PNHP

What about the insurance subsidies?

What about the insurance subsidies?

Health Reform Subsidy Calculator

Kaiser Family Foundation
Based on the Patient Protection and Affordable Care Act (including subsequent amendments in the Health Care and Education Reconciliation Act of 2010), as signed by the President.
The premiums are illustrative examples in 2014 dollars derived from estimates of average premiums for 2016 from the Congressional Budget Office.
Premium subsidies are based on a silver plan (with an actuarial value of 70%), so all premiums shown are for silver coverage. People may be able to pay a lower premium for less comprehensive coverage (i.e., a bronze plan, with an actuarial value of 60%). The tables showing results by age and income also reflect premiums for silver coverage, though the minimum insurance that people would be required to obtain would be bronze coverage.
The actual premium calculated is adjusted for family type, and for age (within the three to one limit specified in the proposal). Subsidized people can enroll in more expensive plans, but must pay the full difference in the premium.
Health Reform Subsidy Calculator:
http://healthreform.kff.org/SubsidyCalculator.aspx#incomeAgeTables

On June 28, the Supreme Court will release its ruling on the constitutionality of the Affordable Care Act. If the full Act is repealed, individuals who would have purchased plans in the state insurance exchanges will receive neither their premium subsidies nor their tax credits for out-of-pocket expenses. What precisely would they be losing?
Let’s use the Health Reform Subsidy Calculator to check a few examples. In each example, we will assume that the policyholder is 45, has a family of four, and does not have employer coverage available. For this family living in a region with a medium cost factor, the predicted premium for the silver plan (70% actuarial value) is $14,245. In the examples, we will change only the income level.
Income:  $31,155 (133% of poverty)
Premium payment:  None – covered by Medicaid
Maximum out-of-pocket costs:  None – covered by Medicaid
Income:  $31,156 (133% of poverty plus $1)
Premium payment:  $935
Maximum out-of-pocket costs:  $4,167
Note that at this level, one additional dollar of income results in the family losing the more comprehensive benefits of the Medicaid program, and mandates that they pay a premium of $935 plus potential out-of-pocket expenses of $4,167, for a total exposure of $5,202. That’s a staggering amount at this income level. Compliance surely would be a problem, not by lack of will but simply by inability to pay.
Income:  $93,700 (400% of poverty)
Premium payment:  $8,901
Maximum out-of-pocket costs:  $8,333
Income:  $93,701 (400% of poverty plus $1)
Premium payment:  $14,245
Maximum out-of-pocket costs:  $12,500
So at an income of $93,700, the premium would be $8,901 and the potential out-of-pocket costs would be $8,333, for a total exposure of $17,234. That is quite a dent for a family that is trying to save for two college educations, a retirement fund, and maybe for replacement of the broken-down family automobile. But add just one more dollar of income and the premium shoots up to $14,245 and potential out-of-pocket expenses to $12,500, for a total of $26,745. Then what are you going to cut out of the family budget? And isn’t the $9,511 increase quite a “tax” to pay on that one dollar of additional income?
Just the premium increase alone might cause this family to downgrade their coverage from silver (70% actuarial value) to bronze (60%) in order to save on the premium. If so, this family literally would be placing a bet that none of them would develop a serious medical problem, and it would lose the bet if any of them did so. Should we really be forcing a family to gamble on its health care coverage?
If the Affordable Care Act is repealed, all of this goes away, and many more would remain with no coverage at all. That would be tragic. But even if the Act is upheld, this coverage is still far from satisfactory, and should be unacceptable as a standard for our nation. Regardless of the Supreme Court decision, we should replace the Affordable Care Act with a program that really does work: a single payer, improved Medicare for all.

Affordable Care Act: We can do better

By Laurence S. Jacobs, M.D.
The Democrat and Chronicle (Rochester, N.Y.), June 18, 2012

The country now awaits the upcoming Supreme Court decision regarding the Affordable Care Act (ACA). No matter what decision is made, however, it is important to recognize the inadequacies of the ACA, and to understand the optimal solution to our health insurance crisis.

It should be recognized that the ACA has a number of commendable features. These include the expansion of Medicaid, enhanced funding for community health centers, restrictions on rescission of policies and on denials of coverage based on pre-existing conditions, and the provision for coverage of children up to age 26 on their parents’ policies. However, these could have all been enacted on a stand-alone basis.

However, the ACA entails many problems, of access, cost, and equity. When fully implemented by 2019, the ACA will cover less than half of our currently uninsured, leaving approximately 26 million people without health insurance. Such uninsurance is presently instrumental in the deaths of about 50,000 people per year, nearly one every minute. Many people forgo needed care because of costs; in 2010, 75 million working age adults went without necessary care due to costs!

Health insurance premiums have more than doubled since 2000; many middle-income families are faced with policies that consume up to 10 percent of income, yet provide poor coverage which offers little protection against financial ruin in case of major illness. Employer programs now cost over $15,000 annually for family coverage, and many covered people will increasingly have to deal with a limited provider network and minimal coverage, as employers reduce options and shift rising costs to employees. Skimpy insurance, with high deductibles, copays and other out-of-pocket expenses, comprise the new norm of unaffordable underinsurance.

While the personal bankruptcy rate due to medical bills in the rest of the industrialized world is zero, more than 60 percent of such bankruptcies in the United States are related to medical bills; almost 80 percent of those being bankrupted had health insurance prior to illness. The rate has not declined in Massachusetts since passage of that state’s health reform bill, as much of the new coverage there is bare bones high deductible policies. Since the ACA contains no effective cost-control measures, the situation summarized above can be expected to worsen if the ACA survives in any form following the Supreme Court decision.

We are alone in the industrialized world in employing a profit-driven private insurance system for funding our health care. The result is a fragmented patchwork of coverage, and chronic conflict between generation of returns for shareholders versus taking care of patients. The fragmentation results in extraordinary inefficiencies, with 31 cents of every health care dollar (totaling $400 billion per year) diverted to overhead, marketing, profit, executive compensation and the imposition of excessive paperwork on providers. In contrast, Medicare runs on an overhead of under 3 percent. Rather than continuing to funnel our health insurance coverage and processes through these private, profit-driven companies, we should follow the example of much of the developed world and institute a single-payer, simplified mechanism for funding our national health care.

