PNHP

A health insurance broker speaks up

A health insurance broker speaks up

A Broker’s Lament: We Brought This On Ourselves

By John Sinibaldi
The Health Care Blog
March 7, 2009
A huge segment of the American population is simply far too strapped to ever afford the premiums and costs associated with health insurance/health care as it is structured today.
It isn’t the employees of government (local, county, state or federal) who will demand immediate change. It isn’t the employees of institutional companies (the Motorolas, GEs, Microsofts of the country) who will demand change. It isn’t those on Medicare or Medicaid or the VA who will demand change. It isn’t the wealthy. It isn’t the poor. And, it isn’t the vast majority of health insurance agents who work with large group clients (because, while that market is becoming ever more difficult and the work more taxing, they’re still selling SOMETHING to these bigger businesses and government entities).
Why don’t these people see what I’m seeing? Simply because, while they are feeling the effects of the rise in health care/health insurance costs and the downturn in the economy, most of these businesses and their employees and dependents (and the affluent) have yet to have a clue about how expensive things really are (or in the case of the rich, they can still afford their out-of-pocket expenses). The agents who market to large employers are still making lots of money (I know, I rub elbows with them at my local Health Underwriters meetings once a month).
That leaves individuals and small businesses and the agents who work primarily in those markets – the very folks most beleaguered by the current situation. While the employee of a regional electric utility is complaining about monthly payroll deductions for his family that now exceed $500 or more on a $60,000 annual salary, the longtime employee of a local small electrician is looking at monthly payroll deductions for his family of $1,500 on a $35,000 annual salary. His apprentice is younger, and so is “fortunate” to have monthly deductions for his family of only $900 on a $20,000 annual salary. The electrician’s helper making $9/hr can’t afford even his half of the premium for just himself.
Individuals on personal health insurance policies are also feeling the “pinch.” Most of my individual clients see increases of 18-25% a year.
It is all of these folks (and there are tens of millions of them), coupled with those who have already been priced out of the market altogether, who will fuel the fire for radical reform. It is these folks who complain – long, loud and bitterly – that the American dream is leaving them behind. It is these folks to whom the politicians will ultimately listen, because they’re the ones making all the noise. It is these folks who will ultimately define what the next set of reforms looks like – and those reforms will NOT be confined only to the small group and individual markets – nor do these folks give a rat’s rear end if the insurance industry is involved. (After all, we’re doing such a wonderful job for them now.)
And, in my opinion, rightfully so. The health insurance industry (with lots of complicity from legislators, lobbyists and industry groups like ours) has let them down. Period. We have chased profits, chased commissions, swallowed every piece of spin the insurance industry has fed us, and generally ignored the growing number of folks who are beyond dissatisfied with the status quo. They’re mad, and they’re not going to take it any more.
We’re not talking about 5 million, or 15 million people. No, when you add together all small group employees and their dependents, with those who have individual coverage, and the 50 million or so who have no coverage, you’re talking about 100 million people or more.
We have brought this upon ourselves, because we (the industry, maybe not each of us individually) have ignored what folks want in favor of what WE want. The industry has ignored calls for more efficient claims and billing, lower bloat, curtailing outrageous CEO and executive salaries, and a more reasonable approach to return on investment. Our industry has ignored any attempt at out-of-the-box thinking to get reasonably priced health insurance to most low-wage Americans, instead focusing on mis-communications to get Americans to buy into what the industry wants (“High Deductible Health Plans are good for you. We don’t care if you can’t afford the deductible. Now accept that fact and shut up.”) Most of all, our industry has simply ignored an ever-louder clamor for us to get our act together. Instead of focusing on a long-term vision for the future of the industry (one that actually includes the very consumers to whom we sell products), the health insurance carriers have instead bellied up to the short-term trough of immediate reward (executive compensation, shareholder value, golden parachutes).
I’m normally not negative, either. I’ve always considered myself a realist. Yet here I am, watching every prediction I’ve made over the past 15 years on forums like this come true.
The saddest part is listening to all of the gnashing of teeth and screeching and wailing, mostly from the very folks who have repeatedly turned a deaf ear to the situation year after year because they were making gobs of money. (Yes, I’m talking about a lot of you on this very forum). In fact, some of you are still wearing your rose-colored glasses, and acting like if you just click your red-sequined shoes together, you’ll be able to get back home.
Well, you ain’t Dorothy, and this ain’t Oz.
Let’s see what the President and Congress come up with, and try to work with it – because it is inevitable that the reforms will be major, because we’ve waited too long to save our current system as we know it.
I will not apologize for the above, and I will probably not respond to the rants, flames and cacophony that are sure to ensue. We brought this upon ourselves, so now we’ll have to deal with it.
Note by Brian Klepper: John Sinibaldi is a St. Petersburg, FL-based health insurance agent – or as his industry association prefers to be called, “Health Underwriters” – catering primarily to small employer groups. He’s posted reality-based columns here in the past, including a particularly pithy one recently on small group coverage in Florida. The fiery comment above was written to colleagues on a national health care brokers’ forum.
http://www.thehealthcareblog.com/the_health_care_blog/2009/03/a-brokers-lament-we-brought-this-on-ourselves.html

John Sinibaldi has provided a consistent voice behind the scenes expressing many of the problems with our private insurance industry and the clear need for reform. His observations have been very helpful to me in providing insight to many of these issues, from the industry’s perspective.
In spite of his personal efforts, along with the efforts of many more of us, the problems grow worse. It has reached the threshold such that he now feels compelled to speak up quite frankly to his colleagues in their health care brokers’ forum.
John Sinibaldi really cares. He believes that health insurance should assist patients in receiving the health care that they need. The system fails far too many today. He sees no other option than to support comprehensive change that places patients first, even though that will be highly disruptive to his own business and that of his colleagues. We need to listen to him.
(For those who would like more of John Sinibaldi’s invaluable insight on brokering health insurance, access his commentary at the link above, and then scroll down to “Posted by: John Sinibaldi | Mar 9, 2009 7:21:02 AM” and read his comment above.)

A health insurance broker speaks up

A Broker's Lament: We Brought This On Ourselves

By John Sinibaldi
The Health Care Blog
March 7, 2009

A huge segment of the American population is simply far too strapped to ever afford the premiums and costs associated with health insurance/health care as it is structured today.

It isn’t the employees of government (local, county, state or federal) who will demand immediate change. It isn’t the employees of institutional companies (the Motorolas, GEs, Microsofts of the country) who will demand change. It isn’t those on Medicare or Medicaid or the VA who will demand change. It isn’t the wealthy. It isn’t the poor. And, it isn’t the vast majority of health insurance agents who work with large group clients (because, while that market is becoming ever more difficult and the work more taxing, they’re still selling SOMETHING to these bigger businesses and government entities).

Why don’t these people see what I’m seeing? Simply because, while they are feeling the effects of the rise in health care/health insurance costs and the downturn in the economy, most of these businesses and their employees and dependents (and the affluent) have yet to have a clue about how expensive things really are (or in the case of the rich, they can still afford their out-of-pocket expenses). The agents who market to large employers are still making lots of money (I know, I rub elbows with them at my local Health Underwriters meetings once a month).

