), and physical trauma (higher mortality). However, it is not clear that enrolling in a state-funded health plan would help the uninsured because Medicaid recipients also seem to experience a similar disparity in other settings, including pneumonia, appendicitis, abdominal aortic aneurysm repair, limb-threatening ischemia, and surgery for colorectal carcinoma. Of note, this Medicaid disparity was also present in our full cohort but was not convincingly present in the adjusted analysis of patients with no comorbid disease, especially in teaching hospitals.
http://archsurg.jamanetwork.com/article.aspx?articleid=1392156

Uninsured patients operated on for brain tumors have a higher in-hospital mortality than do insured patients. Regardless of the reasons why, this study adds to the abundance of studies that demonstrate that being uninsured can be bad for your health. Even patients with Medicaid may experience similar adverse outcomes.
The Affordable Care Act will leave 30 million uninsured, and it relies partially on Medicaid to expand coverage. Thus the Affordable Care Act may still be bad for the health of many of us.
We need a single program that provides all of us with high quality care – an improved Medicare for all. We should not put up with a deficient health care program that leaves some of us sick or even dead.

By Cathy Schoen, Robin Osborn, David Squires, Michelle Doty, Petra Rasmussen, Roz Pierson and Sandra Applebaum
Health Affairs, November 15, 2012

To explore the experiences of physicians as health reform policies unfold, we surveyed primary care physicians in the following ten countries in 2012: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, the United Kingdom, and the United States.

***
Swiss and US patients often face substantial deductibles as well as cost sharing, although Swiss health insurance standards reduce rates for low-income people and limit out-of-pocket liability to levels well below those in the United States.

***
The United States is alone among the study countries in segmenting the population by income and age for government-sponsored health insurance and in its lack of coordinated policies across multiple private and public insurers.

***
US and Canadian physicians’ responses to questions regarding after-hours arrangements mirror patients’ experiences: In the 2010 international population survey on patient experience with health care services, Canadian and US patients were more likely than those in other countries to have used emergency departments and among the most likely to say that it was difficult to obtain health care after hours.

***
In 2012, 59 percent of US physicians said that their patients often have difficulty paying out-of-pocket costs for medical care – a percentage well above that in any other country.

***
In the United States, physicians’ perceptions of affordability or difficulties getting specialized care varied by patient insurance mix. Doctors with high proportions of uninsured or Medicaid patients were the most likely to say that their patients often faced long waits for specialized care.

***
To gauge primary care physicians’ perspectives overall, the survey asked about their views of their country’s health system, their satisfaction with the practice of medicine, and their perceptions of change in recent years. Repeating a pattern observed in earlier surveys, US and German physicians were the most negative about their health care systems, with only 15 percent and 22 percent, respectively, saying that the system needs only minor changes versus fundamental change or rebuilding. German and US physicians were also the least likely to say that they were satisfied or very satisfied with practicing medicine.

***
As countries aim to reduce health care costs, some countries have looked to coverage restrictions on treatments or medications or to reviews of physician care decisions. Although such interventions may target the appropriateness of care, they can also have the unintended consequence of imposing time and administrative burdens on physicians. Among the study countries, US physicians were the most likely to say that such time concerns are a major problem: More than half of US respondents said that they or their staff spend too much time getting patients care because of coverage restrictions on treatment or medications.

Notably, the share of Dutch doctors expressing concern about this issue has more than doubled since the 2009 survey (increasing from 10 percent to 26 percent). This suggests that problems are emerging with the growing complexity of health insurance practices in the Netherlands.

***
Regarding after-hours access to primary health care services, all of the study countries except the United States and Canada have policies for after-hours coverage. The low rates of after-hours arrangements reported by Canadian and US physicians indicate that such arrangements are slow to develop if they must depend on the actions of individual practices.

***
Insurance design also matters. US physicians stand out, as they have in past surveys, for saying that their patients often have difficulty paying for care and that insurance restrictions on care decisions consume substantial doctor and staff time. The other countries in the study all provide universal coverage and, with the exception of Switzerland, have little or no cost sharing for primary care and essential medications. All of the other countries limit out-of-pocket expenses to levels well below those typical in US insurance.

