Highmark looks to expand hospital and physician ownership

By Emily Berry
amednews.com, December 26, 2011

Faced with a future where its home region’s largest health system could be outside of its network, Pittsburgh-based Highmark plans to buy and affiliate with more hospitals and physician practices.

Highmark’s June announcement that it would purchase West Penn Allegheny Health System established its first large-scale foray in the clinical side of the health care business. It also contributed to the deterioration of contract negotiations with the University of Pittsburgh Medical Center, which sees West Penn as a competitor.

Highmark’s new direction is similar to what other insurers are trying to do. Insurers, hospitals and physicians are merging, affiliating and contracting in new ways as they seek alternatives to fee-for-service payment arrangements and look ahead to a post-reform health system, said Kevin Ryan, a Chicago-based attorney.

During a conference call with reporters Dec. 8, Highmark Executive Vice President David O’Brien said the West Penn deal “is only a small part of our strategy going forward.”

“We are in discussions with physicians and hospitals,” O’Brien said. “We’re looking to expand our footprint in the provider world. We think the future for us strategically is being able to work closely with providers, to be in the provider space.”

UPMC sees Highmark’s strategy as aimed primarily at undercutting UPMC’s standing in the market so that Highmark can drive members of its health plan to cheaper care settings, UPMC spokesman Paul Wood said.

“What Highmark is doing is essentially transforming from a neutral insurer where every subscriber could go to any hospital, to a competing integrated delivery and financing system. That puts them in direct competition with UPMC,” he said. UPMC and Highmark are fighting in federal court over issues arising during contentious contract negotiations. UPMC’s contract with Highmark expires on June 30, 2012.

http://www.ama-assn.org/amednews/2011/12/26/bisb1226.htm

Highmark, a Blue Cross Blue Shield licensee in Pennsylvania and West Virginia, is “transforming from a neutral insurer where every subscriber could go to any hospital, to a competing integrated delivery and financing system,” according to spokesman Paul Wood of the University of Pittsburgh Medical Center (UPMC). Or as Highmark’s David O’Brien says, they are moving into “the provider space.” This is yet one more example of the insurers trying to take over the health care delivery system.

Besides providing a management that places it own business interests before all else, it also locks in the exorbitantly high administrative costs characteristic of these organizations. Even worse, patients already had lost provider choice when plans such as Blue Cross and Blue Shield switched from indemnity plans to preferred provider organizations with their restrictive provider networks, but now, by now becoming the actual providers, the plans will no doubt establish severe penalties (zero coverage?) for obtaining care outside of their own intrinsic health care delivery systems. How does that benefit patients?

Many do recognize that the private insurance model is no longer sustainable, and that it is only a matter of time before the switch to a single payer system becomes inevitable. The question is, what will we do with the private insurers once they are the health care delivery system? Scary thought.

Hospitals Adopt Drug Industry Sales Strategy

By Phil Galewitz
Kaiser Health News, December 13, 2011

The University of Chicago Medical Center is one of a growing number of hospitals nationwide hiring former drug and device sales representatives to visit doctors’ offices to persuade them to use their services over competing facilities.

In visits that can last five to 20 minutes, the reps may try to win doctors’ loyalty by helping them get better times on operating room schedules or easier patient referrals to hospital-based specialists. The sales reps can also carry messages back to the hospital, like a doctor’s request for a new medical device to be available in surgery.

While hospitals have always tried to woo doctors to refer patients to them, the institutions are growing more direct in their efforts. The hospitals mine data to see which doctors have the most profitable, well-insured patients, and then they assign those doctors to a sales rep.

HCA Inc., the nation’s largest for-profit hospital chain, has at least 150 employees who make physician visits – or about one per hospital, said spokesman Ed Fishbough.

Convinced the sales-call strategy is fueling higher admissions, Tenet Healthcare Corp., the nation’s third largest for-profit hospital chain, has doubled its sales force in the past two years. The company now has 152 “physician liaisons” at its 49 hospitals, most of which are in California, Texas and Florida.

About two-thirds of Tenet’s liaisons are former drug and device sales reps, and they can make tens of thousands of dollars in bonuses if doctors increase their referrals to the hospitals. “These people are really good and really assertive and very sophisticated,” said Stephen Newman, Tenet’s chief operating officer.

http://www.kaiserhealthnews.org/stories/2011/december/14/hospitals-adopt-drug-industry-sales-strategy.aspx?referrer=search

The for-profit hospital chains – HCA and Tenet – both infamous for prior ethical lapses, have instituted tarnished sales programs that are now being adopted by others, including the not-for-profit University of Chicago Medical Center. They are using “assertive” former pharmaceutical and medical device sales reps to siphon off the most profitable and best insured patients, by convincing physicians to change their hospital referral patterns.