That leaves individuals and small businesses and the agents who work primarily in those markets – the very folks most beleaguered by the current situation. While the employee of a regional electric utility is complaining about monthly payroll deductions for his family that now exceed $500 or more on a $60,000 annual salary, the longtime employee of a local small electrician is looking at monthly payroll deductions for his family of $1,500 on a $35,000 annual salary. His apprentice is younger, and so is “fortunate” to have monthly deductions for his family of only $900 on a $20,000 annual salary. The electrician’s helper making $9/hr can’t afford even his half of the premium for just himself.

Individuals on personal health insurance policies are also feeling the “pinch.” Most of my individual clients see increases of 18-25% a year.

It is all of these folks (and there are tens of millions of them), coupled with those who have already been priced out of the market altogether, who will fuel the fire for radical reform. It is these folks who complain – long, loud and bitterly – that the American dream is leaving them behind. It is these folks to whom the politicians will ultimately listen, because they’re the ones making all the noise. It is these folks who will ultimately define what the next set of reforms looks like – and those reforms will NOT be confined only to the small group and individual markets – nor do these folks give a rat’s rear end if the insurance industry is involved. (After all, we’re doing such a wonderful job for them now.)

And, in my opinion, rightfully so. The health insurance industry (with lots of complicity from legislators, lobbyists and industry groups like ours) has let them down. Period. We have chased profits, chased commissions, swallowed every piece of spin the insurance industry has fed us, and generally ignored the growing number of folks who are beyond dissatisfied with the status quo. They’re mad, and they’re not going to take it any more.

We’re not talking about 5 million, or 15 million people. No, when you add together all small group employees and their dependents, with those who have individual coverage, and the 50 million or so who have no coverage, you’re talking about 100 million people or more.

We have brought this upon ourselves, because we (the industry, maybe not each of us individually) have ignored what folks want in favor of what WE want. The industry has ignored calls for more efficient claims and billing, lower bloat, curtailing outrageous CEO and executive salaries, and a more reasonable approach to return on investment. Our industry has ignored any attempt at out-of-the-box thinking to get reasonably priced health insurance to most low-wage Americans, instead focusing on mis-communications to get Americans to buy into what the industry wants (“High Deductible Health Plans are good for you. We don’t care if you can’t afford the deductible. Now accept that fact and shut up.”) Most of all, our industry has simply ignored an ever-louder clamor for us to get our act together. Instead of focusing on a long-term vision for the future of the industry (one that actually includes the very consumers to whom we sell products), the health insurance carriers have instead bellied up to the short-term trough of immediate reward (executive compensation, shareholder value, golden parachutes).

I’m normally not negative, either. I’ve always considered myself a realist. Yet here I am, watching every prediction I’ve made over the past 15 years on forums like this come true.

The saddest part is listening to all of the gnashing of teeth and screeching and wailing, mostly from the very folks who have repeatedly turned a deaf ear to the situation year after year because they were making gobs of money. (Yes, I’m talking about a lot of you on this very forum). In fact, some of you are still wearing your rose-colored glasses, and acting like if you just click your red-sequined shoes together, you’ll be able to get back home.

Well, you ain’t Dorothy, and this ain’t Oz.

Let’s see what the President and Congress come up with, and try to work with it – because it is inevitable that the reforms will be major, because we’ve waited too long to save our current system as we know it.

I will not apologize for the above, and I will probably not respond to the rants, flames and cacophony that are sure to ensue. We brought this upon ourselves, so now we’ll have to deal with it.

Note by Brian Klepper: John Sinibaldi is a St. Petersburg, FL-based health insurance agent – or as his industry association prefers to be called, “Health Underwriters” – catering primarily to small employer groups. He’s posted reality-based columns here in the past, including a particularly pithy one recently on small group coverage in Florida. The fiery comment above was written to colleagues on a national health care brokers’ forum.

http://www.thehealthcareblog.com/the_health_care_blog/2009/03/a-brokers-lament-we-brought-this-on-ourselves.html

Comment:

By Don McCanne, MD

John Sinibaldi has provided a consistent voice behind the scenes expressing many of the problems with our private insurance industry and the clear need for reform. His observations have been very helpful to me in providing insight to many of these issues, from the industry’s perspective.

In spite of his personal efforts, along with the efforts of many more of us, the problems grow worse. It has reached the threshold such that he now feels compelled to speak up quite frankly to his colleagues in their health care brokers’ forum.

John Sinibaldi really cares. He believes that health insurance should assist patients in receiving the health care that they need. The system fails far too many today. He sees no other option than to support comprehensive change that places patients first, even though that will be highly disruptive to his own business and that of his colleagues. We need to listen to him.

(For those who would like more of John Sinibaldi’s invaluable insight on brokering health insurance, access his commentary at the link above, and then scroll down to “Posted by: John Sinibaldi | Mar 9, 2009 7:21:02 AM” and read his comment above.)

The Health-Care Crisis Hits Home

By Karen Tumulty
Time Magazine
Thursday, Mar. 05, 2009

San Antonio — When you’ve been strong and fit your whole life, it can be easy to discount your body’s first whispers of sickness as merely the side effects of daily living. Looking back over the past three years, my older brother Patrick now understands the meaning of his increasingly frequent bouts of fatigue, his fluctuating appetite and the fact that his blood pressure had crept up to 150/90. But Pat had always put off going to the doctor until he had to. Having bought health insurance that carried a $2,500 deductible, he knew he would have to pay for a checkup himself. That is no small consideration for someone who makes $9 an hour, as my brother did in his job as an administrative assistant for a lighting firm in San Antonio. He also struggles with Asperger’s syndrome, a disorder sometimes described as high-functioning autism. Pat can multiply three-digit numbers in his head with ease, but he has trouble accepting the unfamiliar and adjusting to the unforeseen.

The unforeseen was exactly what turned up when Pat went in for a physical on Nov. 30, 2007, his first in five years. The doctor found high levels of blood and protein in his urine, results that were confirmed in another round of tests in December. Soon after that, Pat discovered that his urine had turned brown and foamy. In the middle of all this, he was laid off from his job, and finding a new one while doing temp work was his most pressing concern. Finally, last July my brother’s doctor insisted that he see a specialist, who quickly ordered a biopsy. That’s when Pat, who is now 54, learned that his kidneys were failing.

The diagnosis was only the first shock. The second came a few weeks later, in an Aug. 5 letter from Pat’s health-insurance company. For six years — since losing the last job he had that provided medical coverage — Pat had been faithfully paying premiums to Assurant Health, buying a series of six-month medical policies, one after the other, always hoping he would soon find a job that would include health coverage. Until that happened, “unexpected illnesses and accidents happen every day, and the resulting medical bills can be disastrous,” Assurant’s website warned. “Safeguard your financial future with Short Term Medical temporary insurance. It provides the peace of mind and health care access you need at a price you can afford.”

Kidney failure would seem to be one of those disastrous “unexpected illnesses” that Pat thought he was insuring himself against. But apparently he was wrong. When my mother, panicked, called to tell me that the insurance company was refusing to pay Pat’s claims, I told her not to worry; bureaucratic mix-up, I assumed. I said I’d take care of it, bringing to bear my 15 years of experience covering health policy, sitting through endless congressional hearings on the subject and even moderating a presidential candidates’ forum on the issue.

Confident of my abilities to sort this out or at least find the right person to fix the problem, I made some calls to the company. I got nowhere. That’s when I realized that the national crisis I’d written so much about had just hit home.