Such a scheme would be primarily a payment mechanism. Patients would have free choice of physician, hospital and other health care facilities. Moreover, only a single-payer system offers effective methods for cost control, such as global hospital budgeting, capital planning, negotiated fees and bulk purchasing. It is easy to understand why the health insurance industry and the pharmaceutical industry, stakeholders who benefit from the status quo, have fought against a single-payer plan with every means available to them.

No matter what the Supreme Court decides, we have the opportunity as a country to embrace a solution to this problem, if we have the political will to do so. Two-thirds of the population and 59 percent of physicians support the establishment of a national health insurance program. It is the right thing to do and, increasingly, it is imperative that we do so.

Dr. Laurence S. Jacobs is Professor of Medicine Emeritus at the University of Rochester and Vice-Chair of the Finger Lakes Chapter of Physicians for a National Health Program.

http://www.democratandchronicle.com/article/20120619/OPINION02/120618010/Affordable-Care-Act-We-can-do-better?nclick_check=1

Single payer, not free market, is the answer

By Patricia Downs Berger, M.D.
Letters, Boston Globe, June 16, 2012

In the June 13 op-ed “A free market brings down health costs” Jeff Jacoby asked, “What is the best way to make sure that Americans with chronic medical conditions … can afford the insurance they need?” Jacoby’s answer is the free market, a business model based on “supply and demand, competition, and flexible prices.” He seems to forget that medical care is not a commodity that we buy and sell, but a basic human necessity.

Universal access to affordable, high-quality medical care is what we all want for ourselves and our families, but it can only happen if we have a single-payer system that embodies this goal. Such a system means that there would be a single government entity that would pay health care bills instead of myriad private companies and government plans.

Everyone would have a government-issued medical card to use for medical care that would replace the for-profit health insurance industry coverage, and there would be no more premiums, deductibles, or co-insurance that act as barriers to seeking care.

Single payer would be publicly funded through the tax system and federal and state funds already committed to health care through programs such as Medicare, Medicaid, and the Children’s Health Insurance Program. Single payer is not a pie-in-the-sky theory. Variations have been working well in industrialized nations where health costs are half of what we spend in the United States and health outcomes are better.

Dr. Patricia Downs Berger co-chairs Mass-Care, a campaign for a single payer health care system for Massachusetts. She resides in Brookline.

http://articles.boston.com/2012-06-16/letters/32247699_1_single-payer-health-care-health-costs

Innovation leader – Medicare or private insurance?

How Medicare Solves Private Plans’ Problems and Vice Versa

By Austin Frakt, PhD
JAMA Forum, June 21, 2012

In a new article in the Annual Review of Economics, Katherine Baicker, Amitabh Chandra, and Jon Skinner point out some of the ways Medicare has helped solve a coordination problem among private plans:
 
“It is natural to ask why private providers have not adopted ACOs [Accountable Care Organizations, groups that give coordinated health care and for whom payment is tied to achieving health care quality outcomes and goals that can lead to cost savings] or more bundled payments on their own. This remains a puzzle. One explanation is that it is a coordination problem—all insurers may want to adopt larger bundled payments, but no single insurer can make the transition. This is certainly consistent with the historical record on the adoption of prospective payment for hospital care. Once it was introduced in Medicare, private plans were quick to adopt it. Similarly, private hospitals were quick to use the federal government’s efforts to measure quality of care even though nothing stopped them from forming consortiums to measure quality before these federal efforts.”

Their points are generally valid in that it’s common for private plans to adopt certain types of payment reforms and quality monitoring after these measures are introduced in Medicare but not before. Nevertheless, there are some examples of ACO-like contracts made by private plans ahead of the Medicare counterparts. And that doesn’t count the failed attempts at capitation (establishing a dollar amount to cover the cost of health care services provided for an individual during a specified length of time) by private insurers and provider groups in the 1990s. I don’t think this invalidates the general point the authors make. It seems Medicare has solved a coordination problem among private insurers.
 
Indeed, some of the things Medicare will do are properly viewed as public goods. All but a handful of large, dominant health plans cannot convince large hospital systems to accept a new form of payment system. But Medicare can. What health plan will do its own comparative effectiveness analysis to determine which interventions work best for managing a condition? Medicare will or could. The results of both of these types of innovations, and others, will be public information and can benefit all plans and all consumers.
 
History shows that Medicare has done some things private plans seem unable to do, and then private plans voluntarily copy Medicare. But it goes the other way too.
 
For example, private plans have innovated in ways that traditional Medicare has not. Managed care, consumer-directed health plans, prescription drug benefits, and catastrophic coverage all exist or existed in the commercial market before adoption by Medicare (if ever). In some cases, the Medicare program, though not the traditional fee-for-service arm of Medicare itself, followed private plans’ lead, adding managed care plans (Medicare Advantage) and a prescription drug benefit (Part D), for example.

There does seem to be a coordination problem among private plans that Medicare solves. Likewise, the private sector sometimes does a better job of designing health plan options. That both plan types, private and government, play a worthwhile role needn’t be shocking or blasphemous. The fact that they both play worthwhile roles ought to be widely acknowledged. Naturally, it often isn’t—least of all, it seems, in our politically charged health policy debates.

http://newsatjama.jama.com/2012/06/21/jama-forum-how-medicare-solves-private-plans-problems-and-vice-versa/

Comment: 

By Don McCanne, MD

Austin Frakt makes the point that both Medicare and the private health insurers have each independently introduced innovations that then can help the other when these innovations are shared. But when you look at the respective innovations, it becomes obvious which innovator it is that truly serves the interests of patients.

Medicare attempts to create greater value when using taxpayer and premium dollars for the payment of health care services. Thus you see innovations such as the adoption of prospective payment for hospital care. We benefit both as taxpayers and as patients.

Look at the innovations of private insurers that Frakt mentions: managed care, consumer-directed health plans, and prescription drug benefit plans. These designs take away choice of health care professionals and institutions, choice of drug benefits, and also erect financial barriers between the patient and health care. Here the process of innovation is not used to benefit patients, but rather is designed to enhance the business model of the intermediary intruder – the private insurance plans.