In contrast to other countries with multiple insurers, US private insurers often use prior authorization and employ varying drug formularies and complex benefit designs, with little standardization. Recent studies confirm that the resulting insurance-related complexity adds substantially to US practice costs as a result of increased paperwork and time demands.

In patient surveys, the United States also stands out for insurance-related time concerns. US experiences provide a cautionary example for other countries regarding the time and resource costs of complexity.

***
In general, US primary care physicians’ views and experiences endorse the need for reform, including enhanced access. US physicians who reported that their patients often faced cost or other access barriers were the most likely to say that the system required major change.

http://content.healthaffairs.org/content/early/2012/11/13/hlthaff.2012.0884.abstract

Comment:

By Don McCanne, MD

We spend by far the most money per capita on health care. Yet, compared to primary care physicians in other nations, U.S. physicians are by far the most negative about our health system, with only 15 percent saying that “the system needs only minor changes” (versus fundamental change or rebuilding).

The perspective provided by the excerpts posted above should drive the citizens of our nation to demand comprehensive reform. Are we up to it?

A Survey Of Primary Care Doctors In Ten Countries Shows Progress In Use Of Health Information Technology, Less In Other Areas

By Cathy Schoen, Robin Osborn, David Squires, Michelle Doty, Petra Rasmussen, Roz Pierson and Sandra Applebaum
Health Affairs, November 15, 2012

To explore the experiences of physicians as health reform policies unfold, we surveyed primary care physicians in the following ten countries in 2012: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, the United Kingdom, and the United States.

***
Swiss and US patients often face substantial deductibles as well as cost sharing, although Swiss health insurance standards reduce rates for low-income people and limit out-of-pocket liability to levels well below those in the United States.

***
The United States is alone among the study countries in segmenting the population by income and age for government-sponsored health insurance and in its lack of coordinated policies across multiple private and public insurers.

***
US and Canadian physicians’ responses to questions regarding after-hours arrangements mirror patients’ experiences: In the 2010 international population survey on patient experience with health care services, Canadian and US patients were more likely than those in other countries to have used emergency departments and among the most likely to say that it was difficult to obtain health care after hours.

***
In 2012, 59 percent of US physicians said that their patients often have difficulty paying out-of-pocket costs for medical care – a percentage well above that in any other country.

***
In the United States, physicians’ perceptions of affordability or difficulties getting specialized care varied by patient insurance mix. Doctors with high proportions of uninsured or Medicaid patients were the most likely to say that their patients often faced long waits for specialized care.

***
To gauge primary care physicians’ perspectives overall, the survey asked about their views of their country’s health system, their satisfaction with the practice of medicine, and their perceptions of change in recent years. Repeating a pattern observed in earlier surveys, US and German physicians were the most negative about their health care systems, with only 15 percent and 22 percent, respectively, saying that the system needs only minor changes versus fundamental change or rebuilding. German and US physicians were also the least likely to say that they were satisfied or very satisfied with practicing medicine.

***
As countries aim to reduce health care costs, some countries have looked to coverage restrictions on treatments or medications or to reviews of physician care decisions. Although such interventions may target the appropriateness of care, they can also have the unintended consequence of imposing time and administrative burdens on physicians. Among the study countries, US physicians were the most likely to say that such time concerns are a major problem: More than half of US respondents said that they or their staff spend too much time getting patients care because of coverage restrictions on treatment or medications.

Notably, the share of Dutch doctors expressing concern about this issue has more than doubled since the 2009 survey (increasing from 10 percent to 26 percent). This suggests that problems are emerging with the growing complexity of health insurance practices in the Netherlands.

***
Regarding after-hours access to primary health care services, all of the study countries except the United States and Canada have policies for after-hours coverage. The low rates of after-hours arrangements reported by Canadian and US physicians indicate that such arrangements are slow to develop if they must depend on the actions of individual practices.

***
Insurance design also matters. US physicians stand out, as they have in past surveys, for saying that their patients often have difficulty paying for care and that insurance restrictions on care decisions consume substantial doctor and staff time. The other countries in the study all provide universal coverage and, with the exception of Switzerland, have little or no cost sharing for primary care and essential medications. All of the other countries limit out-of-pocket expenses to levels well below those typical in US insurance.