The previous four weeks had left my brother with more than $14,000 in bills from hospitals, doctors and labs. And that was just to figure out what was wrong with him. Actually treating his disease was going to be unimaginably more expensive. Patrick needed help quickly, and we didn’t have a clue where or how to start looking for it.

The Underinsured

When we talk about health-care reform, we usually start with the problem of the roughly 45 million (and rising) uninsured Americans who have no health coverage at all. But Pat represents the shadow problem facing an additional 25 million people who spend more than 10% of their income on out-of-pocket medical costs. They are the underinsured, who may be all the more vulnerable because, until a health catastrophe hits, they’re often blind to the danger they’re in. In a 2005 Harvard University study of more than 1,700 bankruptcies across the country, researchers found that medical problems were behind half of them — and three-quarters of those bankrupt people actually had health insurance. As Elizabeth Warren, a Harvard Law professor who helped conduct the study, wrote in the Washington Post, “Nobody’s safe … A comfortable middle-class lifestyle? Good education? Decent job? No safeguards there. Most of the medically bankrupt were middle-class homeowners who had been to college and had responsible jobs — until illness struck.”

If there is a ground zero for both problems, it is Texas, where I grew up and where my parents and brothers still live. About 1 in 4 Texans is uninsured, the highest rate in the country. The vast majority of the uninsured — 8 in 10 — live in households in which someone works, typically for a small business. But only 37% of Texas companies with fewer than 50 employees offer medical coverage.

The state’s Medicaid program is notoriously stingy. State law requires counties to provide care only to those deemed “indigent,” defined as people who earn less than 21% of the federal poverty line, or $2,274 a year for a single adult and $4,630 for a family of four. Many counties, particularly rural ones, do no more than that minimum. So Texas — a state with relatively little regulation of the health-insurance industry — is fertile territory for insurance companies selling bare-bones coverage at low prices.

But falling ill without adequate insurance leaves you at risk no matter where you live. Since 2005, the American Cancer Society (ACS) has maintained a national call center for cancer patients struggling with their bills. In that time, more than 21,000 people have called in asking for help. Every story is different, but the contours of the problem tend to be depressingly similar: the 10-year-old leukemia patient in Ohio who, after three rounds of chemotherapy and a bone-marrow transplant, had almost exhausted the maximum $1.5 million lifetime benefit allowed under her father’s employer-provided plan; the Connecticut grocery-store worker who put off the radiation treatments for her Stage 2 breast cancer because she had used up her company plan’s $20,000 annual maximum and was $18,000 in debt; the New Hampshire accountant who, unable to work during his treatment for Stage 3B stomach cancer, had to stop paying his mortgage to afford a $1,120 monthly premium for coverage with the state’s high-risk insurance pool.

What makes these cases terrifying, in addition to heartbreaking, is that they reveal the hard truth about this country’s health-care system: just about anyone could be one bad diagnosis away from financial ruin. Most people get their coverage where they work. But Anna McCourt, a supervisor at the ACS call center, says employees often have difficulty understanding the jargon in insurance policies. Even human-resources personnel may not fully understand all the intricacies of a policy when briefing a new employee. Coverage that seems generous when you are healthy — eight annual doctor visits or three radiation courses — quickly proves insufficient if you find yourself really sick.

Between Coverage and Safety Net

Pat’s decision to save some money by buying short-term insurance was a big mistake, says Karen Pollitz, project director of Georgetown University’s Health Policy Institute and a leading expert on the individual-insurance market. “These short-term policies are a joke,” she says. “Nobody should ever buy them. It is false security that is being sold. It’s junk.”

That’s because diagnosing and treating an illness may not fall neatly into six-month increments. While Pat had been continuously covered since 2002 by the same company, Assurant Health, each successive policy treated him as a brand-new customer. In looking back over Pat’s medical records, the company noticed test results from December, eight months earlier. Though Pat’s doctors didn’t determine the precise cause of the problem until the following July, his kidney disease was nonetheless judged a “pre-existing condition” — meaning his insurance wouldn’t cover it, since he was now under a different six-month policy from the one he had when he got those first tests.

After 33 years of wrestling with insurance companies, Deborah Haile, payment coordinator at the San Antonio Kidney Disease Center, where Pat went for treatment, has pretty much figured out the system. So when I put in my first desperate call to her, on Aug. 20, 2008, she offered to make another run at Assurant. Within an hour, Haile called back, her voice bristling with anger. “Cancel that policy,” she advised me. “Your brother is wasting his money on premiums, and he’s going to need it.”

There was at least one thing we didn’t have to worry about, Haile assured me. Pat’s kidney doctor, Peter Smolens, would keep treating him even if he couldn’t pay. Smolens, a thin, soft-spoken man, later told me that about 10% of his patients have inadequate insurance or none at all. He has agonized with some as they struggled with hard choices, like whether to have a hospital biopsy or pay their mortgage. As a physician, he said, “you just see them. You know you’re not going to get paid.”

As grateful as we were for Smolens’ forbearance, that still left us with the question of how to keep up with the rapidly mounting bills for drugs and lab work. Haile put us in touch with B.J. Smith, a social worker at the center. Patient and reassuring, Smith turned out to be the angel we needed. She had only recently returned to work after taking off seven years to stay home with her two children. The first thing she advised Pat was to start paying his bills, all of them, even if it meant putting down only a few dollars a month on each one. Otherwise, everything he had — his one-bedroom condominium, 2003 Saturn Ion and $36,000 in savings — would be put at risk, as the letters from collection agencies had begun to arrive. Smith called Pat’s medical creditors one by one and set up the arrangements: $51.89 a month to one hospital, $76 to another, installments of $4.78 a month to $111.89 a month on six different sets of LabCorp bills. Then there was the $626 he owed two radiologists. One agreed to knock off $22 as a hardship discount, writing Pat, “We are happy that we could be of assistance to you and your family in this time of need.”

A paradox of medical costs is that people who can least afford them — the uninsured — end up being charged the most. Insurance companies, with large numbers of customers, have the financial muscle to negotiate low rates from health-care providers; individuals do not. Whereas insured patients would have been charged about $900 by the hospital that performed Pat’s biopsy (and pay only a small fraction of that out of their own pocket), Pat’s bill was $7,756. For lab work — and there was a lot of it — he was being charged as much as six times the price an insurance company would pay. One pathology lab’s bill alone was $3,290.

Over time, with Smith’s guidance, Pat learned to trim his bills here and there. Instead of refilling small prescriptions, for instance, he could buy some drugs more cheaply in bulk. (A hundred pills of one blood-pressure medication was less than $16 at Costco, compared with $200 at the pharmacy.) But that didn’t address the cost of his care going forward. Pat’s kidney function, which was 48% when Smolens first saw him last summer, has fallen to between 35% and 40%. And there are now outward, obvious signs of Pat’s illness: he is lethargic, his eyes are puffy, and his lower legs and ankles are swollen to twice their normal size.

The disease — whose cause Pat’s doctors doubt they will ever know — is winning. Now Smolens is trying to figure out whether Pat, whose Asperger’s gives him a low tolerance for the demands of a complicated medical regimen, should move from his current medications to a more aggressive approach that includes immuno suppressing chemotherapy drugs. The newer drugs can cost $10,000 a treatment; even the old ones can easily run $500 a month. “It’s almost like a black hole in terms of the potential costs,” Smolens told me. “But when you look at the alternative — progressive kidney failure — then you’re talking about having to receive dialysis, and the average cost of dialysis treatments in this country is $60,000 per year plus.”