Frakt points out that these private innovations are being used by Medicare in the private Medicare Advantage plans and in the private Part D Medicare drug benefit. True, but these are terrible innovations to introduce into Medicare because they waste funds and reduce choice while increasing administrative complexity. Medicare’s adoption of private innovations has been a bad thing, not a good thing.

Coordinated care is certainly beneficial and should be expected regardless of whether Medicare or private insurers are paying the bills. There may be instances where bundling of payment would be appropriate, just as capitation has been appropriate in selected circumstances. If it benefits both taxpayers and patients, it would be appropriate. The risk is that the business mind of the private insurers will most likely morph accountable care organizations into intermediary intruders designed to benefit third party payers, likely at a cost to patients. That is not a desirable innovation.

Frakt does make the important point that Medicare does not provide catastrophic coverage, whereas some private plans do. Medicare certainly should as well. But that’s not really a private plan innovation; it’s merely a benefit that should have been included in Medicare in the first place. That is one more reason why we advocate for an improved Medicare for all, rather than merely for a universal expansion of the existing Medicare program.

Government can do it. In fact, it is leading on the catastrophic coverage benefit by making it a requirement through the Affordable Care Act. Innovation in the private sector benefits the private sector. Innovation in the government serves the public interest. Trading public and private innovation is not in our interest when we come out the losers.

Innovation leader – Medicare or private insurance?

How Medicare Solves Private Plans’ Problems and Vice Versa

By Austin Frakt, PhD
JAMA Forum, June 21, 2012
In a new article in the Annual Review of Economics, Katherine Baicker, Amitabh Chandra, and Jon Skinner point out some of the ways Medicare has helped solve a coordination problem among private plans:
“It is natural to ask why private providers have not adopted ACOs [Accountable Care Organizations, groups that give coordinated health care and for whom payment is tied to achieving health care quality outcomes and goals that can lead to cost savings] or more bundled payments on their own. This remains a puzzle. One explanation is that it is a coordination problem—all insurers may want to adopt larger bundled payments, but no single insurer can make the transition. This is certainly consistent with the historical record on the adoption of prospective payment for hospital care. Once it was introduced in Medicare, private plans were quick to adopt it. Similarly, private hospitals were quick to use the federal government’s efforts to measure quality of care even though nothing stopped them from forming consortiums to measure quality before these federal efforts.”
Their points are generally valid in that it’s common for private plans to adopt certain types of payment reforms and quality monitoring after these measures are introduced in Medicare but not before. Nevertheless, there are some examples of ACO-like contracts made by private plans ahead of the Medicare counterparts. And that doesn’t count the failed attempts at capitation (establishing a dollar amount to cover the cost of health care services provided for an individual during a specified length of time) by private insurers and provider groups in the 1990s. I don’t think this invalidates the general point the authors make. It seems Medicare has solved a coordination problem among private insurers.
Indeed, some of the things Medicare will do are properly viewed as public goods. All but a handful of large, dominant health plans cannot convince large hospital systems to accept a new form of payment system. But Medicare can. What health plan will do its own comparative effectiveness analysis to determine which interventions work best for managing a condition? Medicare will or could. The results of both of these types of innovations, and others, will be public information and can benefit all plans and all consumers.
History shows that Medicare has done some things private plans seem unable to do, and then private plans voluntarily copy Medicare. But it goes the other way too.
For example, private plans have innovated in ways that traditional Medicare has not. Managed care, consumer-directed health plans, prescription drug benefits, and catastrophic coverage all exist or existed in the commercial market before adoption by Medicare (if ever). In some cases, the Medicare program, though not the traditional fee-for-service arm of Medicare itself, followed private plans’ lead, adding managed care plans (Medicare Advantage) and a prescription drug benefit (Part D), for example.
There does seem to be a coordination problem among private plans that Medicare solves. Likewise, the private sector sometimes does a better job of designing health plan options. That both plan types, private and government, play a worthwhile role needn’t be shocking or blasphemous. The fact that they both play worthwhile roles ought to be widely acknowledged. Naturally, it often isn’t—least of all, it seems, in our politically charged health policy debates.
http://newsatjama.jama.com/2012/06/21/jama-forum-how-medicare-solves-private-plans-problems-and-vice-versa/

Austin Frakt makes the point that both Medicare and the private health insurers have each independently introduced innovations that then can help the other when these innovations are shared. But when you look at the respective innovations, it becomes obvious which innovator it is that truly serves the interests of patients.
Medicare attempts to create greater value when using taxpayer and premium dollars for the payment of health care services. Thus you see innovations such as the adoption of prospective payment for hospital care. We benefit both as taxpayers and as patients.
Look at the innovations of private insurers that Frakt mentions: managed care, consumer-directed health plans, and prescription drug benefit plans. These designs take away choice of health care professionals and institutions, choice of drug benefits, and also erect financial barriers between the patient and health care. Here the process of innovation is not used to benefit patients, but rather is designed to enhance the business model of the intermediary intruder – the private insurance plans.
Frakt points out that these private innovations are being used by Medicare in the private Medicare Advantage plans and in the private Part D Medicare drug benefit. True, but these are terrible innovations to introduce into Medicare because they waste funds and reduce choice while increasing administrative complexity. Medicare’s adoption of private innovations has been a bad thing, not a good thing.
Coordinated care is certainly beneficial and should be expected regardless of whether Medicare or private insurers are paying the bills. There may be instances where bundling of payment would be appropriate, just as capitation has been appropriate in selected circumstances. If it benefits both taxpayers and patients, it would be appropriate. The risk is that the business mind of the private insurers will most likely morph accountable care organizations into intermediary intruders designed to benefit third party payers, likely at a cost to patients. That is not a desirable innovation.
Frakt does make the important point that Medicare does not provide catastrophic coverage, whereas some private plans do. Medicare certainly should as well. But that’s not really a private plan innovation; it’s merely a benefit that should have been included in Medicare in the first place. That is one more reason why we advocate for an improved Medicare for all, rather than merely for a universal expansion of the existing Medicare program.
Government can do it. In fact, it is leading on the catastrophic coverage benefit by making it a requirement through the Affordable Care Act. Innovation in the private sector benefits the private sector. Innovation in the government serves the public interest. Trading public and private innovation is not in our interest when we come out the losers.