In contrast to other countries with multiple insurers, US private insurers often use prior authorization and employ varying drug formularies and complex benefit designs, with little standardization. Recent studies confirm that the resulting insurance-related complexity adds substantially to US practice costs as a result of increased paperwork and time demands.

In patient surveys, the United States also stands out for insurance-related time concerns. US experiences provide a cautionary example for other countries regarding the time and resource costs of complexity.

***
In general, US primary care physicians’ views and experiences endorse the need for reform, including enhanced access. US physicians who reported that their patients often faced cost or other access barriers were the most likely to say that the system required major change.

http://content.healthaffairs.org/content/early/2012/11/13/hlthaff.2012.0884.abstract

Comment:

By Don McCanne, MD

We spend by far the most money per capita on health care. Yet, compared to primary care physicians in other nations, U.S. physicians are by far the most negative about our health system, with only 15 percent saying that “the system needs only minor changes” (versus fundamental change or rebuilding).

The perspective provided by the excerpts posted above should drive the citizens of our nation to demand comprehensive reform. Are we up to it?

A Survey Of Primary Care Doctors In Ten Countries Shows Progress In Use Of Health Information Technology, Less In Other Areas

By Cathy Schoen, Robin Osborn, David Squires, Michelle Doty, Petra Rasmussen, Roz Pierson and Sandra Applebaum
Health Affairs, November 15, 2012
To explore the experiences of physicians as health reform policies unfold, we surveyed primary care physicians in the following ten countries in 2012: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, the United Kingdom, and the United States.
***
Swiss and US patients often face substantial deductibles as well as cost sharing, although Swiss health insurance standards reduce rates for low-income people and limit out-of-pocket liability to levels well below those in the United States.
***
The United States is alone among the study countries in segmenting the population by income and age for government-sponsored health insurance and in its lack of coordinated policies across multiple private and public insurers.
***
US and Canadian physicians’ responses to questions regarding after-hours arrangements mirror patients’ experiences: In the 2010 international population survey on patient experience with health care services, Canadian and US patients were more likely than those in other countries to have used emergency departments and among the most likely to say that it was difficult to obtain health care after hours.
***
In 2012, 59 percent of US physicians said that their patients often have difficulty paying out-of-pocket costs for medical care – a percentage well above that in any other country.
***
In the United States, physicians’ perceptions of affordability or difficulties getting specialized care varied by patient insurance mix. Doctors with high proportions of uninsured or Medicaid patients were the most likely to say that their patients often faced long waits for specialized care.
***
To gauge primary care physicians’ perspectives overall, the survey asked about their views of their country’s health system, their satisfaction with the practice of medicine, and their perceptions of change in recent years. Repeating a pattern observed in earlier surveys, US and German physicians were the most negative about their health care systems, with only 15 percent and 22 percent, respectively, saying that the system needs only minor changes versus fundamental change or rebuilding. German and US physicians were also the least likely to say that they were satisfied or very satisfied with practicing medicine.
***
As countries aim to reduce health care costs, some countries have looked to coverage restrictions on treatments or medications or to reviews of physician care decisions. Although such interventions may target the appropriateness of care, they can also have the unintended consequence of imposing time and administrative burdens on physicians. Among the study countries, US physicians were the most likely to say that such time concerns are a major problem: More than half of US respondents said that they or their staff spend too much time getting patients care because of coverage restrictions on treatment or medications.
Notably, the share of Dutch doctors expressing concern about this issue has more than doubled since the 2009 survey (increasing from 10 percent to 26 percent). This suggests that problems are emerging with the growing complexity of health insurance practices in the Netherlands.
***
Regarding after-hours access to primary health care services, all of the study countries except the United States and Canada have policies for after-hours coverage. The low rates of after-hours arrangements reported by Canadian and US physicians indicate that such arrangements are slow to develop if they must depend on the actions of individual practices.
***
Insurance design also matters. US physicians stand out, as they have in past surveys, for saying that their patients often have difficulty paying for care and that insurance restrictions on care decisions consume substantial doctor and staff time. The other countries in the study all provide universal coverage and, with the exception of Switzerland, have little or no cost sharing for primary care and essential medications. All of the other countries limit out-of-pocket expenses to levels well below those typical in US insurance.
In contrast to other countries with multiple insurers, US private insurers often use prior authorization and employ varying drug formularies and complex benefit designs, with little standardization. Recent studies confirm that the resulting insurance-related complexity adds substantially to US practice costs as a result of increased paperwork and time demands.
In patient surveys, the United States also stands out for insurance-related time concerns. US experiences provide a cautionary example for other countries regarding the time and resource costs of complexity.
***
In general, US primary care physicians’ views and experiences endorse the need for reform, including enhanced access. US physicians who reported that their patients often faced cost or other access barriers were the most likely to say that the system required major change.
http://content.healthaffairs.org/content/early/2012/11/13/hlthaff.2012.0…

