PNHP

Insurers battle and patients lose

Insurers battle and patients lose

Insurer Battles Physician Group

By Anna Wilde Mathews
The Wall Street Journal, February 29, 2012
A clash between health insurer Blue Shield of California and a doctor group that sold its operations to UnitedHealth Group Inc. highlights emerging tensions as lines blur between health insurers and medical providers.
On Tuesday, the health insurer filed a demand for at least $10.5 million in damages from Monarch HealthCare, a 2,300-physician association based in Irvine, Calif., that last fall sold its management arm to UnitedHealth’s Optum health-services unit.
Among the allegations: that Monarch sought to steer Blue Shield members away from Blue Shield and toward competing health plans, and that its doctors started declining to see some Blue Shield members. The complaint says these moves violated Blue Shield’s contract with Monarch, which the insurer has previously said will end on May 1.
“It seems crazy to be contracted with someone who’s a direct competitor, and share everything you design with them,” said Juan Davila, senior vice president for network management at Blue Shield, which has 3.3 million members. Blue Shield felt its “worry was proved true” by Monarch’s alleged actions, he said.
At the root of the clash is the deal unveiled last fall for Monarch’s operations arm to be acquired by Optum, the unit of UnitedHealth Group, which is also the parent of UnitedHealthcare, the nation’s biggest insurer. Because California law bans most entities from directly employing practicing doctors, acquisitions involving independent-practice associations like Monarch often have complex structures.
The dispute raises issues for both sides. Blue Shield says in its complaint that it lost existing and prospective members. Also, its provider network will soon lack one of Orange County’s biggest doctor groups. Monarch risks losing some patients who are Blue Shield members.
In its complaint, Blue Shield said it had around 19,200 members in commercial and Medicare Advantage plans last September who used Monarch doctors. In May, Blue Shield’s members have to pay more to keep seeing Monarch doctors, who would become out-of-network providers.
Similar static is beginning to surface elsewhere as health plans have begun buying medical providers, and some providers have started making insurer-style moves, with some considering direct approaches to employers and even seeking to launch their own health plans.
WellPoint Inc.’s Anthem Blue Cross broke off a deal with Monarch to create a cooperative “accountable-care organization” and also said in a letter to doctors that it will discontinue its health-maintenance organization relationship with Monarch in the future. In the letter last October, an Anthem official said the ACO move came as “a result of the group’s pending transaction” with Optum.
http://online.wsj.com/article/SB10001424052970203833004577251773887296652.html

These disputes between UnitedHealth’s Monarch HealthCare, Blue Shield of California, and WellPoint’s Anthem Blue Cross not only impose a great disservice on their patients, but also should outrage all of us over the fact that these health care intermediaries act as if they regard patients to be their chattel – jerking them around in order to fulfill their own business goals. How long are we going to continue to tolerate this reprehensible industry? They may need us, but we don’t need them.

CMS on actuarial value and cost sharing reductions

Actuarial Value: Why It Matters And How It Will Work

By Lynn Quincy
Health Affairs Blog, February 28, 2012

On February 24, 2012, the Department of Health and Human Services (HHS) released guidance describing a proposed method for estimating the actuarial value of health plan benefit designs in 2014. The actuarial value measures the percentage of expected medical costs that a health plan will cover. It can be considered a general summary measure of health plan generosity. As such, it can help consumers make sense of their health plan options by providing an overall measure of coverage in addition to discrete information on deductibles, copayments, and coinsurance, etc.

A Trade-Off Between Simplicity And Accuracy
 
The bulletin highlights — but doesn’t resolve — a tension between simplicity and accuracy in the estimation of actuarial value. HHS initially proposes to use a “practical and easy-to-use” calculator that would utilize the “handful” of cost-sharing features that have a large impact on a plan’s actuarial value, such as deductible, co-insurance, and maximum out-of-pocket. This approach may not take into account more subtle features of a plan, such as service specific deductions or exceptions to the out-of-pocket limit.

There are trade-offs, however, from taking this “practical” approach.  First, cost-sharing features that may be only worth a few points of actuarial value can have a big impact on an individual consumer’s cost-sharing obligations. Second, high level plan features like the maximum out-of-pocket can vary in how reliably they reflect patient cost-sharing. One study found that plans with similar reported out-of-pocket maximums actually differed by thousands of dollars in the final cost to patients due to exceptions to the maximum.

