PNHP

Tiered and limited networks deprive patients of choice

Tiered and limited networks deprive patients of choice

Plans steer patients to lower-cost hospitals

By Liz Kowalczyk
The Boston Globe
February 10, 2011

Hundreds of small businesses have signed up in the past month for a new Blue Cross Blue Shield health insurance plan that charges employees hefty fees for seeking care at more expensive hospitals, in an effort to steer them to lower cost care.

The popularity of the plan — Blue Cross Blue Shield of Massachusetts says it is the fastest launch ever of a new product — is the latest sign that the once radical idea has been embraced as a way to control soaring health care costs, even as pricier hospitals warn of a possible backlash and cuts in services.

Other Massachusetts insurers also report brisk business in plans that offer lower premiums in exchange for limits on use of high-cost care. The plans either charge consumers extra for receiving care from popular but expensive hospitals or doctors, or bar them altogether from seeking treatment at those institutions and practices.

The Blue Cross Hospital Choice plan, which went on sale last month, charges members, for example, an extra $1,000 for an inpatient stay or outpatient surgery, and $450 more for an MRI, at 15 higher-cost hospitals, including Massachusetts General and Brigham and Women’s hospitals, Children’s Hospital Boston, and UMass Memorial Medical Center in Worcester.

In Massachusetts, insurers traditionally have offered wide-open networks, meaning members can check into a pricey teaching hospital to deliver a baby rather than go to a less expensive community hospital, and can schedule MRIs in a hospital outpatient department, even when freestanding clinics provide similar service for less money. But amid intense scrutiny into why health care costs in Massachusetts are climbing 7.5 percent a year, “tiered” and “limited” networks have emerged as an immediate way to control costs.

But executives at Partners HealthCare, the parent organization of Massachusetts General and Brigham and Women’s, said that while these new policies are making providers more sensitive to price, they have pitfalls.

Dr. Thomas Lee, head of Partners’ physician group, said some people will become seriously ill and realize they can’t go to, or can’t afford, their first-choice hospital.

http://www.boston.com/business/healthcare/articles/2011/02/10/plans_steer_patients_to_lower_cost_hospitals/?page=full

Although private insurers in California have led the way in innovative product changes in an attempt to keep insurance premiums competitive (at the great cost of impairing the protection afforded by their products), Massachusetts is now serving as the laboratory for what we might expect under the Affordable Care Act (ACA), since Massachusetts got a jump start on the ACA model.

What determines which insurance policy people will select for themselves or for their families? The premiums or the benefits? If they are relatively healthy, which most people are, they may look at both, but the decision will most likely come down to choosing a plan with a premium that they can barely afford over a plan with a premium that is totally beyond their means. They are less likely to study the fine print on the benefits that states, for instance, the less expensive plan uses “tiered” or “limited” networks.

As this Boston Globe article indicates, the financial penalties for using a higher tiered facility can be very severe. And limited networks? The plan pays nothing outside of the network. Plan-approved provider networks have been used by the insurers as a tool to leverage the negotiations for provider rates. The expansion in the use of tiered or limited networks now uses the patient as a tool – contrary to their own interests – in an attempt to reduce spending so that premiums remain affordable, if only barely so.

Tiered and limited plans are growing rapidly in Massachusetts. Some of the most prestigious academic medical centers in the nation are being targeted and could face serious budget constraints. In using these tools of the marketplace, financial decisions are not being made based on what services should be provided and paid for; instead they are being made on the basis of what will best support the market of private insurance plans. As a result, serious damage could be inflicted on the infrastructure of our health care delivery system.

Imagine Medicare engaging in this behavior. You really can’t. Although always a work in process, Medicare includes the entire health care delivery system as its network, and reimburses at rates that have some semblance of maintaining the financial viability of the delivery system, while reining in waste. It can do better, and would do so if it were purchasing essentially all care provided in the United States, through an improved Medicare for all. The multiple tools of a single payer system would dramatically improve the efficiency of our health care purchasing.