This is not about making the best use of a region’s health care resources. This is about hospitals cherry picking the most lucrative physicians and their patients, while making other competing hospitals, which are often safety-net institutions, the victims of adverse selection. We are already witnessing the closure of some of these institutions because of the inability to meet their costs.

This strategy is working. Sales calls are fueling higher admissions. What does this say about the physicians who are complicit in this activity? Can we really expect them to support altruistic policies in support of more equitable health care in the community at large, when they are being offered lucrative opportunities to practice in a more physician-friendly environment?

Under a well designed single payer system, capital improvements would be based on regional planning and budgeted separately, providing the facilities and equipment appropriate for the needs of the community. Hospitals would be placed on global budgets, providing enough financial resources to fulfill their mission of health care. Passive investors would be removed by eliminating for-profit ownership of hospitals. This would change the hospitals’ primary mission of making the greatest profit that the market will bear, to one of simply serving the health care needs of the community.

A comment from a recent Quote of the Day on the social consequences of segregation of the affluent (Nov. 25) seems to be very appropriate here. I wrote, “As the more affluent members of our society continue to concentrate themselves in their upscale neighborhoods, they take our resources with them, including some of the best of our health care services. Not only do they leave behind fewer resources for low- and moderate-income families, they also leave behind the political will to do something about it.”

Dems’ ‘Mediscare’ a dubious winner

By Angie Drobnic Holan and Bill Adair
Politico, December 20, 2011

Republicans muscled a budget through the House of Representatives in April that they said would take an important step toward reducing the federal deficit. Introduced by Rep. Paul Ryan of Wisconsin, the plan kept Medicare intact for people 55 or older, but dramatically changed the program for everyone else by privatizing it and providing government subsidies. Democrats pounced.

• Just four days after the party-line vote, the Democratic Congressional Campaign Committee released a Web ad, saying seniors will have to pay $12,500 more for health care “because Republicans voted to end Medicare.”

• Rep. Steve Israel of New York, chairman of the DCCC, appeared on cable news shows and declared that Republicans voted to “terminate Medicare.”

• A Web video from the Agenda Project, a liberal group, said the Ryan plan would leave the country “without Medicare” and showed a Ryan look-alike pushing an old woman in a wheelchair off a cliff.

• And just last month, House Minority Leader Nancy Pelosi sent a fundraising appeal that read, “House Republicans’ vote to end Medicare is a shameful act of betrayal.”

PolitiFact debunked the Medicare charge in nine separate fact-checks rated False or Pants on Fire, most often in attacks leveled against Republican House members.

Now, PolitiFact has chosen the Democrats’ claim as the 2011 Lie of the Year.

At times, Democrats and liberal groups were careful to characterize the Republican plan more accurately. Another claim in the ad from the Agenda Project said the plan would “privatize” Medicare, which received a Mostly True rating from PolitiFact. President Barack Obama also was more precise with his words, saying the Medicare proposal “would voucherize the program, and you potentially have senior citizens paying $6,000 more.”

With a few small tweaks to their attack lines, Democrats could have been factually correct, said Norman Ornstein, a resident scholar at the American Enterprise Institute, a conservative think tank. “I actually think there is no need to cut out the qualifiers and exaggerate,” he said.

http://www.politico.com/news/stories/1211/70705.html

And…

Long-Term Analysis of a Budget Proposal by Chairman Ryan

Congressional Budget Office
April 5, 2011

Among other changes, the proposal would convert the current Medicare program to a system under which beneficiaries received premium support payments – payments that would be used to help pay the premiums for a private health insurance policy and would grow over time with overall consumer prices. The change would apply to people turning 65 beginning in 2022; beneficiaries who turn 65 before then would remain in the traditional Medicare program, with the option of converting to the new system.