There’s another paradox: if Pat gets sick enough to need dialysis, as he well may, the Federal Government will pick up those staggering costs under the Medicare program for end-stage renal disease. But until that point is reached — and the goal is to keep him from getting there — his options are limited. Now that he is sick, it would be nearly impossible for him to purchase another insurance policy on the individual market. Since he lives independently and holds a job, it would be difficult for him to qualify for Social Security disability benefits. While Texas, like 34 other states, has a high-risk pool for those who are hard to insure, the program is twice as expensive as an average individual health-insurance policy. And my brother would have to wait 12 months to join with a pre- existing condition, under the state’s “adverse selection” regulations that seek to prevent uninsured people from joining the pool only after they get sick.

As we were running out of options, Smith told us there was one more avenue to try. Bexar County — where San Antonio is located and an estimated 30% of people under 65 do not have health coverage — has a health-care program for the uninsured that is far more generous than most in Texas and practically unique in the country. Rather than continuing to wait for the uninsured to show up in its emergency rooms, in 1997 the Bexar County hospital district established a system called CareLink for those who make 200% of the poverty line or less. (In his current job, answering queries that come in to a text- message information service, Pat earns $1,257 a month, which means he qualifies.)

CareLink operates much like a health-maintenance organization for its 55,000 clients, negotiating prices with health-care providers and then billing clients on a sliding scale according to their income. (Pat’s CareLink bills run around $40 a month.) And it puts a heavy emphasis on preventive care; on Pat’s first examination at an austere CareLink clinic in northwestern San Antonio, he got tetanus and flu shots as part of the deal. Another stroke of good fortune: Pat’s kidney doctor, Smolens, is a participating specialist with CareLink.

For primary care, CareLink assigned Pat to Dr. Carolyn Eaton, an engaging woman who has been working with the system for about a year. What alarms her most about the new patients she has seen lately, Eaton says, is how long people wait — diabetics whose feet are numb, cancer patients already in the advanced stages of the disease — before they seek treatment. “When people fall on hard times, they’re kind of embarrassed,” Eaton says. “Their health care ends up becoming much more expensive.”

It’s not a seamless system. Pat gets confused navigating between Smolens, who prescribes tests and medications, and CareLink, which must approve them. “The fact is, for guys like Pat, it requires a lot more work to do the same sorts of things” that would be a snap if he had insurance, says Smolens, sighing.

The Limits of Personal Choice

As this country prepares to engage in its first serious debate over comprehensive health-care reform in 15 years, there are two leading approaches to covering the 45 million uninsured and reining in costs. One, which President Barack Obama is putting forward, would force more employers to offer coverage to their workers, with subsidies and other incentives to make it more affordable. The other, advocated by Republicans (including Senator John McCain in the recent presidential campaign), would take away some of the tax advantages that come with getting coverage at work and thereby put many Americans who are now covered by their employers into the marketplace on their own. The idea is that they would be the ones best equipped to decide which plan suits their individual needs.

Pat’s experience suggests it is difficult for an individual to make such judgments. And the existing market for these kinds of policies leaves a lot to be desired. A 2006 Commonwealth Fund study found that only 1 in 10 people who shopped for insurance in the individual market ended up buying a policy. Most of the others couldn’t find the coverage they needed at a price they could afford.

The individual health-care consumer has very little power or information. Still, it turns out that there are ways to fight back. As I was reporting my brother’s story, I discovered something about Pat’s former insurance company: last May, insurance regulators in Connecticut imposed a record $2.1 million in penalties on two Assurant subsidiaries for allegedly engaging unfairly in a practice called postclaims underwriting — combing through short-term policyholders’ medical records to find pretexts to deny their claims or rescind their policies. In one case, a woman whose non-Hodgkin’s lymphoma was diagnosed in 2005 was denied coverage because she had told her doctor on a previous visit that she was feeling tired. Assurant agreed to pay the fine but admitted no wrongdoing.

So I contacted the Texas Department of Insurance, identifying myself as both the sister of an aggrieved policyholder and a journalist. Officials there suggested that Pat file a complaint against the company. Each year the department receives as many as 11,000 complaints and manages to get $12 million to $13 million back for consumers, Audrey Selden, the department’s consumer-protection chief, told me. “It is important to complain.”

And it’s easy too. It took Pat and me less than 10 minutes to fill out the complaint form over the Internet. That was Jan. 14, 2009. On Feb. 9, we had an answer: Assurant maintained that it had done nothing wrong and that Pat should never have relied on short-term coverage over a long period. But given “the extraordinary circumstances involved,” the company agreed to pay his claims from last year, when the policy was still in force. (Pat canceled it on Aug. 22, 2008.) Those extraordinary circumstances, I assume, included the fact that the state insurance department was sniffing around.

After we received the insurance company’s decision, I tried to talk to Assurant for this story. Its only response was a written statement from Scott Krienke, senior vice president for product lines: “Due to privacy regulations, we cannot discuss the specifics of any of our customers’ coverage.” But he also noted that “Assurant Health’s Short Term Medical product is designed for people experiencing a break in the continuity of their permanent medical coverage. Our Individual Medical plans are more appropriate for those who have an ongoing need for medical coverage.”

I wish the company had told my brother that when it sold him the policy in the first place.

State of Change: Talking About Health Reform, But Not About A Cure

By John Nichols
The Nation
Washington, DC
March 6, 2009

Health care reform is a vital and engaging concern for America–and for Americans.

But you would not know it from Thursday’s White House Forum on Health Reform, which was so narrowly focused and uninspiring that it almost made Hillary Clinton’s bumbling efforts of the 1990s look good.

President Obama sounded some of the right notes:

Now I know people are skeptical about whether Washington can bring about this change. Our inability to reform health care in the past is just one example of how special interests have had their way, and the public interest has fallen by the wayside. And I know people are afraid we’ll draw the same old lines in the sand, give in to the same entrenched interests, and arrive back at the same stalemate we’ve been stuck in for decades.

But I am here today because I believe that this time is different. This time, the call for reform is coming from the bottom up, from all across the spectrum–from doctors, nurses and patients; unions and businesses; hospitals, health care providers and community groups. It’s coming from mayors, governors and legislatures–Democrats and Republicans–who are racing ahead of Washington to pass bold health care initiatives on their own. This time, there is no debate about whether all Americans should have quality, affordable health care–the only question is, how?

Unfortunately, that is a mighty major “only question.”

And the people who in the past have answered it wrong were in the room and at the table Thursday. Indeed, they were bragging about their successes in blocking past reform initiatives. “I don’t see what happened in the ’90s as a failure,” Congressman Joe Barton, the Texas conservative who is the ranking Republican on the House Energy and Commerce Committee, told a breakout session at Thursday’s forum.

Barton was not an outlier.

The East Room at the White House was packed with the political players, union leaders and corporate lobbyists–some of them good, many of them bad–and a few administration-designated “Everyday Americans,” who helped to illustrate the depth of the crisis that the insiders have allowed to metastasize over the past decade or so.

Only a handful of serious reformers got in the room.