We spend by far the most money per capita on health care. Yet, compared to primary care physicians in other nations, U.S. physicians are by far the most negative about our health system, with only 15 percent saying that “the system needs only minor changes” (versus fundamental change or rebuilding).
The perspective provided by the excerpts posted above should drive the citizens of our nation to demand comprehensive reform. Are we up to it?

By Bridget Lavelle and Pamela J. Smock
Journal of Health and Social Behavior, November 12, 2012

Abstract

This article bridges the literatures on the economic consequences of divorce for women with that on marital transitions and health by focusing on women’s health insurance. Using a monthly calendar of marital status and health insurance coverage from 1,442 women in the Survey of Income and Program Participation, we examine how women’s health insurance changes after divorce. Our estimates suggest that roughly 115,000 American women lose private health insurance annually in the months following divorce and that roughly 65,000 of these women become uninsured. The loss of insurance coverage we observe is not just a short-term disruption. Women’s rates of insurance coverage remain depressed for more than two years after divorce. Insurance loss may compound the economic losses women experience after divorce and contribute to as well as compound previously documented health declines following divorce.

From the Discussion

Not all women are equally likely to lose health insurance after divorce. Those insured as dependents on husbands’ employer-based insurance plans are most vulnerable to insurance loss, while stable, full-time employment buffers against it. Women from moderate-income (200–300% FPL) families are particularly vulnerable. Many of these women fall into the ranks of the near-poor after divorce, with too much money to qualify for Medicaid but not enough to purchase private health insurance coverage.

Our findings also add to the body of evidence that the current health care and insurance system in the United States is inadequate for a population in which multiple family and job changes over the life course are not uncommon. It remains to be seen how effectively the Affordable Care Act (ACA) of 2010 — expected to be fully implanted by 2014 — will remedy the problem of insurance loss after divorce.

Moving forward, policy makers should be aware that a system that induces a de facto linkage between marital status and health insurance may have unintentional adverse consequences.

http://hsb.sagepub.com/content/early/2012/11/09/0022146512465758.full.pdf+html

Comment:

By Don McCanne, MD

For a wide variety of reasons, our bizarre, fragmented, though expensive system of financing health care leaves many people vulnerable to financial hardship and impaired access to care. This study shows that women who divorce are at great risk of becoming uninsured and consequently may compound both economic losses and health declines.

Even within the population of divorced women multiple factors play a role in whether or not the person is insured, or in what form of insurance the person may have – whether it is public or private, employer-sponsored or purchased in the individual market. Even if insured, the variations in coverage can disrupt established relationships with health care professionals because of non-congruent networks, and can expose the individual to a wide range of potential financial barriers because of the differences in cost sharing with the various forms of coverage.

Will the Affordable Care Act (ACA) correct these deficiencies? Some lower-income individuals may be eligible for Medicaid, but many states have indicated that they will not use the provisions of ACA to expand eligibility for the program. Divorced women with modest incomes may find that their incomes are too high to qualify for Medicaid, yet still too low to be able to pay their share of the premium after any subsidies. Some may be exempt from the requirement to purchase insurance, while others may be subject to a penalty for not having insurance, even though they simply do not have adequate funds to pay the premiums. In either instance, they will remain uninsured.