Under the proposal, most elderly people would pay more for their health care than they would pay under the current Medicare system. For a typical 65-year-old with average health spending enrolled in a plan with benefits similar to those currently provided by Medicare, CBO estimated the beneficiary’s spending on premiums and out-of-pocket expenditures as a share of a benchmark: what total health care spending would be if a private insurer covered the beneficiary. By 2030, the beneficiary’s spending would be 68 percent of that benchmark under the proposal.

http://www.cbo.gov/ftpdocs/121xx/doc12128/04-05-ryan_letter.pdf

PolitiFact has chosen the Democrats’ claim that “Republicans voted to end Medicare” as 2011 Lie of the Year. The facts that led the Democrats to attack the Ryan Medicare plan that the House Republicans passed are not in dispute. PolitiFact’s lie accusation stemmed simply from the imprecision of the Democrats’ political rhetoric, and not from a dispute about the actual facts that Democrats were attempting to publicize through simple sound bites.

Under the Republican-approved proposal, the traditional Medicare program would be phased out totally and replaced with private insurance plans. Much of the financing responsibility would gradually shift to the Medicare beneficiaries. According to the Congressional Budget Office, by 2030 two-thirds of the costs would be paid by the beneficiary, and only one-third paid by the government. In almost no way does this resemble the Medicare program that we know.

Nevertheless this almost entirely new program would still carry the Medicare label. Thus PolitiFact can argue that, technically, Republicans did not vote to end Medicare. But substantively, the infrastructure of the traditional Medicare program would be ended with not much more than the label surviving.

Norman Ornstein makes the important point that the Democrats would have been factually correct had they made a few small tweaks to their attack lines (e.g., “end Medicare as we know it,” which was used effectively). That is a lesson that we all should learn.

Unfortunately, PolitiFact did knock its credibility down a notch on this one. Poorly crafted sounds bites are worthy of a demerit, but the shocking truth behind the crucial message that the Democrats were trying to convey certainly did not warrant the “Pants on Fire” 2011 Lie of the Year award. That award should have been bestowed instead upon the Republicans who claimed that they voted to save Medicare.

This article on unaffordable under-insurance was covered in a previous Quote of the Day (Dec. 8), but a new response posted on the In These Times website follows:

Health Reform Devolves Into ‘Unaffordable Under-Insurance’

By Roger Bybee
In These Times, December 7, 2011

Response by “Art As Social Inquiry”
19 Dec 2011

Thank you for this piece.  I draw similar conclusions from my informal research.  I am looking at how we access healthcare in the US by painting portraits and telling the stories of those who are using the system.  More recently, the portraits are of people who actually HAVE insurance but because they are under-insured, they are suffering great financial and physical hardships.  The great secret in the US is that millions of us are under-insured and don’t know it unless we suffer a medical catastrophe.  This secret will be exposed if the essential benefits package of the ACA is too skimpy. People will get sick, think they are insured and find that even with insurance medical bills will eat up their savings. And they will be very angry. I don’t know…this next difficult phase may be the crucial first step toward a single-payer system? The ACA will help many millions, but is it enough? The question will always be “Can a for-profit system for delivering medical care really see to the needs of a country’s greatest asset – it’s people?”

http://inthesetimes.com/working/entry/12348/health_reform_runs_into_unaffordable_under-insurance

“Art As Social Inquiry” is actually portrait painter Theresa BrownGold.

From her website:

Health Care in the United States

Art As Social Inquiry

This is a series of what will be 100-plus paintings depicting a cross-section of Americans. The titles of the paintings designate the kind of health insurance coverage or lack of coverage the sitters have. The goal is to paint a picture of the American health care system in the faces of our country’s citizens from the very best health coverage to the most horrific of circumstances resulting from a person’s lack of coverage. Who are we when it comes to health care? Let’s not be afraid to look at real people and be touched by their experiences – from the best to the worst – as we navigate this very big issue. There is no agenda but to ask, “What’s your experience? What are your thoughts on the subject?”

http://artassocialinquiry.org/projects/healthcare/

Comment: 

By Don McCanne, MD

We have long heard tragic stories of the uninsured, but now the under-insured are joining them with their sad tales. Theresa BrownGold’s series of portraits on Health Care in the United States tells us stories of a cross section of Americans, while relating them to their insurance status.

You might take a moment to look at two extremes in her series. First click on the third portrait in the eighth row – painted in a style that indicates that the person is no longer with us. Those of us who have been in the trenches certainly recognize the description as being all too typical of when the U.S. health care system fails us miserably.

The other portrait to click on is the politician in the seventh row on the left, with blue eyes and wearing a blue sweater pulled over an open-collar white shirt. Again, many of us will recognize his description as being one of those power players who seem to be oblivious to the plight of those not well served by our health care system.