Vermont Gov. Proposes Single-Payer Health Plan

By Aimee Miles
Kaiser Health News, Feb 08, 2011

Vermont Gov. Peter Shumlin, who was elected last November after promising to reform health care in the state, unveiled a bill  Tuesday that would abolish most forms of private health insurance and move state residents into a publicly funded insurance pool.

His much anticipated proposal lays out a strategy that leaves a number of key details—including how to pay for the system—open for debate.

Under Shumlin’s “single-payer” system, Vermont residents would receive health benefits paid for by the state, regardless of their employment status or income. The plan is designed to help stem rising health costs, which state officials say have become unsustainable.

“Health care costs are climbing at a rate of more than 12 times the growth of the Vermont economy, and we’re not getting the best value for our money,” Shumlin said in a prepared statement. “The time for change has come.”

Former Vermont governor Howard Dean, who unsuccessfully sought to institute a single-payer system in 1994, praised the effort.

“It makes a lot of sense and it’ll save them a ton of money,” he said in an interview.

Some Democrats advocated for a national single-payer plan when Congress was debating the federal health overhaul that passed in March, but that plan was never considered politically viable because of widespread opposition and concerns about cost. Even efforts to offer a public option insurance plan that would compete against private insurers for consumers’ business failed after conservative Democratic senators refused to support it. Instead, the health law opted for tighter regulation of existing private plans, with a mandate that almost every American purchase health insurance.

Skeptics have questioned whether Shumlin’s reform agenda is feasible.  Lt. Gov. Phil Scott, a Republican, said before Shumlin’s bill was released that he had received letters from a number of state residents who have concerns.

“They’ve heard about the bill and they’ve heard the thoughts, but the devil’s in the details, and they’d like to see what it means to them,” Scott said.

The governor’s plan calls for creation of a health reform board this year to make recommendations for the plan. A full single-payer plan would not be operational before 2014.

Shumlin, a Democrat, has garnered some support for a health overhaul in the legislature, where Democrats overwhelmingly control both houses. The legislature had already commissioned its Harvard economist William Hsiao, who helped design Taiwan’s single-payer system, along with MIT economist Jonathan Gruber and Vermont policy consultant Steve Kappel to provide recommendations on how to reform Vermont’s health car system. Shumlin’s plan takes many of those recommendations into account.

But Republicans in the state have raised concerns and business groups have not yet signed on.  The state also will need to clear a series of administrative hurdles at the federal level.

The Need For Waivers

Shumlin’s strategy seeks to take advantage of federal resources that will kick in under the new health law in 2014. By that time, every state is expected to have its own “health exchange,” an online marketplace where consumers can shop for private health plans that meet new federal standards. Shumlin’s proposal involves using federal funding to build and exchange infrastructure that could later be converted to support the single-payer system.

But because a single-payer plan is not sanctioned in the health law, Vermont would also need to secure waivers from the federal government in order to move forward with its plans.

“At each step of the way, we may be dealing with constraints as far as federal law, and march forward,” said Anya Rader Wallack, Shumlin’s special assistant on health care reform.

The federal health law allows states such as Vermont to request waivers to opt out of many of its requirements starting in 2017, so long as they present an alternative that would achieve the same goals—broader health coverage for more people—with equal or greater success.

But Vermont legislators, fearing that support could shift against single-payer during the next election cycle, don’t want to wait another six years to deliver their reforms. They’re hoping they’ll be able to opt out of the health care law sooner.

That puts Vermont in a delicate position: for now, at least, the state will need to work out a plan to comply with the federal health law while simultaneously laying the groundwork for its own plan.  To make matters more complicated, Vermont officials would also have to work with federal officials to make critical payment adjustments within Medicare, the federal health program for seniors and disabled individuals.

Funding Is An Open Question

The governor’s team has not yet devised a way to pay for the new system. They plan to return to the legislature in 2013 with proposals, according to Wallack.

Hsiao and colleagues had earlier recommended that the state levy a payroll tax divided between employers and employees—an idea that raised alarm bells with small business owners.