Thanks to pressure from the Leadership Conference for Guaranteed Healthcare, Physicians for a National Health Program, Unions for Single Payer Health Care and the Progressive Democrats of America, an invitation was extended to House Judiciary Committee chair John Conyers, D-Michigan, the sponsor of H.R. 676, legislation that seeks to create a the single-payer insurance program that would take profiteering out of the health care system.

A few other real reformers were heard from–including Californian Congressman Pete Stark.

And Dr. Oliver Fein, the director of Physicians for a National Health Plan was in the room.

But right before the doctor from Physicians for a National Health Plan on the White House list of “Community Leaders and Stakeholders Expected to Attend” were the CEOs of Pfizer and Pharmaceutical Research and Manufacturers of America (PhRMA).

And while the doctor was not included on any of the lists of breakout session speakers, the CEOs were, along with representatives of the U.S. Chamber of Commerce, America’s Health Insurance Plans, the Blue Cross Blue Shield Association and the Business Roundtable.

In other words, the overwhelming weight of opinion at what was supposed to be a wide-ranging discussion of health reform was–at best–on the side of tinkering with the existing for-profit system.

Change we can believe in was not on the agenda.

Who could have put it there?

Dr. Quentin Young, the Chicago physician who served as the Rev. Martin Luther King Jr.’s personal physician and whose medical office once included a young Chicago activist named Barack Obama on its patient list, ought to be at the table. Here’s Young discussing his support for single payer.

And where, on the lost list of members of Congress present, was the name of U.S. Rep. Tammy Baldwin? Elected to Congress as an outspoken advocate for single-payer health care, the Wisconsin Democrat is a member of the key committee in the House that deals with health care issues–Energy and Commerce–and she has succeeded in developing bipartisan coalitions that allow for state experimentation with various reform plans. In other words, she’s a principled yet very practical player in the debate.

Baldwin should have been speaking.

So, too, should have been the working nurses of the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC), the union that represents 85,000 RNs in all 50 states.

Ardent advocates for real reform, CNA/NNOC members correctly argue that: “Insurance-based reform will fail, and undermine public trust; only Medicare for All can achieve administration goals”

Here’s what the nurses are saying:

While welcoming President Obama’s call for achieving “comprehensive” healthcare reform this year, “a laudable commitment and a huge departure from the dismal healthcare policies of the past eight years,” the California Nurses Association/National Nurses Organizing Committee warned that most of proposals floating around Congress would default on the promise and principles set by the administration.

“And, they would almost certainly fail to contain the rising costs that put so many families in peril or to repair our broken healthcare system,” said CNA/NNOC Co-president Geri Jenkins, RN.

“That’s the reason the majority of the nation’s nurses and doctors–the very people who have the most daily interaction with our healthcare system and see its failures and tragedies up front, favor a single-payer approach, or expanding Medicare to all.”

“To achieve the lasting and cost-effective reform the president seeks and most Americans desire, we must confront the source of the present crisis–an insurance industry that has been steadily pricing people out of access to care, or bankrupting them if they attempt to use it,” Jenkins said. “Insurance company practices drive skyrocketing costs, a problem that won’t be solved by more technology, electronic medical records, or any other stopgap measures some propose.”

Jenkins welcomed the principles outlined by the administration for reform, and the call for progressive tax changes to help finance them, but warned that any reform “premised on expanding an insurance-based system will likely fail, frustrate the public desire for a real solution to our healthcare crisis, and undermine the political capital the administration has earned for reform.”

“Private insurance plans aren’t universal because they exclude people based on pre-existing conditions or age or anyone else they think will be expensive to cover. They don’t guarantee choice of physician or hospital, but limit you to their network of providers.

“The insurers won’t assure affordability because they are constantly raising premiums, deductibles, co-pays, and other fees to generate high revenues and profits. They can’t guarantee safety and quality because they actively discourage the delivery of care or deny treatments, diagnoses, or referrals they don’t want to pay for. And, they will never be fiscally responsible because there is no independent oversight, decisions are made in secret in closed boardrooms or CEO offices, and, their priority is profits, not care,” Jenkins said.

“Medicare for all, however, does succeed in all eight areas. It removes the incentive for price gouging, and it takes control of our health away from the insurance companies, and puts it where it belongs, in the hands of patients, families, and their doctors and nurses,” said Jenkins.

This reform, she added also promotes national recovery by creating 2.6 million new jobs, infusing $317 billion in new business and public revenues, and injecting $100 billion more in wages into the U.S. economy, according to a recent CNA/NNOC study.

HR 676, the U.S. National Health Care Act by Rep. John Conyers, is the plan that best meets the grand vision painted by our president. “We call on Congress and the administration to work with us to enact it,” Jenkins said.

The point here is not to give up on the Obama administration as a vehicle for real reform.

White House forums of the sort that was held Thursday are “for the cameras” events that set the tone–not the policy–of an administration.

The president knows that single-payer is the right fix for what ails the American health care system.

He was once a reasonably consistent advocate for a single-payer system, appearing at events in Chicago organized by Dr. Young and Physicians for a National Health Care Plan.

As recently as last August, Obama told a health care forum in New Mexico that, “If I were designing a system from scratch, I would probably go ahead with a single-payer system.”

The insurance industry and its allies don’t want to start from scratch and make a system that works.

They want to keep patching up a system that doesn’t work–that fails to provide care to roughly 50 million Americans, that leaves another 50 million under-insured and that is defined more by its cost overruns than its quality–so that they can keep profiteering.

Thursday’s White House sessions provided a great forum for advocates of “patching up” and “tinkering” with a broken system.

But that’s not the treatment that is needed. That’s a prescription for failure.

Obama is better positioned that any president in decades — perhaps ever — to design a system from scratch.

The special interests, corporate insiders and congressional compromisers who made the mess and fear the change won’t remind him of that fact–as Thursday’s forum so amply illustrated.

Real reformers should keep banging on the doors and demanding a place at the table.

Single payer is not “an alternative.”

It is not one of “various treatment options.”

It is the cure.

Grim Prognosis For Massachusetts Reform

Letter to the Editor
Health Affairs, 28, no. 2 (2009): 604-605
doi: 10.1377/hlthaff.28.2.604

To the editor:

Gabel and colleagues (October 28 Web Exclusive) hope that favorable employer attitudes mean that Massachusetts’ 2006 health reform will succeed where the state’s similar 1988 health reform failed. In truth, the demise of the 1988 law had more to do economic cycles — the collapse of the Massachusetts Miracle — than with corporate attitudes. Unfortunately, this history, along with the recent downturn in the economy, implies a grim prognosis for the current Massachusetts reform.

The 1988 reform died because health care costs continued to soar, while a recession shrank tax revenues just as tens of thousands lost their jobs and private coverage. (Unemployment rose from 3.2% in 1988 to 9.1% two years later). Neither massive expansion of state funding to subsidize coverage for the poor, nor a costly mandate — the two main mechanisms to expand coverage under both the 1988 and 2006 laws — was tenable in a cooling economy.

Despite costs of $1.1 billion this year, the 2006 law has covered only half of the uninsured, and has left many more with inadequate coverage. A recent Boston Globe/Blue Cross survey found that 9% of Massachusetts residents avoided or postponed care within the past year because of costs; 14% had failed to fill a prescription; and 14% had run up medical debts. The inadequacy of the new coverage is also evident in Blendon’s et al’s survey (October 28 Web Exclusive); those directly affected by the reform were actually more likely to say that reform had hurt than helped them. This seemingly paradoxical result probably reflects the fact that most of the newly-insured had previously been eligible for completely free care at safety net hospitals and clinics paid for by Massachusetts’ free care pool.