Everyone has a story, whether good or bad. We can thank Theresa BrownGold for giving us so many pictures, each worth a thousand words and more, motivating us to continue to do our best to see that all stories become good ones.

This article on unaffordable under-insurance was covered in a previous Quote of the Day (Dec. 8), but a new response posted on the In These Times website follows:

Health Reform Devolves Into ‘Unaffordable Under-Insurance’

By Roger Bybee
In These Times, December 7, 2011

Response by “Art As Social Inquiry”
19 Dec 2011

Thank you for this piece.  I draw similar conclusions from my informal research.  I am looking at how we access healthcare in the US by painting portraits and telling the stories of those who are using the system.  More recently, the portraits are of people who actually HAVE insurance but because they are under-insured, they are suffering great financial and physical hardships.  The great secret in the US is that millions of us are under-insured and don’t know it unless we suffer a medical catastrophe.  This secret will be exposed if the essential benefits package of the ACA is too skimpy. People will get sick, think they are insured and find that even with insurance medical bills will eat up their savings. And they will be very angry. I don’t know…this next difficult phase may be the crucial first step toward a single-payer system? The ACA will help many millions, but is it enough? The question will always be “Can a for-profit system for delivering medical care really see to the needs of a country’s greatest asset – it’s people?”

http://inthesetimes.com/working/entry/12348/health_reform_runs_into_unaffordable_under-insurance

“Art As Social Inquiry” is actually portrait painter Theresa BrownGold.

From her website:

Health Care in the United States

Art As Social Inquiry

This is a series of what will be 100-plus paintings depicting a cross-section of Americans. The titles of the paintings designate the kind of health insurance coverage or lack of coverage the sitters have. The goal is to paint a picture of the American health care system in the faces of our country’s citizens from the very best health coverage to the most horrific of circumstances resulting from a person’s lack of coverage. Who are we when it comes to health care? Let’s not be afraid to look at real people and be touched by their experiences – from the best to the worst – as we navigate this very big issue. There is no agenda but to ask, “What’s your experience? What are your thoughts on the subject?”

http://artassocialinquiry.org/projects/healthcare/

We have long heard tragic stories of the uninsured, but now the under-insured are joining them with their sad tales. Theresa BrownGold’s series of portraits on Health Care in the United States tells us stories of a cross section of Americans, while relating them to their insurance status.

You might take a moment to look at two extremes in her series. First click on the third portrait in the eighth row – painted in a style that indicates that the person is no longer with us. Those of us who have been in the trenches certainly recognize the description as being all too typical of when the U.S. health care system fails us miserably.

The other portrait to click on is the politician in the seventh row on the left, with blue eyes and wearing a blue sweater pulled over an open-collar white shirt. Again, many of us will recognize his description as being one of those power players who seem to be oblivious to the plight of those not well served by our health care system.

Everyone has a story, whether good or bad. We can thank Theresa BrownGold for giving us so many pictures, each worth a thousand words and more, motivating us to continue to do our best to see that all stories become good ones.

Health and social services expenditures: associations with health outcomes

By Elizabeth H Bradley, Benjamin R Elkins, Jeph Herrin, Brian Elbel
BMJ Quality & Safety, March 29, 2011

Abstract

Objective
To examine variations in health service expenditures and social services expenditures across Organisation for Economic Co-operation and Development (OECD) countries and assess their association with five population-level health outcomes.

Design
A pooled, cross-sectional analysis using data from the 2009 release of the OECD Health Data 2009 Statistics and Indicators and OECD Social Expenditure Database.

Setting
OECD countries (n=30) from 1995 to 2005.

Main outcomes
Life expectancy at birth, infant mortality, low birth weight, maternal mortality and potential years of life lost.

Results
Health services expenditures adjusted for gross domestic product (GDP) per capita were significantly associated with better health outcomes in only two of five health indicators; social services expenditures adjusted for GDP were significantly associated with better health outcomes in three of five indicators. The ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost, after adjusting for the level of health expenditures and GDP.

Conclusion
Attention to broader domains of social policy may be helpful in accomplishing improvements in health envisioned by advocates of healthcare reform.

http://qualitysafety.bmj.com/content/20/10/826.abstract

And…

To Fix Health, Help the Poor

By Elizabeth H. Bradley and Lauren Taylor
The New York Times, December 8, 2011

IT’S common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality. Why are these other countries beating us if we spend so much more? The truth is that we may not be spending more – it all depends on what you count.