Third, by opting for a simple calculator, HHS envisions insurers using supplementary methods to calculate actuarial value if their plan design doesn’t fit neatly into the calculator. This could greatly undermine the goal of using a common method of calculating actuarial value to ensure that plan comparisons are truly “apples to apples.” A recent study demonstrated that the same plan design can yield different actuarial value estimates, if different methods are used to calculate it.

Addressing A Tension Between Actuarial Value And Out-Of-Pocket Maximums

Depending on the actuarial model being used, some researchers have found it impossible to hit the required actuarial value targets and the lower out-of-pocket limit requirements simultaneously. While it may seem counter-intuitive, allowing for a higher out-of-pocket maximum means lower deductibles can be offered while still hitting the required actuarial value target. As many consumers will not hit their out-of-pocket maximum, flexibility to use higher out-of-pocket limits benefits a greater number of consumers.

In a nutshell, HHS proposes to let actuarial value targets trump maximum out-of-pocket rules if this conflict arises. HHS intends to publish an annual notice providing guidance as to the out-of-pocket levels that would be consistent with the actuarial value targets for households with incomes from 100 percent to 250 percent of FPL, presumably reflecting the types of estimates being produced by the federal calculator. For households with incomes of 250 percent to 400 percent of FPL – which are also entitled to lower out-of-pocket maximums under the ACA but remain tied to the standard actuarial value benchmark of 70 percent – HHS proposes to do away with the requirement for lower out-of-pocket maximums altogether.

http://healthaffairs.org/blog/2012/02/28/actuarial-value-why-it-matters-and-how-it-will-work/

CMS: Actuarial Value and Cost-Sharing Reductions Bulletin (16 pages):
http://www.cciio.cms.gov/resources/files/Files2/02242012/Av-csr-bulletin.pdf

Comment: 

By Don McCanne, MD

The actuarial value of a health plan represents the average percentage of covered services that a plan is expected to pay for, the balance being paid by the patient. The Affordable Care Act calls for four levels of plans, ranging from 60 percent to 90 percent actuarial values. Cost sharing, such as deductibles, coinsurance, and maximum out-of-pocket amounts, is an important consideration in determining the actuarial value of the plan.

The excerpts above include only two of many complex considerations in trying to standardize rules for establishing actuarial values and associated cost sharing. For instance, in trading off simplicity and accuracy, “plans with similar reported out-of-pocket maximums actually differed by thousands of dollars in the final cost to patients due to exceptions to the maximum.” Also, “For households with incomes of 250 percent to 400 percent of FPL – which are also entitled to lower out-of-pocket maximums under the ACA but remain tied to the standard actuarial value benchmark of 70 percent – HHS proposes to do away with the requirement for lower out-of-pocket maximums altogether.”

By selecting this model of reform, not only do we compound the administrative excesses in health care financing, we also compound some of the inequities in our system. Policy wonks will want to read the full CMS Bulletin covering these complex issues (link above).

It is hoped that those who continue to push for implementation of ACA will finally realize the futility of their efforts and join us in advocating for equitable, efficient reform for all of us through a single payer national health program.

As Court Showdown Nears, Our Health Care System Still a Mess

By Rose Ann DeMoro
The Huffington Post, Feb. 27, 2012

With the approaching Supreme Court showdown on the President Obama’s 2010 health care law (the Affordable Care Act, modeled, of course, on Mitt Romney’s law in Massachusetts), the U.S. health care system remains a dysfunctional mess, as nurses bear witness to every day.

In late March, the Court will devote six hours over three days to oral arguments on the legal challenges to the law — the most time the Court has given a case in 56 years. The testimony will likely be accompanied by a possible record 100 “friend of the court” briefs, Kaiser Health News reported February 16.

While the ACA had some undeniable positive elements, such as permitting young adults up to age 26 to remain on their parents health plan, and a few limitations on insurance industry abuses, such as barring them from denying coverage due to pre-existing conditions, our health care nightmare is far from over.

And, as nurses have reported repeatedly the past year, the economic crisis has great aggravated the suffering with broad declines in health status that are directly linked to job loss, unpayable medical bills, and families having to choose between paying for food, housing, clothing or health care.

As to the law itself, despite its name, the ACA has done little to actually make health care affordable. Out-of-pocket health costs for families continue to soar largely unabated. Nurses now routinely see patients who have postponed needed care, sometimes even life-saving or life-prolonging care, because of the co-pays and deductibles.

A Commonwealth Fund study in November, comparing the U.S. to other high income countries, found that the U.S. stands out for sick adults having cost and access problems with 27 percent unable to pay medical bills in the past year, compared to from 1 percent to 14 percent in other countries, and 42 percent skipping doctors visits, recommended care, or not filling prescriptions.