Update on deaths from being uninsured

Dying for Coverage: The Deadly Consequences of Being Uninsured

Families USA
June 2012

Key Findings

* Across the nation, 26,100 people between the ages of 25 and 64 died prematurely due to a lack of health coverage in 2010.

* Between 2005 and 2010, the number of people who died prematurely each year due to a lack of health coverage rose from 20,350 to 26,100.

* Between 2005 and 2010, the total number of people who died prematurely due to a lack of health coverage was 134,120.

Why Insurance Matters

* The uninsured are less likely to have a usual source of care outside of the emergency room.

* The uninsured often go without screenings and preventive care.

* The uninsured often delay or forgo needed medical care.

* Uninsured Americans are sicker and die earlier than those who have insurance.

* The uninsured pay more for medical care.

http://familiesusa2.org/assets/pdfs/Dying-for-Coverage.pdf

Comment: 

By Don McCanne, MD

In 2010, about 26,000 of the nearly 50 million people without health insurance died due to the lack of that insurance. At best, about 26 million people will remain uninsured if the Affordable Care act is upheld by the Supreme Court. That means that we will continue to accept about 13,000 deaths per year as a consequence of our failure to enact a single payer national health program.

It is one thing to accept inordinate financial waste in our system in order to cater to the private insurance industry, but it is quite another to accept so much suffering and death. The former reflects on our illogical willingness to accept social injustices in order to cater to the moneyed class, but to knowingly accept the latter reflects on the most basic moral fiber of our society.

Is it that people don’t understand? Or are we really that animalistic?

Addendum:

Today’s Quote of the Day used updated numbers from Families USA on the number of deaths that result from being uninsured. Their numbers were based on the 2002 methodology of the Institute of Medicine.
However, under “Methodology,” the Families USA report states, “A study published by Harvard Medical School researchers late in 2009 that used more recent data found that the lack of health insurance now raises mortality rates by 40 percent. If we had applied the latter estimate of the impact of uninsurance on mortality, rather than the 25 percent figure used by the IOM, our mortality estimates would have increased substantially.”
The numbers are worse than those reported earlier today. Rather than zeroing in on sterile recalculations, let’s think about the real people whose lives are lost and what we need to do to prevent that in the future.
The Harvard study, authored by co-founders of PNHP and their colleagues:

Update on deaths from being uninsured

Dying for Coverage: The Deadly Consequences of Being Uninsured

Families USA
June 2012
Key Findings
* Across the nation, 26,100 people between the ages of 25 and 64 died prematurely due to a lack of health coverage in 2010.
* Between 2005 and 2010, the number of people who died prematurely each year due to a lack of health coverage rose from 20,350 to 26,100.
* Between 2005 and 2010, the total number of people who died prematurely due to a lack of health coverage was 134,120.
Why Insurance Matters
* The uninsured are less likely to have a usual source of care outside of the emergency room.
* The uninsured often go without screenings and preventive care.
* The uninsured often delay or forgo needed medical care.
* Uninsured Americans are sicker and die earlier than those who have insurance.
* The uninsured pay more for medical care.
http://familiesusa2.org/assets/pdfs/Dying-for-Coverage.pdf

In 2010, about 26,000 of the nearly 50 million people without health insurance died due to the lack of that insurance. At best, about 26 million people will remain uninsured if the Affordable Care act is upheld by the Supreme Court. That means that we will continue to accept about 13,000 deaths per year as a consequence of our failure to enact a single payer national health program.
It is one thing to accept inordinate financial waste in our system in order to cater to the private insurance industry, but it is quite another to accept so much suffering and death. The former reflects on our illogical willingness to accept social injustices in order to cater to the moneyed class, but to knowingly accept the latter reflects on the most basic moral fiber of our society.
Is it that people don’t understand? Or are we really that animalistic?
Addendum:

Today’s Quote of the Day used updated numbers from Families USA on the number of deaths that result from being uninsured. Their numbers were based on the 2002 methodology of the Institute of Medicine.
However, under “Methodology,” the Families USA report states, “A study published by Harvard Medical School researchers late in 2009 that used more recent data found that the lack of health insurance now raises mortality rates by 40 percent. If we had applied the latter estimate of the impact of uninsurance on mortality, rather than the 25 percent figure used by the IOM, our mortality estimates would have increased substantially.”
The numbers are worse than those reported earlier today. Rather than zeroing in on sterile recalculations, let’s think about the real people whose lives are lost and what we need to do to prevent that in the future.
The Harvard study, authored by co-founders of PNHP and their colleagues:

NHIS report on insurance coverage

Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2011

By Robin A. Cohen, Ph.D., and Michael E. Martinez, M.P.H., M.H.S.A.
CDC, Division of Health Interview Statistics, National Center for Health Statistics
June 2012

The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is releasing selected estimates of health insurance coverage for the civilian noninstitutionalized U.S. population based on data from the 2011 National Health Interview Survey (NHIS).

* In 2011, 46.3 million persons of all ages (15.1%) were uninsured at the time of interview, 58.7 million (19.2%) had been uninsured for at least part of the year prior to interview, and 34.2 million (11.2%) had been uninsured for more than a year at the time of interview.

* In 2011, the percentage of children under age 18 years who were uninsured at the time of interview was 7.0%.

* Among adults aged 19–25, the percentage uninsured at the time of interview decreased from 33.9% (10 million persons) in 2010 to 27.9% (8.4 million) in 2011.

* Among adults aged 19–25, 56.2% were covered by a private plan in 2011, an increase from 2010 (51.0%).

Estimates of enrollment in HDHPs and CDHPs
 
Based on data from the 2011 NHIS, 29.0% of persons under age 65 with private health insurance were enrolled in an HDHP (high-deductible health plan), including 9.2% who were enrolled in a CDHP (consumer-directed health plan) and 19.9% who were enrolled in an HDHP without a health savings account (HSA). Enrollment in HDHPs increased from 25.3% in 2010 to 29.0% in 2011. There was a significant increase in enrollment in HDHPs without HSAs, and in CDHPs, between 2007 (when NHIS started collecting this information) and 2011.