Even the partial gains of the 2006 reform are now in jeopardy, and its collapse may well leave patients worse off than ever. The reform was partly financed by draining funds from the free care pool, and hence from safety net providers. Now, with tax revenues plummeting, the governor plans to pull another $100 million from funds owed to the safety net hospitals in the Boston area (disclosure: we work as primary care doctors at one of them, where these cuts are projected to require hundreds of layoffs and the closure of critical services and community clinics). Further budget cuts likely lie ahead, and the ranks of the uninsured will doubtless swell.

In the end, Massachusetts’ 2006 reform may be remembered as a short-lived expansion of publicly-subsidized coverage that served as political cover for the permanent destruction of institutions that have provided care and advocacy for New England’s poor for decades.

Steffie Woolhandler, M.D., M.P.H.
David U. Himmelstein, M.D.
Cambridge Hospital/Harvard Medical School

An ailing economy needs national health insurance

By Lance Dickie
Seattle Times editorial columnist
March 5, 2009

The effort launched by President Obama to overhaul the nation’s health-care system does not match the urgency of the times. He is for change yet to be defined.

In the curious way that policy advances, hard times are the best of times for moving beyond a clumsy, massively expensive private-health-insurance industry the country can no longer afford.

As a crashing economy pushes millions out of their jobs and homes, continuing to link access to medical care to employment is hazardous to the nation’s health. Anxious households reached this conclusion well ahead of the politicians.

Even before the economy turned upside-down, fewer employers offered health insurance. Covered workers paid ever-higher premiums, copays and deductibles for skimpier benefits.

Annual health-care costs soared past inflation rates. Hundreds of private insurers with thousands of plans not only failed at cost containment, they also drove up expenses for clients, doctors, hospitals and patients with obscene administrative overhead.

Obama rolled out his blueprint for health-care reform this week, along with the cabinet-level administrators who will pursue its enactment. They include Kansas Gov. Kathleen Sebelius, nominated as secretary of health and human services, Nancy-Ann DeParle, administration coordinator of health policy, and Peter Orszag, White House budget director.

They are charged by the president to promote broad principles of universal coverage, lower premiums, consumer choice of health plans and ending refusal of coverage for pre-existing conditions. Obama wants a 10-year, $634-billion reserve to “finance fundamental reform of our health-care system that will bring down costs and expand coverage.”

The administration’s approach is narrowly and unacceptably about the status quo, changing the current system of private insurers. The conversation broadened when supporters of single-payer national health insurance were belatedly invited to Thursday’s White House health-care forum.

Single payer covers everyone. Doctors, hospitals and all the medical-care system stay private, but paperwork and bills are routed through and paid by the federal government. Think Medicare.

Advocates include the 12,500 members of Physicians for a National Health Program. Two single-payer plans have patiently awaited their moment for years: H.R. 676, introduced by Rep. John Conyers, D-Mich., and H.R. 1200, introduced by Rep. Jim McDermott, D-WA.

Obama’s stimulus plan pushes back on health-care costs, ending excess payments to Medicare Advantage programs. The newly unemployed get help to hang onto their employer coverage longer. Money flows to health clinics, such as the Community Health Association of Spokane.

As for broader health-care reform, McDermott counsels patience. His experience and frustration go back to the early Clinton years and the administration’s failed reform attempts. The Seattle Democrat is now plainly optimistic. He hears consumers, major employers, unions and medical professionals all say the status quo is unacceptable.

McDermott, freshly back from war-zone trips to Iraq and Afghanistan, said the discussion to come is for the nation to agree everyone will contribute to a common fund that pays for coverage for all.

Potential savings are huge, as are the benefits of keeping a private doctor and every one having one. The national conversation must occur first. McDermott is confident the times are ripe for it to happen.

Lance Dickie’s column appears regularly on editorial pages of The Times. His e-mail address is ldickie@seattletimes.com

http://seattletimes.nwsource.com/html/opinion/2008818515_opina06lance.html

As Obama Hosts Summit on Healthcare, Marginalized Advocates Ask Why Single-Payer is Ignored

Democracy Now

President Obama hosted a White House summit Thursday on reforming healthcare. While President Obama said every idea must be considered, the idea of creating a single-payer national health insurance program appears to have already been rejected. We speak to Harper’s senior editor Luke Mitchell, author of the article “Sick in the Head: Why America Won’t Get the Health-Care System It Needs.” [includes rush transcript]

Guest:

Luke Mitchell, senior editor at Harper’s Magazine and author of the article “Sick in the Head: Why America Won’t Get the Health-Care System It Needs.”
Rush Transcript
This transcript is available free of charge. However, donations help us provide closed captioning for the deaf and hard of hearing on our TV broadcast. Thank you for your generous contribution.

JUAN GONZALEZ: President Barack Obama convened 120 experts to the White House Thursday for a summit on healthcare. Participants included doctors, health insurance companies, lawmakers and patients. Obama vowed to make passing healthcare reform a priority this year.

PRESIDENT BARACK OBAMA: In this effort, every voice has to be heard. Every idea must be considered. Every option must be on the table. There should be no sacred cows. Each of us must accept that none of us will get everything that we want and that no proposal for reform will be perfect. If that’s the measure, we will never get anything done. But when it comes to addressing our healthcare challenge, we can no longer let the perfect be the enemy of the essential.

JUAN GONZALEZ: While the President said every idea must be considered, the idea of creating a single-payer national health insurance program has already been rejected. White House spokesperson Robert Gibbs said Thursday, “The President doesn’t believe that’s the best way to achieve the goal of cutting costs and increasing access.”

Initially, no supporters of single payer were invited to the summit. After protests were called, the White House invited Democratic Congressman John Conyers and the president of the Physicians for a National Health Program.

AMY GOODMAN: Single-payer advocates have also been largely silenced in the media. A new study being released today by FAIR, Fairness and Accuracy in Reporting, found the views of advocates of single payer have only been aired five times in the hundreds of major newspaper, broadcasts and cable stories about healthcare reform over the past week. No single-payer advocate has appeared on a major TV broadcast or cable network to talk about the policy during that period.

Well, to talk more about this, we’re joined by Luke Mitchell. He’s senior editor at

Harper’s Magazine. His article in the February issue is called “Sick in the Head: Why America Won’t Get the Health-Care System It Needs.”

Welcome to Democracy Now!, Luke.

LUKE MITCHELL: Thank you for having me, Amy.

AMY GOODMAN: So, why isn’t single payer being considered? Why has it been rejected out of hand? Why do you think it’s the only answer?

LUKE MITCHELL: Well, it’s amazing how far–how out of hand it’s been rejected. Max Baucus said a couple of months ago that everything is on the table. Max Baucus, the US senator who’s going to have a big hand in coming up with whatever reform we do see this year, said everything is on the table, except single payer. He went out of his way to say that we can’t have single payer.

And I think there are a couple of reasons why they’re so explicitly rejecting it. One of them is that it’s a threat to a great deal of people who are making a lot of money right now, which is to say the insurance companies. A single-payer system would take a lot of money out of the insurance system, the private insurance system. And it’s also something that a lot of people in Washington understand as ideologically threatening, that is to say, they equate a single-payer system with what they call, quote, “socialized medicine,” unquote.