Nationally, premiums have jumped on average 50 percent over the past seven years with more than six in 10 Americans now living in states where their premiums consume a fifth or more of median earnings.

Universal coverage remains a far off dream. Fifty million Americans still have no health coverage. Another 29 million are underinsured, meaning they have massive holes in their health plans, an increase of 80 percent since 2003, according to the journal Health Affairs. The percentage of adults with no health insurance at 17.3 percent in the third quarter of 2011 was the highest on record, up from 14.4 percent just three years earlier, Gallup reported.

On quality, the U.S. continues to fall far behind other nations.

What should have been a shocking, under-reported study from the University of Washington last June found that more than 80 percent of U.S. counties in free fall on life expectancy compared to nations with the best life expectancies. Some U.S. counties are more than 50 years behind their international counterparts, meaning they have the life expectancy that those nations had in 1957.

One reason for this disturbing news is the regression in death rates for childbearing women. The U.S. ranks just 41st in the world, and it has been getting worse, according to the World Health Organization. The average mortality rate within 42 days of childbirth has actually doubled in two decades, from 6.6 deaths per 100,000 live births in 1987 to 13 deaths per 100,000 in 2007. One reason, a 10 percent cut in federal spending for maternal and child health programs the past seven years.

Those who think giving more handouts to the private insurers and other health care corporations will improve these dreadful statistics should think again. The wholesale domination of our health by the same Wall Street types who tanked our economy is exactly what has caused the falling health barometers on access, cost, and quality.

There is an alternative which most of the rest of the world has discovered, a national or single-payer system, such as expanding and adequately funding Medicare to cover everyone. Even in other countries where conservative politicians have proposed privatization or sweeping health cuts they are being met with an aroused public unwilling to trade their health systems for the broken model we have here.

Whether the 2010 law is fully or partially thrown out by the courts, repealed in Congress, or fully implemented, the need for real reform, single payer/Medicare for all, will continue to grow. At this point the fight for single payer is being taken up state by state, a movement that we will continue to proudly support.

Rose Ann DeMoro is executive director, National Nurses United, AFL-CIO, and California Nurses Association.

http://www.huffingtonpost.com/rose-ann-demoro/supreme-court-health-care_b_1299807.html

CMS on actuarial value and cost sharing reductions

Actuarial Value: Why It Matters And How It Will Work

By Lynn Quincy
Health Affairs Blog, February 28, 2012
On February 24, 2012, the Department of Health and Human Services (HHS) released guidance describing a proposed method for estimating the actuarial value of health plan benefit designs in 2014. The actuarial value measures the percentage of expected medical costs that a health plan will cover. It can be considered a general summary measure of health plan generosity. As such, it can help consumers make sense of their health plan options by providing an overall measure of coverage in addition to discrete information on deductibles, copayments, and coinsurance, etc.
A Trade-Off Between Simplicity And Accuracy
The bulletin highlights — but doesn’t resolve — a tension between simplicity and accuracy in the estimation of actuarial value. HHS initially proposes to use a “practical and easy-to-use” calculator that would utilize the “handful” of cost-sharing features that have a large impact on a plan’s actuarial value, such as deductible, co-insurance, and maximum out-of-pocket. This approach may not take into account more subtle features of a plan, such as service specific deductions or exceptions to the out-of-pocket limit.
There are trade-offs, however, from taking this “practical” approach.  First, cost-sharing features that may be only worth a few points of actuarial value can have a big impact on an individual consumer’s cost-sharing obligations. Second, high level plan features like the maximum out-of-pocket can vary in how reliably they reflect patient cost-sharing. One study found that plans with similar reported out-of-pocket maximums actually differed by thousands of dollars in the final cost to patients due to exceptions to the maximum.
Third, by opting for a simple calculator, HHS envisions insurers using supplementary methods to calculate actuarial value if their plan design doesn’t fit neatly into the calculator. This could greatly undermine the goal of using a common method of calculating actuarial value to ensure that plan comparisons are truly “apples to apples.” A recent study demonstrated that the same plan design can yield different actuarial value estimates, if different methods are used to calculate it.
Addressing A Tension Between Actuarial Value And Out-Of-Pocket Maximums
Depending on the actuarial model being used, some researchers have found it impossible to hit the required actuarial value targets and the lower out-of-pocket limit requirements simultaneously. While it may seem counter-intuitive, allowing for a higher out-of-pocket maximum means lower deductibles can be offered while still hitting the required actuarial value target. As many consumers will not hit their out-of-pocket maximum, flexibility to use higher out-of-pocket limits benefits a greater number of consumers.
In a nutshell, HHS proposes to let actuarial value targets trump maximum out-of-pocket rules if this conflict arises. HHS intends to publish an annual notice providing guidance as to the out-of-pocket levels that would be consistent with the actuarial value targets for households with incomes from 100 percent to 250 percent of FPL, presumably reflecting the types of estimates being produced by the federal calculator. For households with incomes of 250 percent to 400 percent of FPL – which are also entitled to lower out-of-pocket maximums under the ACA but remain tied to the standard actuarial value benchmark of 70 percent – HHS proposes to do away with the requirement for lower out-of-pocket maximums altogether.
http://healthaffairs.org/blog/2012/02/28/actuarial-value-why-it-matters-and-how-it-will-work/
CMS: Actuarial Value and Cost-Sharing Reductions Bulletin (16 pages):
http://www.cciio.cms.gov/resources/files/Files2/02242012/Av-csr-bulletin.pdf