As the authors of this report state, “policy makers should be aware that a system that induces a de facto linkage between marital status and health insurance may have unintentional adverse consequences.” That statement can apply to the innumerable other factors that determine whether or not a person is covered, and, if so, by which of the highly variable public and private forms of coverage that differ in their ability to ensure both access and financial security.

Everyone should automatically have full coverage for life. Divorce, and all of the other variables throughout life, should have absolutely nothing to do with a program designed to prevent greater financial insecurity in the face of health care needs. We need to improve Medicare and provide it for everyone, automatically, for life.

Divorce and Women’s Risk of Health Insurance Loss

By Bridget Lavelle and Pamela J. Smock
Journal of Health and Social Behavior, November 12, 2012

Abstract

This article bridges the literatures on the economic consequences of divorce for women with that on marital transitions and health by focusing on women’s health insurance. Using a monthly calendar of marital status and health insurance coverage from 1,442 women in the Survey of Income and Program Participation, we examine how women’s health insurance changes after divorce. Our estimates suggest that roughly 115,000 American women lose private health insurance annually in the months following divorce and that roughly 65,000 of these women become uninsured. The loss of insurance coverage we observe is not just a short-term disruption. Women’s rates of insurance coverage remain depressed for more than two years after divorce. Insurance loss may compound the economic losses women experience after divorce and contribute to as well as compound previously documented health declines following divorce.

From the Discussion

Not all women are equally likely to lose health insurance after divorce. Those insured as dependents on husbands’ employer-based insurance plans are most vulnerable to insurance loss, while stable, full-time employment buffers against it. Women from moderate-income (200–300% FPL) families are particularly vulnerable. Many of these women fall into the ranks of the near-poor after divorce, with too much money to qualify for Medicaid but not enough to purchase private health insurance coverage.

Our findings also add to the body of evidence that the current health care and insurance system in the United States is inadequate for a population in which multiple family and job changes over the life course are not uncommon. It remains to be seen how effectively the Affordable Care Act (ACA) of 2010 — expected to be fully implanted by 2014 — will remedy the problem of insurance loss after divorce.

Moving forward, policy makers should be aware that a system that induces a de facto linkage between marital status and health insurance may have unintentional adverse consequences.

http://hsb.sagepub.com/content/early/2012/11/09/0022146512465758.full.pdf+html

Comment:

By Don McCanne, MD

For a wide variety of reasons, our bizarre, fragmented, though expensive system of financing health care leaves many people vulnerable to financial hardship and impaired access to care. This study shows that women who divorce are at great risk of becoming uninsured and consequently may compound both economic losses and health declines.

Even within the population of divorced women multiple factors play a role in whether or not the person is insured, or in what form of insurance the person may have – whether it is public or private, employer-sponsored or purchased in the individual market. Even if insured, the variations in coverage can disrupt established relationships with health care professionals because of non-congruent networks, and can expose the individual to a wide range of potential financial barriers because of the differences in cost sharing with the various forms of coverage.

Will the Affordable Care Act (ACA) correct these deficiencies? Some lower-income individuals may be eligible for Medicaid, but many states have indicated that they will not use the provisions of ACA to expand eligibility for the program. Divorced women with modest incomes may find that their incomes are too high to qualify for Medicaid, yet still too low to be able to pay their share of the premium after any subsidies. Some may be exempt from the requirement to purchase insurance, while others may be subject to a penalty for not having insurance, even though they simply do not have adequate funds to pay the premiums. In either instance, they will remain uninsured.

As the authors of this report state, “policy makers should be aware that a system that induces a de facto linkage between marital status and health insurance may have unintentional adverse consequences.” That statement can apply to the innumerable other factors that determine whether or not a person is covered, and, if so, by which of the highly variable public and private forms of coverage that differ in their ability to ensure both access and financial security.

Everyone should automatically have full coverage for life. Divorce, and all of the other variables throughout life, should have absolutely nothing to do with a program designed to prevent greater financial insecurity in the face of health care needs. We need to improve Medicare and provide it for everyone, automatically, for life.