Among them is Scott, who also owns a construction company. “I understand some of the arguments for this type of system was to take the burden off employers and I guess I’m not seeing where that burden is being moved,” Scott said.

Rick Rayfield, who owns a bookstore in Waitsfield, is tentatively in favor of a single-payer system—but wants to see how the legislature hammers out key details.

“It seems to me we’re trying to develop a philosophy about who pays for healthcare without asking ourselves exactly what we’re willing to pay for,” he said.  “We’re being asked if a single-payer system is something we would like without saying what we’re going get for it.”

Still, Rayfield sees some advantages. “I guess I’m so overwhelmed by the stupid complexity of the (current) system as it is that I just adore the simplicity of the single-payer plan,” he said.

Supporters of the change say the need is dire. They point to statistics showing that health spending more than doubled in Vermont between 1992 and 2009. Shumlin’s office has estimated the state would save $500 million in the first year of a single-payer plan.

That would come from reduced insurance marketing and administrative costs. Hospitals and physicians also lose time and money in filling out claims information for every private health plan they bill.

Shumlin’s plan recommends paying physicians and hospitals in a way that encourages them to provide higher quality care without providing unnecessary services.

“There’s a lot of smart things the governor’s doing,” Dean said. “The smartest thing of all is that he’s … saying, ‘We’re not going to come up with funding mechanism until we change the payment system.'”

http://www.kaiserhealthnews.org/Stories/2011/February/08/vermont-governor-shumlin-single-payer.aspx

Big employers shift more health costs onto employees

By Claudia Fegan, M.D.
Hyde Park Herald (Chicago), Feb. 9, 2011

Many residents of Hyde Park work for large employers, the University of Chicago being just one example among several. In the wake of the new health law, what benefit changes can workers at these large companies expect to see?
 
A survey of 72 big employers like IBM, Boeing, General Electric, FedEx and others conducted last fall showed that 63 percent of these companies plan to shift more of their health premium costs to employees in 2011, and that 46 percent expect to raise the maximum out-of-pocket costs (co-pays, co-insurance and deductibles) that their employees are expected to bear, including for prescription drugs.
 
In other words, big employers are shifting more of the financial burden for health care onto the shoulders of their employees. Significantly, the new health law doesn’t prohibit such hikes on workers’ share of health costs, and in fact perpetuates the idea that “cost-sharing” by employees is a good thing – despite solid evidence to the contrary.
 
There are some exceptions to this rule, however. Some preventive services like mammograms or colonoscopies will now require no patient co-pays or deductibles. (Some employers already offer this benefit, although studies show most workers don’t avail themselves of such preventive services when they’re offered.)  And patients will not incur a financial penalty if they see an obstetrician or a pediatrician without a referral.
 
But, in general, employees at large companies will be asked to pay higher costs for their care, and will see their wages negatively impacted by employers who will say that the rising costs of health benefits prevent them from giving workers pay raises. Much hinges, of course, on the individual employer and whether your wages and benefits are protected by a union contract.
 
There’s more. Under the new law, better-quality health plans face the threat of being hit with a punitive 40 percent excise tax starting in 2018. This is the so-called Cadillac tax on employers who offer decent health benefits. Because the “Chevy” plans of today are likely, thanks to rising health prices, to be the Cadillac plans of tomorrow, this could easily provoke many big employers to dump their health benefits altogether and to force workers to seek even costlier coverage in the proposed insurance exchanges.
 
Some beneficial parts of the new law include the removal of lifetime caps on benefits (annual limits will stay in place in many cases, however, until 2014), the eligibility of children under age 26 to remain on their parent’s insurance policy, and new restrictions on the ability of private insurers to deny coverage for persons with pre-existing medical conditions.
 
It’s fair to say that the new health law faces an uncertain future. Most big employers take it for granted that the law will survive efforts to repeal it or to declare it unconstitutional, and they are acting accordingly. And in fact most big companies are quite comfortable with it, as are investors who hold shares in health-related companies. They know that the law builds upon the status quo, where private health insurers and Big Pharma hold commanding positions in our system and where profits will still flow into the health industry.
 