The actuarial value of a health plan represents the average percentage of covered services that a plan is expected to pay for, the balance being paid by the patient. The Affordable Care Act calls for four levels of plans, ranging from 60 percent to 90 percent actuarial values. Cost sharing, such as deductibles, coinsurance, and maximum out-of-pocket amounts, is an important consideration in determining the actuarial value of the plan.
The excerpts above include only two of many complex considerations in trying to standardize rules for establishing actuarial values and associated cost sharing. For instance, in trading off simplicity and accuracy, “plans with similar reported out-of-pocket maximums actually differed by thousands of dollars in the final cost to patients due to exceptions to the maximum.” Also, “For households with incomes of 250 percent to 400 percent of FPL – which are also entitled to lower out-of-pocket maximums under the ACA but remain tied to the standard actuarial value benchmark of 70 percent – HHS proposes to do away with the requirement for lower out-of-pocket maximums altogether.”
By selecting this model of reform, not only do we compound the administrative excesses in health care financing, we also compound some of the inequities in our system. Policy wonks will want to read the full CMS Bulletin covering these complex issues (link above).
It is hoped that those who continue to push for implementation of ACA will finally realize the futility of their efforts and join us in advocating for equitable, efficient reform for all of us through a single payer national health program.

‘X’ marks big spot for health costs

By Jonathan D. Walker, M.D.
The Journal Gazette (Fort Wayne, Ind.), Feb. 24, 2012

There is an aspect of our health care system that costs us all a lot of extra money and affects about half the readers of this piece in a very negative way. But to understand it you need some background.

There are two main types of insurance: actuarial and social. Actuarial means that insurance companies know who you are and what you have done, and that determines the cost of insurance. Car and life insurance are examples of actuarial insurance.

Social insurance means that everyone puts in a little bit to help cover everyone – there is no attempt to divide people into who is risky and who isn’t. Medicare is an example, and in a sense so are policemen, firemen, public schools and other programs that we all pay for to have them there when we need them.

Americans have a split personality when it comes to how we pay for health care. For instance, if you are older than 65, most of your health care is covered by social insurance. The majority of us, however, get insurance coverage from private, for-profit companies.

Those companies have to use actuarial methods to survive; they need to look at whom they are insuring and charge premiums based on how risky those people are.

It turns out that there is one big group that automatically gets charged a higher rate by insurance companies. That group is much larger than other groups that insurance companies charge more for, such as smokers and diabetics. The group happens to be women, because on average women have higher health care costs than men. Young women tend to do expensive things like have babies. Middle-aged women have the unfortunate distinction of getting expensive diseases like breast cancer.

Charging more for women is known as “gender rating,” and it has several consequences. First, it means that employers have to pay more if they want to give benefits to female employees, which can translate into less money available for salaries and raises. Additionally, gender rating has a big effect on people with high-deductible insurance plans. Because women on average have more health care expenses, they automatically get a pay cut with high-deductible plans relative to men – on average it is a loss of income of more than $1,000 a year, according to a 2007 study in the Journal of General Internal Medicine. Finally, actuarial methods such as gender rating require each insurance company to have a large bureaucracy that determines everyone’s risk, and those bureaucracies result in administrative costs that make health care more expensive for all of us.