Based on data from 2011, among persons under age 65 with private health insurance, 26.9% with employment-based coverage were enrolled in an HDHP, compared with 52.4% of those with a private plan that was directly purchased or obtained through means other than employment. The percentage of persons covered by employment-based private plans who were enrolled in HDHPs increased from 15.6% in 2007 to 26.9% in 2011. The percentage of persons covered by directly purchased private health plans who were enrolled in HDHPs increased from 39.2% in 2007 to 52.4% in 2011. 

Insurance coverage by poverty status

The percentage of poor children who were uninsured at the time of interview decreased from 1997 through 2011. During the same period, the percentage of poor adults who were uninsured remained relatively stable.

Among children, all poverty status groups experienced an increase in public coverage between 1997 and 2011. However, the largest increase was seen among near poor children, for whom coverage by a public plan increased by 36.5 percentage points during the same period.

The rate of private coverage among near poor children was 25.1 percentage points lower in 2011 than in 1997. Among near poor children the percentage without health insurance and the percentage with private health insurance coverage have declined since 1997, while public coverage has increased. Private coverage generally decreased among near poor adults aged 18–64, from 52.6% in 1997 to 35.4% in 2011, so that the uninsured rate is now higher than the private coverage rate for this population. Private coverage among not poor adults aged 18–64 generally decreased from 1997 through 2011.

http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201206.pdf

Comment: 

By Don McCanne, MD

The good news is that the percentage of individuals uninsured at the time of the National Health Interview Survey declined from 16.0% in 2010 to 15.1% in 2011. The improvements were primarily due to an increase in enrollment of children in public programs, and an increase in enrollment of young adults in their parents’ private insurance plans.

If the Affordable Care Act is upheld, we can anticipate a further increase in enrollment in Medicaid. If not, at least public coverage for low-income children should be maintained.

The more alarming news in this report is the increase in high-deductible health plans, both those acquired through employment and especially those purchased in the individual market. The increase in private coverage made possible through the establishment of state insurance exchanges will be in lower-actuarial value plans – primarily high-deductible plans. Also employers are expected to shift more of their plans to high-deductible coverage.

High-deductible plans equate with underinsurance. These plans leave people with health care needs vulnerable to financial barriers to care. With this report, once again we see that underinsurance is becoming the new standard in America. That wouldn’t occur if we were to adopt an improved Medicare for all.

What SCOTUS ruling might mean to Vermont's single-payer plan

By Mike Miliard, Contributing Editor
Government Health IT, June 18, 2012

“The Affordable Care Act doesn’t do a whole heck of a lot for Vermont,” says Deb Richter, MD, president of Vermont Healthcare For All. “Most of the provisions in it, we’ve already done. It’s kind of a shame, in a way. We would have momentum, and probably could’ve gotten further with single-payer, if the ACA had not happened.”

Vermont comes by its reputation for progressive politics honestly. And one of its signal achievements on that front is a piece of legislation known as Act 48, signed into law by Democratic Governor Peter Shumlin in June 2011, which lays the initial groundwork for the Green Mountain State to make the pioneering move to a single-payer system.

“Because of the growth of our healthcare expenditures every year, we had to do something,” says Peg Franzen, president of the Vermont Workers’ Center, which labored for years to build momentum behind the bill. “Insurance companies are doing what they’re supposed to do; they’re making profits for their shareholders. But that’s not the way we should have a health system set up. Healthcare shouldn’t be a commodity.”

But there’s a long road ahead before so-called Green Mountain Care – tagged by opponents with the predictable epithet of “ShumlinCare” – becomes a reality in Vermont. Political pitfalls on the state and national level mean a single-payer future is far from certain. But since Act 48’s passage a year ago, work on the policy front has been ongoing, aimed at improving the state’s healthcare system, regardless of the outcome.

Seeking to offer near-universal coverage for Vermont’s 626,000 citizens, the state-funded insurance pool is still years away from coming to fruition, and has many questions still to be answered.

One not-inconsequential detail: how it will be funded. A variety of new taxes are under consideration, but won’t be voted on in the near future.

Act 48 also contained provisions to launch a health insurance exchange as required by the ACA, set up pilots to explore medical home and bundled-payment reforms and established the Green Mountain Care Board – a panel of policy experts to set rates, design benefits packages and suggest funding strategies.

Those are just first steps. As noted above, one stumbling block along the way could be the federal Affordable Care Act – which itself is up in the air, of course – with the Supreme Court ruling due by June’s end.

Vermont hopes to use money disbursed by the ACA to help build those insurance exchanges. The federal law says every state must have one by 2014, but it also allows states to petition for a waiver from the national rules if they can prove they’re providing equal or better coverage of their own.

“One major advantage it could (provide) is help bring in federal dollars when people buy health insurance on the exchange,” Richter says. “And then that sum of money is what we would expect to get as a subsidy when we finally do single payer.”

But waivers won’t be available until 2017. In today’s political climate, five years is an eternity. Whether that necessary bit of dispensation ever comes depends “on the administration in Washington,” Richter adds.

If it could happen today, there would be “a good chance” of success, she adds. “Obama has said if he could do it over, then single payer would be the way he would go. He’s also said he believes in states’ rights to innovate and do some models on their own.” If it’s the Romney administration? “I don’t think so.”

The next few years will be pivotal – on policy, politics and public opinion fronts.

“There’s a lot of misinformation out there,” Franzen says. “There’s been a real attempt to spread a lot of fear. Which we knew would happen. When we got into this, we all knew it was going to be a five year or more battle.”

In the meantime, work toward a better healthcare system has been moving forward in earnest. In the year since Act 48 was passed, the Green Mountain Care board has been hard at work on projects around cost containment, says its chair, Anya Rader Wallack.

“Right now we’re very focused on trying to implement payment reform models in the state, moving away from fee-for-service,” she says. “And we’re working with providers around the state to develop some models for doing that.”

Other responsibilities include “a whole realm of benefit design, for both our health benefit exchange and the single-payer financing plan that the governor’s office will be bringing back to the legislature next year,” Wallack says. “For both of those purposes we have to sign off on a benefit package that would form the floor, essentially, for everyone in Vermont. We are waiting for recommendations on those and will have to delve into whether to approve them.”