In our comparative study of 30 industrialized countries, published earlier this year in the journal BMJ Quality and Safety, we broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.

We studied 10 years’ worth of data and found that if you counted the combined investment in health care and social services, the United States no longer spent the most money – far from it. In 2005, for example, the United States devoted only 29 percent of gross domestic product to health and social services combined, while countries like Sweden, France, the Netherlands, Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the combination. We came in 10th.

What’s more, America is one of only three industrialized countries to spend the majority of its health and social services budget on health care itself. For every dollar we spend on health care, we spend an additional 90 cents on social services. In our peer countries, for every dollar spent on health care, an additional $2 is spent on social services. So not only are we spending less, we’re allocating our resources disproportionately on health care.

Unfortunately, instead of learning from countries like Sweden and France, we prefer the frantic scramble to recover money from one part of the health care system only to reallocate it toward retreads of previously failed reforms. We pretend that the fresh schemes are innovative, but they are usually long on promises, short on details and often marked with an annoying acronym: H.M.O., F.S.A., A.C.O. and so forth.

It’s time to think more broadly about where to find leverage for achieving a healthier society. One way would be to invest more heavily in social services. This may be difficult for many Americans to swallow as it suggests a potentially expanded role for government.

(Elizabeth H. Bradley is professor of public health at Yale and faculty director of its Global Health Leadership Institute, where Lauren Taylor is a program manager.)

http://www.nytimes.com/2011/12/09/opinion/to-fix-health-care-help-the-poor.html

And…

Letters, The New York Times, December 18, 2011

To the Editor:

Re “To Fix Health, Help the Poor” (Op-Ed, Dec. 9):

Although Elizabeth H. Bradley and Lauren Taylor never use the words “social determinants of health,” they are illustrating the profound truth that it is the circumstances in which people live and work that determine the health status of any population, in any nation.

Along with that come some counterintuitive truths. First, that health care, while crucial to individual survival, makes at best a modest contribution to population health.

Second, that most social and economic policies are in effect health policies because of their impact on those social determinants. Even a perfect American health care system (let alone what we have now) cannot by itself fix our abysmal maldistribution of health.

When my colleagues and I worked at the nation’s first community health center in the Mississippi Delta in the 1960s, our doctors saved many lives and eased much suffering.

We repaired collapsing plantation shacks. We built sanitary privies. In the face of devastating poverty, unemployment and malnutrition, we organized a cooperative farm where residents grew tons of vegetables, and we found pathways to jobs and education.

Those interventions did far more to save lives, ease suffering and improve our target population’s health than our medical care did.

H. JACK GEIGER
Brooklyn, Dec. 9, 2011

(The writer is professor emeritus of community medicine at the City University of New York Medical School.)

http://www.nytimes.com/2011/12/19/opinion/the-road-from-poverty-to-health.html?ref=opinion

Opponents of health care reform frequently object to the use of statistics such as our lower life expectancy and greater infant mortality, arguing that these represent socioeconomic factors and therefore are not due to deficiencies in our health care system.

There are two problems with their position. One is that this allows them to gloss over the severe deficiencies in our overly expensive but inadequate health care system. The other is that they offer no remedies that might improve the social determinants of health, implying that misery and poverty are a simply matter of personal choice.

As this report shows, “The ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost, after adjusting for the level of health expenditures and GDP.”

The United States has distorted this ratio by spending so much on health care (much misdirected) while spending so little on social services.

We need to spend more money, but not on health care. We are already paying the health care delivery system enough, but we need to have a far more efficient financing system that improves the allocation of those payments.

Where we need to spend more money is on public social services, in the broadest sense of the term. The comment by Jack Geiger shows that it is not so much a matter of money as it is a matter of personal and societal dedication, supported by strong public policy.

We can make America a far better place for the least of us and for the rest of us as well. To accomplish that, we’re going to have to do better in promulgating the virtues of egalitarianism. We certainly could use more help from the One Percenters.

U.S. Department of Health & Human Services
December 16, 2011

On December 16, 2011, the Department of Health and Human Services issued a bulletin outlining proposed policies that will give States more flexibility and freedom to implement the Affordable Care Act.