The new health care law tries to stop gender rating – but the rules won’t take effect until 2014, and they won’t take effect at all if the law is repealed. Unfortunately, insurance company lobbyists made sure that the rules do not apply to all insurance markets, so even if the law remains in place, gender rating will continue. If you are a female with private insurance, it means that you are more expensive to employ and you pay more money for health care because you have two X chromosomes.

There are a lot of data that suggest that we could all save money if we simply agreed that it is better to cover everyone uniformly – but we insist on having a fragmented system with costly bureaucracies that decide who is cheap and who isn’t. Women are bearing a huge part of that burden, and it doesn’t look like that will be changing anytime soon.

Dr. Jonathan D. Walker is a member of Hoosiers for a Commonsense Health Plan. He wrote this for The Journal Gazette.

http://jg.net/article/20120226/EDIT05/302269968

Single-payer system

Dr. Thomas M. Duffy, Northbrook
Letter to the editor, Chicago Tribune, February 25, 2012

I would like to point out that the recent controversy over employers’ religious views and employees’ health coverage would never have happened if our country had a universal coverage, single-payer health care system.

That’s because, under single-payer, employers would no longer have to have any involvement in their employees’ health insurance.

An employer’s religious affiliation or moral beliefs would be a non-issue.

Under single-payer, everyone would have the same health coverage, regardless of whom they worked for.

And under single-payer, losing one’s job would no longer mean losing one’s health insurance.

Something to think about.

http://www.chicagotribune.com/news/opinion/ct-vp-0225voicelettersbriefs-20120225,0,5606304.story?page=2

Immigrant coverage under health reform

Key Facts on Health Coverage for Low-Income Immigrants Today and Under Health Reform

Kaiser Commission on Key Facts
February 2012

As of 2010, there were 38 million immigrants residing in the United States, accounting for 12.5 percent of the total population. They include 16.7 million naturalized citizens and 21.4 million non-citizens, including both lawfully present and undocumented individuals. The Pew Hispanic Center estimates there were 11.2 million undocumented immigrants in the United States as of 2010, accounting for about 3.7 percent of the total population.

In 2010, the median annual household income for non-citizens was $25,000, roughly half the amount for citizen households.

Health coverage for naturalized citizens is very similar to that of U.S.-born citizens, with the majority covered through employer-sponsored or other private coverage. However, non-citizens are three times as likely as U.S.-born citizens to be uninsured due to lower rates of both public and private coverage.

Coverage Options for Immigrants Under Health Reform

Almost all uninsured non-citizens have household incomes that would qualify for Medicaid or tax credits for exchange coverage under reform, but many will continue to face immigrant eligibility restrictions.
 
The Medicaid expansion will make many lawfully present immigrants newly eligible for the program, particularly low-income adults who have very limited eligibility for Medicaid today. However, the five-year wait for coverage will remain in place, limiting eligibility for many lawfully present immigrants, although states will maintain the option to eliminate the waiting period for lawfully residing children and pregnant women.
 
Lawfully present immigrants without access to affordable employer based coverage will be able to purchase health coverage in the new exchanges, and those with incomes up to 400 percent of poverty will be eligible for tax credits. This will include lawfully present immigrants with incomes below 133 percent of poverty who are unable to enroll in Medicaid due to the five-year waiting period. 
 
Undocumented immigrants will remain ineligible for Medicaid and will be ineligible for tax credits and prohibited from purchasing coverage through an exchange, even at full cost.

Safety-net providers will remain a major source of care for immigrants. Today, uninsured individuals, including many uninsured immigrants, often rely on community health centers and clinics for their care. Safety-net providers are seen as a trusted source for care and are able to offer culturally and linguistically appropriate services that meet the needs of diverse populations. Under reform, these providers will likely remain a primary source of care for millions of newly insured individuals, including lawfully present immigrants, as well as citizens and non-citizens who remain uninsured after 2014.

http://www.kff.org/uninsured/upload/8279.pdf

Comment: 

By Don McCanne, MD

Everyone should have health care. How well will the Affordable Care Act (ACA) work for our immigrant population? It depends partly on immigration status.

The ACA provisions apply to naturalized citizens just as they would for native-born citizens. Thus their barriers will be the same as for most of the rest of us. They will face the same issues of whether or not the subsidies will be adequate to purchase private plans, and whether or not they will be exposed to excessive cost sharing with inadequate subsidies when accessing care.

Non-citizen immigrants are faced with the additional problem of having household incomes that average only half that of the U.S. median. Those who are lawfully present also must wait for five years before they are eligible for the Medicaid program. They will be eligible to purchase programs in the new exchanges, though the subsidies will likely be inadequate for those with incomes that already don’t cover other essential needs.