In terms of the single-payer law, “there’s still a lot of work to be done,” she says. But, “as for our work, we’re sort of off and running. We have those responsibilities, regardless of what happens in the future with the single-payer plan.”

Nationally, whether the ACA stands or falls “doesn’t really affect our work at all,” she adds, referring to the Green Mountain Care board. “It affects the single-payer plan, and it affects our implementation of the health benefit exchange, because if the [individual] mandate is removed, it means the state will have to determine whether to pass a mandate at the state level to assure everybody’s covered.”

Single-payer may have far to go before it’s a reality. But even if it ends up a vanishing pipe dream, Vermont is in much better shape, when it comes to keeping its citizens covered, than most other states.

By the same token, even if the Affordable Care Act is upheld and goes into full effect, “at best, it will bring the rest of the country to where Vermont already is,” Richter says. “Act 48 was intended to go beyond that.”

“Regardless of what happens with [single-payer], or with ObamaCare,” Wallack adds, “if we do our job right, we’ll have a more sustainable, higher-quality healthcare system, I think, than anywhere else in the country.”

http://www.govhealthit.com/news/what-scotus-ruling-might-mean-vermonts-single-payer-plan?page=0,1

What SCOTUS ruling might mean to Vermont’s single-payer plan

By Mike Miliard, Contributing Editor
Government Health IT, June 18, 2012

“The Affordable Care Act doesn’t do a whole heck of a lot for Vermont,” says Deb Richter, MD, president of Vermont Healthcare For All. “Most of the provisions in it, we’ve already done. It’s kind of a shame, in a way. We would have momentum, and probably could’ve gotten further with single-payer, if the ACA had not happened.”

Vermont comes by its reputation for progressive politics honestly. And one of its signal achievements on that front is a piece of legislation known as Act 48, signed into law by Democratic Governor Peter Shumlin in June 2011, which lays the initial groundwork for the Green Mountain State to make the pioneering move to a single-payer system.

“Because of the growth of our healthcare expenditures every year, we had to do something,” says Peg Franzen, president of the Vermont Workers’ Center, which labored for years to build momentum behind the bill. “Insurance companies are doing what they’re supposed to do; they’re making profits for their shareholders. But that’s not the way we should have a health system set up. Healthcare shouldn’t be a commodity.”

But there’s a long road ahead before so-called Green Mountain Care – tagged by opponents with the predictable epithet of “ShumlinCare” – becomes a reality in Vermont. Political pitfalls on the state and national level mean a single-payer future is far from certain. But since Act 48’s passage a year ago, work on the policy front has been ongoing, aimed at improving the state’s healthcare system, regardless of the outcome.

Seeking to offer near-universal coverage for Vermont’s 626,000 citizens, the state-funded insurance pool is still years away from coming to fruition, and has many questions still to be answered.

One not-inconsequential detail: how it will be funded. A variety of new taxes are under consideration, but won’t be voted on in the near future.

Act 48 also contained provisions to launch a health insurance exchange as required by the ACA, set up pilots to explore medical home and bundled-payment reforms and established the Green Mountain Care Board – a panel of policy experts to set rates, design benefits packages and suggest funding strategies.

Those are just first steps. As noted above, one stumbling block along the way could be the federal Affordable Care Act – which itself is up in the air, of course – with the Supreme Court ruling due by June’s end.

Vermont hopes to use money disbursed by the ACA to help build those insurance exchanges. The federal law says every state must have one by 2014, but it also allows states to petition for a waiver from the national rules if they can prove they’re providing equal or better coverage of their own.

“One major advantage it could (provide) is help bring in federal dollars when people buy health insurance on the exchange,” Richter says. “And then that sum of money is what we would expect to get as a subsidy when we finally do single payer.”

But waivers won’t be available until 2017. In today’s political climate, five years is an eternity. Whether that necessary bit of dispensation ever comes depends “on the administration in Washington,” Richter adds.

If it could happen today, there would be “a good chance” of success, she adds. “Obama has said if he could do it over, then single payer would be the way he would go. He’s also said he believes in states’ rights to innovate and do some models on their own.” If it’s the Romney administration? “I don’t think so.”

The next few years will be pivotal – on policy, politics and public opinion fronts.

“There’s a lot of misinformation out there,” Franzen says. “There’s been a real attempt to spread a lot of fear. Which we knew would happen. When we got into this, we all knew it was going to be a five year or more battle.”

In the meantime, work toward a better healthcare system has been moving forward in earnest. In the year since Act 48 was passed, the Green Mountain Care board has been hard at work on projects around cost containment, says its chair, Anya Rader Wallack.

“Right now we’re very focused on trying to implement payment reform models in the state, moving away from fee-for-service,” she says. “And we’re working with providers around the state to develop some models for doing that.”

Other responsibilities include “a whole realm of benefit design, for both our health benefit exchange and the single-payer financing plan that the governor’s office will be bringing back to the legislature next year,” Wallack says. “For both of those purposes we have to sign off on a benefit package that would form the floor, essentially, for everyone in Vermont. We are waiting for recommendations on those and will have to delve into whether to approve them.”

In terms of the single-payer law, “there’s still a lot of work to be done,” she says. But, “as for our work, we’re sort of off and running. We have those responsibilities, regardless of what happens in the future with the single-payer plan.”

Nationally, whether the ACA stands or falls “doesn’t really affect our work at all,” she adds, referring to the Green Mountain Care board. “It affects the single-payer plan, and it affects our implementation of the health benefit exchange, because if the [individual] mandate is removed, it means the state will have to determine whether to pass a mandate at the state level to assure everybody’s covered.”

Single-payer may have far to go before it’s a reality. But even if it ends up a vanishing pipe dream, Vermont is in much better shape, when it comes to keeping its citizens covered, than most other states.

By the same token, even if the Affordable Care Act is upheld and goes into full effect, “at best, it will bring the rest of the country to where Vermont already is,” Richter says. “Act 48 was intended to go beyond that.”