So I think what Obama is trying to do is neutralize that threat and get, as he said, the imperfect rather than nothing. And maybe he’s right. There’s clearly a massive resistance to single payer on the Hill.

JUAN GONZALEZ: And this is especially surprising given the fact, as you say in your article, that as recently as 2003 Obama himself said he favored single-payer health insurance.

LUKE MITCHELL: That’s right. That’s right. When I started my Harper’s article, what I wanted to understand is why this approach to healthcare, single payer, which is used in most of the wealthy Western nations, which is much more efficient, which is much more equitable, which is much more amenable to making people healthy, is so far out of the mainstream in the United States. And I think what I found in the article was that–that it’s purely a mental blockage. That is to say that even if you can make the argument, the practical argument, for it–and we can talk about that in a minute–people still don’t want it.

AMY GOODMAN: But we’re in a different time.

LUKE MITCHELL: Yeah.

AMY GOODMAN: It has–you know, the politicians have said that it’s not doable before, but now we are facing a mass crisis, mass unemployment, tens of millions of people without insurance. Even those who have it are having trouble. I wanted to go to Obama yesterday speaking about, at this healthcare summit, the costs of healthcare. In a minute, we’ll go to that. But the times have changed. We’re talking about bailing out banks.

LUKE MITCHELL: Yeah. Well, and indeed, this strikes me as a tremendous opportunity. On the other hand, the idea of universal healthcare was completely out of favor, you know, ten years ago, as well. So we are moving in a positive direction. You know, just a few years ago, the President was able to–found it politically feasible–President George W. Bush found it politically feasible to veto a bill that would insure children. That’s changed.

JUAN GONZALEZ: I wanted to ask you about a company that you mentioned in your article in Harper’s that most Americans have never heard of, but which may benefit a lot from all of this healthcare reform, especially since Obama is talking about computerization of medical records, using stimulus money for that: McKesson.

LUKE MITCHELL: Yeah.

JUAN GONZALEZ: Who is McKesson, or what are they?

LUKE MITCHELL: McKesson is the eighteenth largest corporation in the United States. I actually, when I lived in San Francisco, lived a few blocks from their headquarters, had never heard of them. And as I was researching my Harper’s article, I came across a book by their CEO, John Hammergren, called Skin in the Game, where he was making an argument, basically that was the opposite of the argument for single payer. He was arguing that when you use market solutions, you have a much more efficient system, which I did not find to be a compelling argument.

But he, in making that argument, brought something else to light that was fascinating, which is that he wanted to have more information in the system. And that’s what his company does. They make–among many other things, they process 80 percent of the prescriptions in the United States. It’s more than eBay and Amazon combined, in terms of processing individual orders. And they make all these various computer systems for communicating your health to your doctor and your doctor communicating your health finance to your insurer. That’s obviously going to be a growing business. And one of the things Obama talked about today–yesterday was making that business something that is more useful to people at the ends rather more useful to the people trying to make a profit from it.

AMY GOODMAN: Since single payer is almost never mentioned–

LUKE MITCHELL: Yes.

AMY GOODMAN: –in the media, just explain what it is.

LUKE MITCHELL: Well, it’s–one of the phrases you hear about single payer is “Everybody in, nobody out.” That is to say, in a single-payer system, you don’t have a system for deciding who gets treatment. So, you have one payer, obviously the single payer, usually the government, though it could be a government corporation or some other entity, like a utility. And–

AMY GOODMAN: Like Medicare, Medicaid?

LUKE MITCHELL: Precisely. In fact, there’s a bill–and this is the amazing thing. John Conyers actually wrote a bill several years ago, HR 676. It has 100 sponsors, more or less, on the Hill. And it’s also known as the Medicare for All Act. And it would essentially expand Medicare to every American.

The advantages of single payer are much more than just coverage, though. But it does solve the first moral problem, which is that there are 50 million Americans–now 46, because the Children’s Health Insurance Program has passed–46 million Americans without insurance. And it immediately solves that problem. But it also introduces huge savings into the system, because you don’t have this massive overhead.

And finally, it introduces smart incentives into the system. Right now, the incentive of a private insurer is to keep you healthy as long as you have insurance. And as soon as you don’t have insurance, they don’t care. So, all Americans are going to enter Medicare at sixty-five, even with supplements, and that means the private insurers don’t have such an interest in keeping you healthy after you’re sixty-five, so they don’t encourage things like smoking cessation or weight loss or any of the other things that they would do to keep you going.

But it also, in private insurance, has a very strange incentive. Basically, the role of a private insurance company is to separate people who are going to get sick from people who are not going to get sick. They’re very good at it. They use technology from companies like McKesson to do it. They’re going to get better at it, as we get better at understanding why people become sick, with genetic and proteomic data. And what the insurance company’s goal ultimately is to do is to create two perfect circles: one circle with people who never get sick and who have private insurance, and one circle with people who will get sick and don’t have private insurance. Creating those two circles is very profitable. It takes a lot of money to do it, and it doesn’t help a lot of Americans.

AMY GOODMAN: And yet, right now they say it is unfeasible. The idea of having a middleman in the middle making a profit is what is being considered, even with universal healthcare.

LUKE MITCHELL: Yeah.

AMY GOODMAN: Unless it were to change.

LUKE MITCHELL: Well, you had mentioned Obama himself has said repeatedly that single payer is the best approach, but there are a lot of built-in players that need to be dealt with. And I think that’s a true observation of reality in America today. And certainly, the universal health programs we are seeing on offer right now basically act to bribe those middlemen into not complaining too much. What we have is a mandate system. Pretty much every Democrat who has proposed a system has said we’ll have a mandate, maybe a universal mandate. But it basically requires you to buy private insurance. If you can’t afford the private insurance, the government will fund you. So it’s not a market system exactly; it’s basically government-funded private insurance. And the reason I think that people, normal people, might find that preferable is that normal people have a sort of a preference for what they think of as market solutions. They think this will somehow be more efficient.

AMY GOODMAN: Or perhaps this other system has never been explained to them before.

LUKE MITCHELL: That’s right. And–

AMY GOODMAN: Well, Luke, I just want to say thank you for explaining it to us. We will continue to follow this issue, of course, one of the most important issues in this country today. And we will link to your article at Harper’s Magazine. Luke Mitchell, senior editor at Harper’s Magazine, his piece is called “Sick in the Head: Why America Won’t Get the Health-Care System It Needs.”

http://www.democracynow.org/2009/3/6/as_obama_hosts_summit_on_health

Nurse's insurance nightmare makes her a single-payer advocate

By Michael Vitez
Philadelphia Inquirer
Sat, Mar. 7, 2009

Marilyn Cawthon has been a nurse for 30 years. “All my life I provided health care to people,” she said recently. “I thought when I needed it, it would be there and wouldn’t drive me broke or crazy.”

It nearly did both.

Cawthon got the heart care she needed, but insurance refused to pay – and she was billed $24,000.

Now an intensive care nurse at Lower Bucks Hospital in Bristol Township, Cawthon, 57, ultimately got her insurer to pay – four years later.

Her experience turned her into a foot soldier in the fight to bring single-payer universal health care to the United States.

She will be handing out literature today when U.S. Rep. John Conyers (D., Mich.), sponsor of H.R. 676, a bill to create a single-payer system, holds a town-hall meeting at 10:30 a.m. at Thomas Jefferson University, 11th and Locust Streets.