For immigrants who are undocumented, Congress decided to yield to the forces of anti-immigrant politics, and not only make them ineligible for tax credits for the exchange plans, but also to prohibit them from purchasing the plans with their own funds, even at full cost. It is very unfortunate that Congress co-mingled heath care justice with immigration policy. The sanctity of human life should always prevail over the politics of ideology.

Yes, some will receive excellent care from our safety-net providers, but many will not. Community health centers cannot possibly fill in the full void in coverage.

Most undocumented workers are productive individuals, just like our citizens, and there is no reason that they should not contribute to and participate in a single payer national health program that covers everyone – absolutely everyone.

Immigrant coverage under health reform

Key Facts on Health Coverage for Low-Income Immigrants Today and Under Health Reform

Kaiser Commission on Key Facts
February 2012
As of 2010, there were 38 million immigrants residing in the United States, accounting for 12.5 percent of the total population. They include 16.7 million naturalized citizens and 21.4 million non-citizens, including both lawfully present and undocumented individuals. The Pew Hispanic Center estimates there were 11.2 million undocumented immigrants in the United States as of 2010, accounting for about 3.7 percent of the total population.
In 2010, the median annual household income for non-citizens was $25,000, roughly half the amount for citizen households.
Health coverage for naturalized citizens is very similar to that of U.S.-born citizens, with the majority covered through employer-sponsored or other private coverage. However, non-citizens are three times as likely as U.S.-born citizens to be uninsured due to lower rates of both public and private coverage.
Coverage Options for Immigrants Under Health Reform
Almost all uninsured non-citizens have household incomes that would qualify for Medicaid or tax credits for exchange coverage under reform, but many will continue to face immigrant eligibility restrictions.
The Medicaid expansion will make many lawfully present immigrants newly eligible for the program, particularly low-income adults who have very limited eligibility for Medicaid today. However, the five-year wait for coverage will remain in place, limiting eligibility for many lawfully present immigrants, although states will maintain the option to eliminate the waiting period for lawfully residing children and pregnant women.
Lawfully present immigrants without access to affordable employer based coverage will be able to purchase health coverage in the new exchanges, and those with incomes up to 400 percent of poverty will be eligible for tax credits. This will include lawfully present immigrants with incomes below 133 percent of poverty who are unable to enroll in Medicaid due to the five-year waiting period.
Undocumented immigrants will remain ineligible for Medicaid and will be ineligible for tax credits and prohibited from purchasing coverage through an exchange, even at full cost.
Safety-net providers will remain a major source of care for immigrants. Today, uninsured individuals, including many uninsured immigrants, often rely on community health centers and clinics for their care. Safety-net providers are seen as a trusted source for care and are able to offer culturally and linguistically appropriate services that meet the needs of diverse populations. Under reform, these providers will likely remain a primary source of care for millions of newly insured individuals, including lawfully present immigrants, as well as citizens and non-citizens who remain uninsured after 2014.
http://www.kff.org/uninsured/upload/8279.pdf

Everyone should have health care. How well will the Affordable Care Act (ACA) work for our immigrant population? It depends partly on immigration status.
The ACA provisions apply to naturalized citizens just as they would for native-born citizens. Thus their barriers will be the same as for most of the rest of us. They will face the same issues of whether or not the subsidies will be adequate to purchase private plans, and whether or not they will be exposed to excessive cost sharing with inadequate subsidies when accessing care.
Non-citizen immigrants are faced with the additional problem of having household incomes that average only half that of the U.S. median. Those who are lawfully present also must wait for five years before they are eligible for the Medicaid program. They will be eligible to purchase programs in the new exchanges, though the subsidies will likely be inadequate for those with incomes that already don’t cover other essential needs.
For immigrants who are undocumented, Congress decided to yield to the forces of anti-immigrant politics, and not only make them ineligible for tax credits for the exchange plans, but also to prohibit them from purchasing the plans with their own funds, even at full cost. It is very unfortunate that Congress co-mingled heath care justice with immigration policy. The sanctity of human life should always prevail over the politics of ideology.
Yes, some will receive excellent care from our safety-net providers, but many will not. Community health centers cannot possibly fill in the full void in coverage.
Most undocumented workers are productive individuals, just like our citizens, and there is no reason that they should not contribute to and participate in a single payer national health program that covers everyone – absolutely everyone.