“Regardless of what happens with [single-payer], or with ObamaCare,” Wallack adds, “if we do our job right, we’ll have a more sustainable, higher-quality healthcare system, I think, than anywhere else in the country.”

http://www.govhealthit.com/news/what-scotus-ruling-might-mean-vermonts-single-payer-plan?page=0,1

NHIS report on insurance coverage

Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2011

By Robin A. Cohen, Ph.D., and Michael E. Martinez, M.P.H., M.H.S.A.
CDC, Division of Health Interview Statistics, National Center for Health Statistics
June 2012
The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is releasing selected estimates of health insurance coverage for the civilian noninstitutionalized U.S. population based on data from the 2011 National Health Interview Survey (NHIS).
* In 2011, 46.3 million persons of all ages (15.1%) were uninsured at the time of interview, 58.7 million (19.2%) had been uninsured for at least part of the year prior to interview, and 34.2 million (11.2%) had been uninsured for more than a year at the time of interview.
* In 2011, the percentage of children under age 18 years who were uninsured at the time of interview was 7.0%.
* Among adults aged 19–25, the percentage uninsured at the time of interview decreased from 33.9% (10 million persons) in 2010 to 27.9% (8.4 million) in 2011.
* Among adults aged 19–25, 56.2% were covered by a private plan in 2011, an increase from 2010 (51.0%).
Estimates of enrollment in HDHPs and CDHPs
Based on data from the 2011 NHIS, 29.0% of persons under age 65 with private health insurance were enrolled in an HDHP (high-deductible health plan), including 9.2% who were enrolled in a CDHP (consumer-directed health plan) and 19.9% who were enrolled in an HDHP without a health savings account (HSA). Enrollment in HDHPs increased from 25.3% in 2010 to 29.0% in 2011. There was a significant increase in enrollment in HDHPs without HSAs, and in CDHPs, between 2007 (when NHIS started collecting this information) and 2011.
Based on data from 2011, among persons under age 65 with private health insurance, 26.9% with employment-based coverage were enrolled in an HDHP, compared with 52.4% of those with a private plan that was directly purchased or obtained through means other than employment. The percentage of persons covered by employment-based private plans who were enrolled in HDHPs increased from 15.6% in 2007 to 26.9% in 2011. The percentage of persons covered by directly purchased private health plans who were enrolled in HDHPs increased from 39.2% in 2007 to 52.4% in 2011.
Insurance coverage by poverty status
The percentage of poor children who were uninsured at the time of interview decreased from 1997 through 2011. During the same period, the percentage of poor adults who were uninsured remained relatively stable.
Among children, all poverty status groups experienced an increase in public coverage between 1997 and 2011. However, the largest increase was seen among near poor children, for whom coverage by a public plan increased by 36.5 percentage points during the same period.
The rate of private coverage among near poor children was 25.1 percentage points lower in 2011 than in 1997. Among near poor children the percentage without health insurance and the percentage with private health insurance coverage have declined since 1997, while public coverage has increased. Private coverage generally decreased among near poor adults aged 18–64, from 52.6% in 1997 to 35.4% in 2011, so that the uninsured rate is now higher than the private coverage rate for this population. Private coverage among not poor adults aged 18–64 generally decreased from 1997 through 2011.
http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201206.pdf

The good news is that the percentage of individuals uninsured at the time of the National Health Interview Survey declined from 16.0% in 2010 to 15.1% in 2011. The improvements were primarily due to an increase in enrollment of children in public programs, and an increase in enrollment of young adults in their parents’ private insurance plans.
If the Affordable Care Act is upheld, we can anticipate a further increase in enrollment in Medicaid. If not, at least public coverage for low-income children should be maintained.
The more alarming news in this report is the increase in high-deductible health plans, both those acquired through employment and especially those purchased in the individual market. The increase in private coverage made possible through the establishment of state insurance exchanges will be in lower-actuarial value plans – primarily high-deductible plans. Also employers are expected to shift more of their plans to high-deductible coverage.
High-deductible plans equate with underinsurance. These plans leave people with health care needs vulnerable to financial barriers to care. With this report, once again we see that underinsurance is becoming the new standard in America. That wouldn’t occur if we were to adopt an improved Medicare for all.

Health care system a major factor in African Americans' poorer health

By Jonathan D. Walker, M.D.
Frost Illustrated (Fort Wayne, Ind.), June 13-20, 2012

Part one of two

When it comes to overall health, African Americans tend to do much worse than average. A few examples: according to the Center for Disease Control, death rates for black Americans surpass those of Americans overall for heart disease, cancer, diabetes and HIV. According to a study published in Health Services Research, white males live approximately seven years longer than African American males, and white women live more than five years longer than black women. Finally, African Americans fare far worse when it comes to infant mortality-their rate is almost double the national average.

There are a lot of different reasons for all this. Part of this is genetic – some diseases are simply worse for African Americans, such as prostate cancer and glaucoma (a disease of the eye). Another part of the problem is cultural; African Americans as a group tend to be more apprehensive of the health care system and are less likely to go to a doctor. Other factors include a person’s level of education and income – these can play into lifestyle choices regarding smoking, diet and exercise.

But there is also one huge problem that contributes to this negative outlook for African Americans: lack of insurance. And nowadays, most private insurance plans include such high out-of-pocket expenses that it can be too costly to see a doctor, even if someone has insurance. This is known as “under-insurance,” and it is becoming as much of a problem as having no insurance at all.

How did we end up with so many people – and especially African Americans – struggling to get the health care they need? The answer is complicated, but the basic problem is that we have a very fragmented health care system that consists of a lot of different entities that are looking for ways to maximize profits. Insurance companies deny coverage to anyone they think might cost them money, and keep huge amounts of money that should be used to take care of patients. Drug companies have seen to it that our government cannot bargain over drug prices – as taxpayers, we have to pay whatever price they want. Hospitals are built where the most profitable patients are, often leaving poorer areas with little coverage. Doctors may refuse to see patients who don’t have enough money. The bottom line is that if there are people who aren’t profitable, those people are left out.

It would be great if we could point to one thing to fix. But, there isn’t one thing – the whole system is broken. And, it is even more complicated because everyone in the system feels like they are doing the right thing. They feel they are helping people and want to get their fair share, and it is really hard to convince someone that they might be part of the problem if they believe in what they are doing. The only way people really learn about how cruel our system can be is if they happen to get sick – then they experience firsthand what it is like to have to worry about going broke or bankrupt to stay alive. But most people don’t get sick, so they think everything is OK and they keep the broken system we have because they are afraid to change – especially if their income depends on keeping the system the way it is.