Unfortunately, it’s precisely because the private insurers remain in the driver’s seat that we will suffer from ever-rising costs, from patients putting off needed care because they can’t afford it, and from the squandering of valuable health dollars on excessive paperwork. The result: even though the U.S. spends more per capita than any other nation on earth, our medical outcomes will remain far behind other industrialized nations.
 
I favor a system of financing care known as single-payer national health insurance, an improved Medicare for all. Under a single-payer plan, everyone would be covered, there would be no co-pays or deductibles, and everyone would have free choice of physician and hospital. A one-payer system’s bargaining clout would help us contain costs.
 
Vermont and some other states are taking a look at shifting to a single-payer system. Illinois should do likewise, as should Congress.
 
Claudia Fegan, M.D., is associate chief medical officer for the Ambulatory and Community Health Network for the Cook County Bureau of Health Services. She resides in Hyde Park. [This article was originally published under the headline “My thoughts on health care.”]

Rationing is not the only alternative

By DR. RALPH S. BOVARD
Star Tribune, Feb. 7, 2011

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

THE REV. MARTIN LUTHER KING JR.

In a recent commentary (Opinion Exchange, Jan. 23), Dr. Virginia Dale told readers that they must choose between universal health insurance and rationing.

As a physician, I agree that we must get health care costs down if we’re going to achieve universal coverage, but I strongly disagree that the only way to do it is to ration.

There is another viable and proven option: a single-payer or regulated multipayer health care system, such as exists in every nation in the Organization for Economic Co-operation & Development except the United States and Mexico.

The average OECD nation spends 6 percent to 10 percent of GDP on health care; we spend 17 percent. Their per-person spending averages $3,000 to $5,000 a year, compared with $8,000 in the United States.

We could save huge sums — more than enough to insure the uninsured — by cutting the administrative waste and executive profit in our system, and by collective bargaining to lower the price at which drugs, devices and medical services are sold in this country.

The true “elephant in the room,” to use Dale’s metaphor, is the fact that our health care system has been “privatized” by an insurance industry more intent on lining its pockets than on ensuring that the American people get the public service and care that they pay for.

HMOs reap a hugely profitable business by denying and limiting care (a more severe form of rationing than exists in any other OECD nation) and by taking upward of 20 percent from every premium dollar and even tax-funded programs to pay excessive salaries to people who provide no patient care whatsoever.

The 80 percent they are obligated to spend on your health care is called their medical loss ratio. Nice, huh?

In a recent survey, 23 percent of Americans felt they were inappropriately denied care, compared with 4 percent of Canadians.

It was revealing to look at the political cartoons in the same Opinion Exchange section in which Dale’s commentary appeared.

One showed an American with a letter labeled “DENIED” and a caption stating: “50% of all Americans under 65 have preexisting medical conditions that may prevent them from getting insurance … .”

The next image showed a smirking lawmaker in his Washington office with his feet up. The caption: “100% of the 249 congressmen voting to repeal health care have their health care plan paid for by those same Americans … .”

And that is the truth.

The more somber note is that even if the American depicted in that cartoon has health coverage, with the loss of a job or the onset of a major illness that causes the loss of health benefits, he or she may easily join the millions each year who are bankrupted by medical bills.

That doesn’t happen under universal coverage or a single-payer system.

Providing universal health care is not socialistic. It is the pooling of resources by a highly ordered social structure to provide for the common good. Some call it civilization.

Think about it: This is how we fund all of our public services, including fire, police, water, education, libraries, sewage, parks and recreation, and highways. Health care would seem the most essential of public services.

Why do some people call it “socialized” (like it is a dirty word) only when we apply the term to medical care, but not to the other public services that we fund and use daily?

Tommy Douglas, who was voted the “Greatest Canadian” in 2005, nearly 20 years after his death, for bringing a universal health care system to his nation, was a humble clergyman dedicated to the importance of economic democracy and the “social gospel.”

If only our politicians had an ounce of his moral integrity and commitment to serving the nation’s best interests.