Pre-Existing Condition Insurance – only a glimmer

Covering People with Pre-Exisiting Conditions: Report on the Implementation and Operation of the Pre-Existing Condition Insurance Plan Program

CMS
February 23, 2012

Before the Affordable Care Act, Americans with pre-existing conditions who did not receive health coverage through their employers had few affordable options to get the care they needed. In most States, insurance companies could refuse to sell them coverage, charge exorbitant premiums, or offer them coverage that excluded benefits for their health conditions.

The law ends discrimination against people with pre-existing conditions.

As a bridge to 2014, when these protections apply to all Americans, the law created a new program designed to help the tens of thousands of Americans who have been locked out of the insurance market due to their health conditions. The Pre-Existing Condition Insurance Plan or PCIP is a temporary high-risk health insurance program that makes health coverage available and more affordable immediately to individuals who are uninsured and have been denied health insurance by insurance companies because of a pre-existing condition. Twenty-seven States are operating their own program, often in coordination with existing State High Risk Pools, and 23 States and the District of Columbia have opted to have a Federally-operated program.

The PCIP program will continue to provide affordable coverage to consumers who are enrolled and will facilitate their transition to Affordable Insurance Exchanges in 2014.

Enrollment as of December 31, 2011: 48,879

http://www.cciio.cms.gov/resources/files/Files2/02242012/pcip-annual-report.pdf

Comment:

By Don McCanne, MD

Under the Affordable Care Act (ACA), 48,879 previously uninsurable people with serious medical problems are receiving essential health care services under the pre-exisiting condition insurance program. We can’t celebrate this gain because far too many people are still left out. It is a mere glimmer that doesn’t light our path to reform. But temporarily we should accept what limited benefits ACA does provide, instead of trying to repeal it, while we work on a program that actually is going to take care of everyone – an improved Medicare for all.

Pre-Existing Condition Insurance – only a glimmer

Covering People with Pre-Exisiting Conditions: Report on the Implementation and Operation of the Pre-Existing Condition Insurance Plan Program

CMS
February 23, 2012
Before the Affordable Care Act, Americans with pre-existing conditions who did not receive health coverage through their employers had few affordable options to get the care they needed. In most States, insurance companies could refuse to sell them coverage, charge exorbitant premiums, or offer them coverage that excluded benefits for their health conditions.
The law ends discrimination against people with pre-existing conditions.
As a bridge to 2014, when these protections apply to all Americans, the law created a new program designed to help the tens of thousands of Americans who have been locked out of the insurance market due to their health conditions. The Pre-Existing Condition Insurance Plan or PCIP is a temporary high-risk health insurance program that makes health coverage available and more affordable immediately to individuals who are uninsured and have been denied health insurance by insurance companies because of a pre-existing condition. Twenty-seven States are operating their own program, often in coordination with existing State High Risk Pools, and 23 States and the District of Columbia have opted to have a Federally-operated program.
The PCIP program will continue to provide affordable coverage to consumers who are enrolled and will facilitate their transition to Affordable Insurance Exchanges in 2014.
Enrollment as of December 31, 2011: 48,879
http://www.cciio.cms.gov/resources/files/Files2/02242012/pcip-annual-report.pdf

Under the Affordable Care Act (ACA), 48,879 previously uninsurable people with serious medical problems are receiving essential health care services under the pre-exisiting condition insurance program. We can’t celebrate this gain because far too many people are still left out. It is a mere glimmer that doesn’t light our path to reform. But temporarily we should accept what limited benefits ACA does provide, instead of trying to repeal it, while we work on a program that actually is going to take care of everyone – an improved Medicare for all.

The silent decline of primary health care

By Margaret Newton, M.D.
Brattleboro Reformer, Feb. 23, 2012

Book review: “Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans,” by John Geyman

Dr. John Geyman was a rural family doctor before joining the University of Washington School of Medicine. He eventually chaired its department of family medicine and is now professor emeritus. He has written extensively about America’s urgent need for health care reform. He was president of Physicians for a National Health Program from 2005 to 2007 and is a member of the national Institute of Medicine.

Dr. Geyman began practicing medicine when family doctors knew their patients well and were trusted and overworked community servants. He is a leader in educational and other nonprofit groups that seek solutions to America’s costly and fragmented health care. He has a solid understanding of its conflicting ingredients and politics.

He has witnessed the patient-centered approach of primary practitioners erode over time by forces moving medical care into profit-driven business models controlled by powerful players of the “medical-industrial complex,” a term he likes. (Primary care includes family practice, general internal medicine, general pediatrics and, increasingly, geriatrics.) Primary care, which he sees as essential and central to an efficient health care model, has been diminishing along with America’s health, at an unsustainable cost to all.