America is the only country in the developed world that is like this. Every other developed country has realized that it is better to make sure that everyone gets the treatment they require. And, that’s something to think hard about. No one in those countries has to worry about whether they can pay the bill for themselves or someone they love – they just get the care they need.

Now, we have been trained to think that all those other countries must be bad; that people have to wait for care and that they are always letting people die to save money. No health care system is perfect, but you should study the problem yourself – don’t just accept what the special interests are saying. You will see that a lot of what we hear is either an exaggeration or just plain wrong. It is hard to imagine how all those people, in all those countries, would be putting up with health care systems that don’t take care of them.

There are a number of ways to design a health care system so that everyone gets the care they need, and even have it be cheaper and with better results compared to our current system. But, no one looks closely at this because powerful special interests work very hard to keep it off the table – special interests like insurance companies, drug companies, hospital associations and doctor organizations. However, there is one man who is trying to change that. He is Representative John Conyers Jr., an African American congressman from Michigan, and in the next installment we will look at what he is trying to do to make all of our lives better.

Dr. Walker is an ophthalmologist in town and a member of Physicians for a National Health Program.

http://www.frostillustrated.com/atf.php?sid=10446

Eye on health

By Jonathan D. Walker, M.D.

Part two of two

In the last installment of this story, we reviewed how African Americans tend to do much worse in our health care system. For instance, death rates for black Americans surpass those of Americans overall for heart disease, cancer, diabetes and HIV. We also discussed that there are a number of reasons for this disparity, ranging from genetics to personal lifestyle choices. But there is one other very important reason — there are more African Americans without insurance. And, that problem arises because we have a very fragmented health care system that has placed profits over patients, so that too many people are left out. And, people who are left out get sicker and die sooner no matter what race they are.

It is important to understand that America is the only country in the developed world that is like this. Every other developed country has realized that it is better to simply make sure everyone can get the treatment they require. Think about that. No one in those countries has to worry about whether they can pay the bill for themselves or someone they love — they just get the care they need.

But, special interests work hard to keep us from exploring those other health care systems. And, they especially like to scare us with stories about Canada. There are problems up there, but the situation is actually much better than you
might think — most Canadians would never switch to a health care system like ours. Besides, Canada is only one of many countries — we don’t have to use their approach.

There are many other ways to design a better health care system. For instance, back in the ’90s, Taiwan was having the same health care problems we are having here. So they looked at every other system in the world, and they ended up deciding that our Medicare system looked pretty good. (Medicare is the government insurance plan for people who are disabled or over 65.)

In the end, Taiwan actually ended up improving on Medicare and now the government negotiates with doctors, hospitals and drug companies to set fair prices, and everyone pays a small tax that is much less than what we pay private insurance companies for coverage in America. Citizens even have smartcards that hold their medical history, so their records are always available. The Taiwanese can see any doctor they want, anytime, and no one worries about getting sick and going broke. And, their health care is as advanced as anywhere in the world. Plus, their businesses are freed from the burden of providing insurance; they can compete much better in the global market because everyone is automatically covered from birth to death.

And, remember that their system is based on our Medicare. Medicare is not perfect, but Americans with Medicare are happier than those with private insurance, and much happier than those with no insurance or under-insurance. All you have to do is ask anyone on Medicare if they want to give it up and buy private insurance — you will see. Plus, you are paying into Medicare with your taxes already. But, you are forbidden to use Medicare for yourself unless you are over 65 or disabled — insurance companies have seen to it that you can’t have something that you are paying for. And, Medicare certainly has problems, but most of them stem from the fact that lobbyists and special interest groups have rigged Medicare to pay out far more than it should. Our health care system would be much better if we improved Medicare and expanded it to cover everyone. This approach is known as a “single payer” system — everyone is paid by one entity rather than by a host of different payers.

It so happens that an African American congressman, Representative John Conyers Jr. from Michigan, has introduced a bill known as “The Expanded and Improved Medicare for All Act,” H.R. 676. This bill would: (1) automatically enroll everyone in the plan, (2) provide comprehensive services covering all medically necessary care and drugs, (3) allow free choice of doctor and hospital, (4) eliminate all co-pays and deductibles, (5) create a public, nonprofit agency to pay all the bills, simplifying administration, paperwork, and bureaucracy while saving an estimated $400 billion annually, (6) finance care through progressive taxation, with people paying less than what they are paying now for private insurance, (7) boost job growth by reducing the burden of health costs on businesses, (8) provide powerful cost control tools like bulk purchasing and global budgeting for long-term, sustainable savings.

It would not introduce “government rationing”— it would be really hard to ration anything if we all were depending on it and paying close attention to how it is run. It would eliminate the real rationing that we have right now that is based on the patient’s ability to pay — if you have money you get care and if you don’t, you won’t. In fact, such a system would restore the doctor-patient relationship by removing barriers created by both private insurers and lack of money. It would be transparent and publicly accountable, fair and efficient — if there were problems we would all want it fixed because we would all be part of it. No one would ever have to worry about getting sick and going broke again, and it would be cheaper because we wouldn’t be wasting money on insurance companies, bureaucracy and paperwork.

Dr. Martin Luther King Jr. once said, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.” And he was not just talking about African Americans — he was talking about anyone that is afraid to see a doctor because they can’t afford it. Every other developed country in the world has figured this out, but we ignore them. Our politicians are so influenced by special interest groups, and we are so stuck in thinking that we have to keep the system we have, that we put up with the same expensive, fragmented mess – even if it means that any one of us could be bankrupted at anytime if we get sick.

It would be great if people would look at Rep. Conyers’ bill and realize how much sense it makes. It would be even better if people started to demand that we at least try what he is suggesting — if for no other reason than we are all already paying for it but can’t have it. Mostly, it would be best if no one ever had to fear going to a doctor because of medical bills, and no one ever had to grow up experiencing the inequality of health care that Dr. King was talking about.

Dr. Walker is an ophthalmologist in town and a member of Physicians for a National Health Program.

http://www.frostillustrated.com/atf.php?sid=10477