It is highly misleading to tell the public that our choice is between continued high numbers of uninsured people or rationing.

Our choice is continued high numbers of the uninsured vs. cutting the enormous administrative waste and corporate profit out of our system with a single-payer system that allows us to lower the prices we pay for medical services, drugs and devices to levels paid in other countries.

As taxpayers and voters, we need to demand accountability, and we are not getting it from our current HMO system. The industry has had more than 20 years to get it right and has failed miserably to do so.

 We are getting fleeced. As Paul Wellstone said: “We all do better when we all do better” — not when the CEOs and executives of medical care organizations do obscenely better at the expense of our national health.

Ralph S. Bovard is a steering-committee member of Physicians for a National Health Program-Minnesota Chapter.

http://www.startribune.com/opinion/commentary/115522679.html?elr=KArksc8P:Pc:U0ckkD:aEyKUiD3aPc:_Yyc:aULPQL7PQLanchO7DiUr

Will Mayo Clinic save money as an ACO?

Some insurance companies pushing plans with Mayo Clinic out of network

By Christopher Snowbeck
TwinCities.com
February 5, 2011

Bloomington-based HealthPartners last year started marketing health plans that feature a network of hospitals and doctors that doesn’t include the Mayo Clinic. In exchange for not having access with low co-payments to the iconic Rochester, Minn., clinic, subscribers pay lower premiums when they select a HealthPartners plan with Mayo as an out-of-network option.

Last year, Eagan-based Blue Cross and Blue Shield of Minnesota also started emphasizing health insurance products for individuals in which Mayo isn’t in the network of providers.

Mayo has been celebrated nationally for providing high-quality and low-cost health care, but health insurance brokers say the local reputation is different as far as cost goes.

“Mayo is cheap only compared to other national care centers, but in general is a higher-cost center when compared to its Minnesota peers,” said Christopher Schneeman, a health insurance broker with SevenHills Benefit Partners in St. Paul.

“The Mayo Clinic is world-class,” said Greg Sailer of Sailer Benefit Services in Lake Elmo. “But it’s expensive, and you’re going to pay for it.”

Mayo Clinic officials argue that the Rochester center offers greater value by providing comprehensive care that steers patients to the most-effective treatments. That ultimately adds up to lower overall cost, the clinic says.

“When we looked at Mayo’s total cost of care — the combination of price and utilization — they, on average, have a higher total cost of care than other health systems that are seeing comparable groups of patients,” said (Andrea Walsh, chief marketing officer of HealthPartners).

http://www.twincities.com/ci_17298533

Comment: 

By Don McCanne, MD

For many years, the most common example given of the variations in the costs of health care demonstrated by the Dartmouth Atlas was the high costs of health care in Boca Raton, Florida when compared to Rochester, Minnesota, home of the Mayo clinic. These observed variations throughout the nation have led to the recommendation – now enacted in the Affordable Care Act (ACA) – to establish accountable care organizations (ACOs).

Although the precise details of what constitutes an ACO have not yet been released by HHS, the law states that the ACO will be “accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it.” Payment will be based on a “Medicare Shared Savings Program,” in which the ACO shares with the government the savings for which it is accountable. It is a program designed to reduce health care spending.

Since Mayo Clinic certainly has the capability of providing overall care of the patient, it would seem to be an ideal institution to serve as an ACO. In fact, the authors of the legislation had in mind institutions such as Mayo as important models that could provide high quality care at a lower cost.

But will Mayo deliver at a lower cost? Not according to the current experience in Minnesota. Mayo argues that they provide greater value because they provide “comprehensive care that steers patients to the most-effective treatments,” even if that care is more expensive than elsewhere in Minnesota. (Time for a little soft shoe?)

The point is that the cost savings in ACA, such as the ACOs, are not much more than a fantasy at this point. And for this we gave up universal coverage and have established under-insurance as the new standard. We can still reach our goals of comprehensive, affordable care for everyone by replacing ACA’s financing system with an improved Medicare for all.

Will Mayo Clinic save money as an ACO?