Intended Approach: Comprehensive and Flexible

HHS intends to propose that essential health benefits are defined using a benchmark approach. Under the Department’s intended approach announced today, states would have the flexibility to select a benchmark plan that reflects the scope of services offered by a “typical employer plan.” This approach would give states the flexibility to select a plan that would best meet the needs of their citizens.

States would choose one of the following benchmark health insurance plans:

* One of the three largest small group plans in the state by enrollment;
* One of the three largest state employee health plans by enrollment;
* One of the three largest federal employee health plan options by enrollment;
* The largest HMO plan offered in the state’s commercial market by enrollment.

If states choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state.

The benefits and services included in the benchmark health insurance plan selected by the state would be the essential health benefits package. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.

To prevent federal dollars going to state benefit mandates, the health reform law requires states to defray the cost of benefits required by state law in excess of essential health benefits for individuals enrolled in any plan offered through an Exchange.

These benchmarks are generally regulated by the state and would be subject to state mandates applicable to the small group market.  Thus, those mandates would be included in the state essential health benefits package if the state elected one of the three largest small group plans in that state as its benchmark.

This approach would provide maximum flexibility to states, employers and issuers while providing quality, comprehensive, coverage for consumers.

Coverage

Essential health benefits must include coverage of services and items in all 10 statutory categories. Based on our research, we believe that these benchmarks will cover most of the essential health benefits outlined by the Affordable Care Act. These categories include preventive care, emergency services, maternity care, hospital and physician services, and prescription drugs.

Allowing Plans Flexibility to Innovate and Consumers Greater Choice

To meet the EHB coverage standard, HHS intends to require that a health plan offer benefits that are “substantially equal” to the benchmark plan selected by the state and modified as necessary to reflect the 10 coverage categories. Health plans also would have flexibility to adjust benefits, including both the specific services covered and any quantitative limits, provided they continue to offer coverage for all 10 statutory EHB categories and the coverage has the same value.  Permitting flexibility will provide greater choice to consumers, promoting plan innovation through coverage and design options, while ensuring that plans providing EHBs offer a certain level of benefits.

Fact sheet:
http://www.healthcare.gov/news/factsheets/2011/12/essential-health-benefits12162011a.html

Essential Health Benefits Bulletin (15 pages):
http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf

Comment: 

By Don McCanne, MD

It looks like Health and Human Services has decided that the new standard for health insurance to be offered under the Affordable Care Act will be the cheapest of the three largest small group plans offered in any given state. There will be no national standard. Although they would allow states more generous options other than the skimpy small group plans, with today’s concerns over high health care costs, the cheapest option certainly will be selected by the state stewards.

There is a requirement that 10 categories of health benefits must be included, but the specific services covered within each category will be determined by the insurers. The insurers will retain the flexibility to adjust both the specific services and the amount of those services (quantitative limits).  HHS claims that this benefits us by providing greater choice for consumers and by providing insurers with the opportunity to innovate. Why they should deem that to be beneficial is astonishing when considering that insurer innovation means having to choose between various plans that take away, to varying degrees, choices of providers, benefits, and amount of financial security.

The essential health benefits do not define the cost sharing features of the plans such as deductibles, copayments and coinsurance. Guidance on that will be forthcoming, but we already know that the least expensive plan will be the bronze plan with an actuarial value of 60 percent (the plan pays 60 percent of only the covered health care services). Again, because of our high insurance premiums, most people will select the cheapest actuarial-value plan.

Can you think of anything worse than having cash-starved states selecting the cheapest private plans with the most spartan selection of benefits allowable – benefits selected by the private insurance industry –  and offering those plans to struggling middle-income Americans who will be mandated to purchase these plans when many of them will not be able to afford even the bottom bronze plans in spite of the subsidies? And don’t even think about how they’re going to pay the high out-of-pocket expenses when they actually need health care.

Dissecting out each individual policy perhaps can make them easier to understand, but when you patch them together, just try to explain the resulting health care financing infrastructure to the average individual who just wants health care when needed. Most individuals may not be able to understand the complexities of health policy, but once they’ve been exposed to the new standard, they certainly will understand what is meant by UNAFFORDABLE UNDER-INSURANCE.

Try this thought experiment. Since the common defect in these Quote of the Day policy messages seems to be the dominance of the private insurers, try constructing a health care financing system without the private insurers being included. Wow! That was easy!

All we need now is to elect leaders who are willing to dismiss the insurers so that we can get on with building a system that works for all of us.