Geyman believes that the crux of the primary care provider shortage is the lack of a clear federal policy and oversight for personnel training and funding of primary care and the relative needs of different specialties. There are too many specialists. Training occurs in teaching hospitals and community settings. The national ratio of specialists to generalists varies depending on funding available, priorities of the hospitals and medical centers and choices available to the trainees.

The ratio is also affected by the number practicing doctors who retire, leave clinical medicine entirely or decide to specialize. Many doctors are leaving primary care. Generalists earn by far the least of any doctor groups. Specialists often do primary care but continue to be officially specialists and are paid more accordingly.

Federal Title VII funds a small portion of primary care training and is subject to the usual budget-cutting dialogues. Most funding comes from Medicare payments for hospital care (states may use Medicaid funds). These sources are also affected by federal budget cutting. Medical centers may allocate disproportionate amounts for specialist training despite the nation’s shortage of generalists. There are also periodic bursts of funding to the National Health Service Corps to provide loans to senior medical students who agree to serve in primary care shortage areas. The 2010 Affordable Care Act provides some funds for the NHSC. It is not a long-term solution.

Other educational issues include: insufficient ambulatory care training sites for primary care and the indebtedness of new graduates that lures them toward specialty programs in anticipation of higher incomes and even more manageable lifestyles. Inefficient models for practice groups are another factor. Rural practitioners face additional issues. Providers who are nurse practitioners and physicians now tend to seek specialty jobs versus primary care.

For decades, the primary care doctor to specialist ratio has fluctuated and is now around 30:70, vs. an optimal 50:50. It is getting worse. The laws and appropriations change periodically and lack the flexibility to correlate with regional or national population needs. Funding for residency/fellowship training is influenced by lobbyists, specialty groups, academic medicine, hospitals that train health care providers, equipment manufacturers, insurance companies, federal and state budget-cutting, and more.

Dr. Geyman describes different ways to practice primary care. He outlines his thoughts for reversing the trend of declining primary care practitioners. He is convinced that a single payer model of health care with primary care clinical groups at the core is the best and most cost effective for all. He is committed to a system that is not profit-driven, where the patient comes first, and which serves everyone.

Margaret Newton, MD, is a retired internist and geriatrician. She lives in Brattleboro.

http://www.reformer.com/ovation/ci_20024449

The Pampered Patient: Perverting health care into a luxury commodity

By Jim Hightower
The Austin (Texas) Chronicle, Feb. 23, 2012

In these times of cold health care austerity, it reaffirms one’s faith in humanity to learn that many hospitals are now going the extra mile to provide top quality care for all.

For all superrich people that is – so rich that they can buy their way into “amenities units” that have quietly been built into secluded sections of many hospitals. It’s not medical care that they’re peddling to an elite clientele, but the personal pampering that the superrich expect in all aspects of their lives. “I was supposed to be in Buenos Aires last week taking tango lessons,” a Wall Street executive explained matter-of-factly to a New York Times reporter, “but unfortunately, I hurt my back, so I’m here with my concierge.”

A hospital with a concierge? Yes. That one’s called Eleven West, an exclusive wing of New York’s Mount Sinai Medical Center. “We pride ourselves on getting anything the patient wants,” beamed Eleven West’s director of hospitality. “If they have a craving for lobster tails and we don’t have them on the menu, we’ll go out and get them.”

From New York to L.A., hospitals that draw huge subsidies from us taxpayers (and often are so overcrowded that regular patients are lucky to get a gurney in the hallway) have set aside entire floors for $2,400-a-day deluxe suites. They come with butlers, 5-star meals, marble baths, imported bed sheets, special kitchens, and other amenities for swells who have both insurance and cash to burn.

Not only is it repugnant for the plutocratic elite to pervert health care into a luxury commodity, but their very effort to do so splits asunder America’s essential, uniting principle of the common good. To push for a national policy that treats health care as a fundamental human need – for all – contact Physicians for a National Health Program: www.pnhp.org.

Reference: “Chefs, Butlers, Marble Baths: Hospitals Vie for the Affluent,” www.nytimes.com, January 22, 2012.

Jim Hightower is a national radio commentator, writer, public speaker, and author of the book “Swim Against The Current: Even A Dead Fish Can Go with The Flow.” He was elected and served two terms as Texas Agriculture Commissioner.

http://www.austinchronicle.com/news/2012-02-24/hightower-report-the-pampered-patient/