Some insurance companies pushing plans with Mayo Clinic out of network

By Christopher Snowbeck
TwinCities.com
February 5, 2011

Bloomington-based HealthPartners last year started marketing health plans that feature a network of hospitals and doctors that doesn’t include the Mayo Clinic. In exchange for not having access with low co-payments to the iconic Rochester, Minn., clinic, subscribers pay lower premiums when they select a HealthPartners plan with Mayo as an out-of-network option.

Last year, Eagan-based Blue Cross and Blue Shield of Minnesota also started emphasizing health insurance products for individuals in which Mayo isn’t in the network of providers.

Mayo has been celebrated nationally for providing high-quality and low-cost health care, but health insurance brokers say the local reputation is different as far as cost goes.

“Mayo is cheap only compared to other national care centers, but in general is a higher-cost center when compared to its Minnesota peers,” said Christopher Schneeman, a health insurance broker with SevenHills Benefit Partners in St. Paul.

“The Mayo Clinic is world-class,” said Greg Sailer of Sailer Benefit Services in Lake Elmo. “But it’s expensive, and you’re going to pay for it.”

Mayo Clinic officials argue that the Rochester center offers greater value by providing comprehensive care that steers patients to the most-effective treatments. That ultimately adds up to lower overall cost, the clinic says.

“When we looked at Mayo’s total cost of care — the combination of price and utilization — they, on average, have a higher total cost of care than other health systems that are seeing comparable groups of patients,” said (Andrea Walsh, chief marketing officer of HealthPartners).

http://www.twincities.com/ci_17298533

For many years, the most common example given of the variations in the costs of health care demonstrated by the Dartmouth Atlas was the high costs of health care in Boca Raton, Florida when compared to Rochester, Minnesota, home of the Mayo clinic. These observed variations throughout the nation have led to the recommendation – now enacted in the Affordable Care Act (ACA) – to establish accountable care organizations (ACOs).

Although the precise details of what constitutes an ACO have not yet been released by HHS, the law states that the ACO will be “accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it.” Payment will be based on a “Medicare Shared Savings Program,” in which the ACO shares with the government the savings for which it is accountable. It is a program designed to reduce health care spending.

Since Mayo Clinic certainly has the capability of providing overall care of the patient, it would seem to be an ideal institution to serve as an ACO. In fact, the authors of the legislation had in mind institutions such as Mayo as important models that could provide high quality care at a lower cost.

But will Mayo deliver at a lower cost? Not according to the current experience in Minnesota. Mayo argues that they provide greater value because they provide “comprehensive care that steers patients to the most-effective treatments,” even if that care is more expensive than elsewhere in Minnesota. (Time for a little soft shoe?)

The point is that the cost savings in ACA, such as the ACOs, are not much more than a fantasy at this point. And for this we gave up universal coverage and have established under-insurance as the new standard. We can still reach our goals of comprehensive, affordable care for everyone by replacing ACA’s financing system with an improved Medicare for all.

Single-Payer Solution

Letter, The New York Times
Published: February 5, 2011

To the Editor:

Re “For Governors of Both Parties, Medicaid Looks Ripe to Slash” (front page, Jan. 29):

It is hard for me to understand why the governors, along with corporate chief executives, aren’t lobbying Congress and President Obama for single-payer health insurance.

It would take the burden of providing health insurance off state and corporate budgets and provide the broadest and least expensive health care solution.

Charles Pack
Red Bank, N.J., Jan. 29, 2011

Health or wealth? What's the mission of our health care system?

Switching to a nonprofit system in Maine would put the focus back on care.

By PHILIP CAPER, JOE LENDVAI and JULIE PEASE
The Portland (Maine) Press Herald
February 6, 2011

There has been a great deal of discussion recently about health care reform in America and in Maine. Many Republicans want to repeal last year’s federal health care reform law, and most Democrats want to implement and improve it.

In the meantime, pending full implementation of the law in 2014, health care costs for individuals, employers and the government continue to soar, and the number of uninsured Americans (including Mainers) continues to grow.

Many Americans believe that the forces of the marketplace can solve our health care problems. They won’t, and they can’t. We have been trying marketplace solutions for more than 30 years.

These “solutions” have led to out-of-control costs, rising numbers of uninsured and under-insured patients, the disappearance of primary care providers, fragmented and duplicative care, and a brutal system dominated by for-profit health insurance companies.

In this system, denial of care is the means to increasing profitability. Marketplace solutions have failed.

America spends about twice as much per-person on health care as the average of all other developed countries, even though those countries are able to provide health care to all of their residents.

Furthermore, by almost every measurement, other developed countries have better health care outcomes than we do, and their health care systems are almost universally popular with their people (including their politicians).

How do they do it?

First, only in America is health care considered a business. The mission of a business is to create wealth for its shareholders.

The mission of a health care system is to prevent disease where that is possible, and to diagnose, treat, cure, heal and comfort patients when they are ill.

Only in America has the business mission been permitted to trump the health care mission.

In all other developed countries, health care is financed by the government or nonprofit funds that are tightly regulated by government and run as public utilities. The for-profit financing of health care is not permitted for basic health care services.

Second, only in America is there such fragmentation of health care systems, with multiple tiers of care provided by Medicare, Medicaid, the VA, Tricare and private insurance.

In most other developed countries, everybody is in the same system. With everybody in the same system, everybody has an interest in seeing that the system is adequately funded and run effectively and efficiently.

Third, all other countries have some way of budgeting for health care for all of their citizens.

In America, the system for the civilian population is totally open-ended. Neither the federal government nor the states has yet shown the political will to control costs.

Some states are beginning to apply the brakes, but only if cost restraint is applied selectively to their most vulnerable and politically disenfranchised populations.

It is time for Mainers to replace our fragmented, expensive and fundamentally unfair health insurance system with a single statewide program of health care financing — everybody in, nobody out.

In recent testimony before the Maine Legislature, professor William Hsiao of Harvard University, one of the world’s leading authorities on the financing of health care, estimated that Mainers could save $1 billion in the first year of such a system, and permanently reduce the rate of health care cost increases by 2 percent per year thereafter.

Some of the savings would come from eliminating excessive insurance company profits and executive compensation.

More would come from standardizing benefits and coverage, eliminating the huge administrative costs that doctors, hospitals and other providers of health care incur in dealing with hundreds of plans.

Still more would come from eliminating the fights about money that are a byproduct of so many different insurance programs — who pays, what for, how much — that now consume so much time and effort, and impede the delivery of quality health care.

Replacing our profit-driven system of financing health care with a mission-driven nonprofit system is the necessary first step in reinventing health care in Maine.

Only then will we be able to address the need to effectively reform the way we pay hospitals and other health care providers to reward efficiency and outcomes, rather than profit and volume.

Maine AllCare proposes nothing less than reforming the culture of health care throughout Maine.

Maine AllCare’s vision is for a system for Maine in which:

• All Mainers have access to affordable and appropriate health care and its supporting social and community services.

• No Mainer is in danger of financial ruin because of health care costs or is locked into a job solely because it provides health insurance.

• No Maine employer is faced with health care costs spiraling out of control.

• No Maine worker is faced with stagnant or declining wages or the inability to bargain for better working conditions because of the rising cost of health care.

• Maine patients will no longer have to wonder whether their doctor’s treatment decisions are driven by their health needs or their insurance coverage.

• Maine doctors will no longer have their clinical judgment second-guessed by insurance companies. Medical practice will be decided by health care providers and patients, and will return to being driven by mission, not money.

• Maine hospital executives will be free to offer services determined by the needs of their community, not their need or desire to generate revenue.

• The Legislature will not have to stand by and watch rising MaineCare and state and local government employee costs steadily erode its ability to address other critical priorities.

Can it be done? Absolutely. There are plenty of examples from around the world. All other industrialized countries, many less wealthy than ours, are already doing it.

Can we do it? That depends upon the people of Maine.

The authors serve on the board of directors of Maine AllCare, a nonpartisan, nonprofit group committed to educating the public and policymakers about how to improve on the Patient Protection and Affordable Care Act to make health care in Maine universal, accessible and affordable for all.

http://www.pressherald.com/opinion/health-or-wealth_-whats-the-mission-of-our-health-care-system__2011-02-06.html

Individual mandate falls short in Massachusetts

Lack Of Access Due To Costs Remains A Problem For Some In Massachusetts Despite The State’s Health Reforms

By Cheryl R. Clark, Jane Soukup, Usha Govindarajulu, Heather E. Riden, Dora A. Tovar and Paula A. Johnson
Health Affairs
February 2011

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer.

http://content.healthaffairs.org/content/30/2/247#aff-6

And…

More get waivers of health insurance

By Kay Lazar
The Boston Globe
February 7, 2011

Massachusetts regulators granted more exemptions last year to residents who said they could not afford the health insurance required by the state, waiving the tax penalty for more than half of those who appealed, according to state data.

That is prompting regulators to take a fresh look at how Massachusetts defines affordable when it comes to mandatory health insurance.

Massachusetts residents with the lowest family incomes, less than $33,075 for a family of four, make up the largest share — 43 percent — of the uninsured, according to state data.

“We may want to let them in [to government subsidized health insurance], but it would cost money, and we would have to decide if the state wants to spend money that way,” said committee member Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology.

http://www.boston.com/news/local/massachusetts/articles/2011/02/07/more_get_waivers_of_health_insurance/?page=full

Comment: 

By Don McCanne, MD

Does an individual mandate to purchase private insurance with cost-sharing requirements ensure that citizens will have health care access and be able to afford it? It hasn’t in Massachusetts, and it will not throughout the United States because it is an irreparably flawed mechanism of financing health care.

The literature is replete with policies that would nudge us a little bit closer to the goals of affordability and expanded coverage, but, as Jonathan Gruber, an advocate of the private insurance mandate model, says, “we would have to decide if the state wants to spend money that way.”

But it’s the model, stupid! Dump it and replace it with an improved Medicare for all and then health care will be affordable for everyone. Why does Gruber and the others insist on separating state money from personal money, as if state money is sacred and personal money isn’t? It all belongs to us anyway.

Individual mandate falls short in Massachusetts

Lack Of Access Due To Costs Remains A Problem For Some In Massachusetts Despite The State’s Health Reforms

By Cheryl R. Clark, Jane Soukup, Usha Govindarajulu, Heather E. Riden, Dora A. Tovar and Paula A. Johnson
Health Affairs
February 2011

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer.

http://content.healthaffairs.org/content/30/2/247#aff-6

And…

More get waivers of health insurance

By Kay Lazar
The Boston Globe
February 7, 2011

Massachusetts regulators granted more exemptions last year to residents who said they could not afford the health insurance required by the state, waiving the tax penalty for more than half of those who appealed, according to state data.

That is prompting regulators to take a fresh look at how Massachusetts defines affordable when it comes to mandatory health insurance.

Massachusetts residents with the lowest family incomes, less than $33,075 for a family of four, make up the largest share — 43 percent — of the uninsured, according to state data.

“We may want to let them in [to government subsidized health insurance], but it would cost money, and we would have to decide if the state wants to spend money that way,” said committee member Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology.

http://www.boston.com/news/local/massachusetts/articles/2011/02/07/more_get_waivers_of_health_insurance/?page=full

Does an individual mandate to purchase private insurance with cost-sharing requirements ensure that citizens will have health care access and be able to afford it? It hasn’t in Massachusetts, and it will not throughout the United States because it is an irreparably flawed mechanism of financing health care.

The literature is replete with policies that would nudge us a little bit closer to the goals of affordability and expanded coverage, but, as Jonathan Gruber, an advocate of the private insurance mandate model, says, “we would have to decide if the state wants to spend money that way.”

But it’s the model, stupid! Dump it and replace it with an improved Medicare for all and then health care will be affordable for everyone. Why does Gruber and the others insist on separating state money from personal money, as if state money is sacred and personal money isn’t? It all belongs to us anyway.