Conyers will be at the University of Pennsylvania Newman Center, 3720 Chestnut St., at 1 p.m. for a second town meeting.

“Trying to talk to insurance companies, sending certified letters, calling on the phone, talking to people who said they’d take care of this only to have them never take care of this,” Cawthon explained, “I felt like I was in a maze.”

“When people are sick,” she added, “the last thing they should be worrying about is money. They should be worrying about getting better. The way it is now . . . people are worried about how they are going to pay for it. And that shouldn’t be.”

Single payer is a dramatic change favored by millions of Americans and thousands of health-care professionals, but not supported by President Obama. He is determined to bring about health-care reform this year, but says the United States isn’t ready for that option.

Under a single-payer plan, Americans would contribute to a health-care trust fund through a variety of means, such as a payroll tax, and this fund would pay doctors, hospitals and nursing homes for care. Patients could still choose doctors. There would be no need for insurers.

“The president said, if we were starting from scratch, that would be an excellent way to go,” said Melody Barnes, head of Obama’s Domestic Policy Council, “but at this point, we have to build on our current employment-based system to move forward.”

Obama said Thursday, “I think most of us would agree that if we want to cover all Americans, we can’t make the mistake of trying to fix what isn’t broken. So if somebody has insurance they like, they should be able to keep that insurance.”

Opponents of the single-payer plan say it will result in longer waits to get into hospitals and to see specialists. Since health care will appear to be free, they say, demand will rise, and the government will ration care to control costs, leading to a chronic shortage of physicians.

Cawthon is undaunted. Understanding what she went through might explain why.

Roll back to 2000. Cawthon was a single mother, divorced, supporting two children.

She was suffering from shortness of breath. Her father died of a heart attack at 45, so she knew not to mess around. She went for a stress test in September. Positive.

That day, she quit smoking.

She needed a cardio-catheterization – doctors would go in and check the arteries and valves of her heart, looking for blockages. She scheduled the test for January 2001. She didn’t want to have it before then, because her older daughter was expecting a baby.

In December, a month before the procedure, Cawthon left her job in home health with Jefferson, where she had Personal Choice insurance coverage.

In her new job as a contract nurse, she wouldn’t have insurance. So she thought about keeping her coverage through Jefferson for 18 months, as allowed by the federal COBRA law. She would just pay the premiums out of pocket, rather than having Jefferson pay.

But on Dec. 18, Cawthon called Blue Cross and asked about an individual plan.

About 170 million Americans get group insurance through their jobs. About 17 million buy insurance through individual plans on the open market.

In Pennsylvania, if a person is healthy, individual plans can be cheaper than paying to continue coverage under a group plan through COBRA.

As a single mother, Cawthon was always looking for ways to economize, she said. She signed up.

She wanted to make sure that if she switched plans, she’d still be covered for her surgery.

A letter from Independence arrived Jan. 2, the day before her procedure.

“The requested service has been approved.”

Another paragraph began:

“This letter is not a determination of eligibility or a guarantee of payment.”

Did these mean opposite things? She was confused.

She went ahead the next day and the procedure went well. Her doctor found a clogged artery, did angioplasty to unblock it, put in a stent. She is grateful and thinks this prevented a heart attack.

On Jan. 22, three weeks later, Cawthon received a one-page form letter from Temple University Hospital. It read:

“We have been notified by Blue Cross that your claim for benefits has been DENIED. The reason for this denial is: claim was denied for pre-xcondition. This bill, in the amount of $24,471.82, is now your responsibility.”

Cawthon lit a cigarette.

Here is what happened:

When an American is covered in a group plan through an employer, the insurer cannot deny coverage because of a preexisting condition.

But when a person seeks an individual plan, in Pennsylvania and 43 other states, coverage can be denied for a preexisting condition.

One trigger allowing an insurer to deny coverage is a lack of insurance in the previous two years.

Before Cawthon worked at Jefferson, she’d gone through February, March and April of 2000 without insurance. That allowed Independence to look at her medical history, see she had a heart ailment, and deny her coverage.

Hence, the $24,000 bill.

The confusing letter she received the day before her procedure confirmed that she needed help, but also said coverage couldn’t be guaranteed. Cawthon said she didn’t understand.

It gets more complicated.

The law gave Cawthon 63 days after she left Jefferson to get covered under COBRA.

Temple sent Cawthon the bill. But she didn’t get an official denial from the insurer for nine months – too late to go back and get the surgery covered under COBRA. She was stuck with a $24,000 bill she said she couldn’t pay.

The debt ruined her credit rating. The interest rate of her car loan was 16 percent.

On Nov. 20, 2004, she read a newspaper story about G. Fred DiBona, president and chief executive officer of Independence, and his fight with cancer and determination to live.

Cawthon wrote him that night. She hoped he would beat the cancer. She also told him, “I counted on your insurance company to help me out, and it’s been a nightmare.”

A letter came back, signed by Fred DiBona. He said he’d look into it. He died soon after. But he had been good to his word.

On Jan 19, 2005, a letter came from the insurer: “A decision has been made to … have the claim reprocessed for payment. . . . This . . . is a one-time exception.”

Marilyn cried that day.

She interprets the letter as: “In honor of Fred, we’re going to give you a break.”

Elizabeth Williams, an Independence spokeswoman, said that wasn’t the reason. The denial “was accurate,” Williams said, “but the period between when she had the surgery and October, when she got that letter, that’s an unnecessary delay.”

All this led Cawthon to support a single-payer plan, she said, to hand out literature today. Every day, she helps save lives. Only now, she often wonders, “Are these patients going to go through the same thing I went through?”

“The whole thing is about quality of life,” she said. “You don’t want to give patients another heart attack when you start pummeling them with bills.”

http://www.philly.com/philly/hp/news_update/20090307_Nurse_s_insurance_nightmare_makes_her_a_single-payer_advocate.html

Urgent message to single payer supporters Join us for Obama regional governor's health care summit in Vermont to Insist on Single Payer

Dear Friend:

Vermont Governor Jim Douglas and Massachusetts Governor Deval Patrick have been asked by President Obama to host a regional New England health care summit at the University of Vermont on March 17th. We do not expect to be invited not do we expect single payer to be considered.

At the recent White House summit on health reform the first person to speak at the close of the forum was the head of the American Health Insurers Plans. The rest of those in attendance were mostly lobbyists from special interest groups. The single payer view was all but excluded.

In fact, no single payer advocate was invited until thousands of messages reached the White House, including word that doctors were going to protest on the sidewalk. At the end of the day prior to the summit, the White House quickly invited a solitary physician to represent the view of a large majority of physicians and a overwhelming majority of Americans: we need single payer national health insurance now.

When it comes to the debate in Washington, DC, single payer stands ignored, like the elephant in the room, in spite of all of the evidence that it saves money, contains future spending, will include everyone and will improve the economy. But with the last minute invitation to the White House we learned an important lesson:

We can make a difference! Right now we are the marginalized majority. We might expect this treatment from the Bush administration. But it is unforgivable from President Obama. The majority of Americans want a single payer health care system in the United States. The majority of doctors want single payer. The President has promised an open, transparent process, with all proposals considered. It is time to insist that single payer be a part of this process.

We are organizing a peaceful and respectful protest in front of the summit meeting at the University of Vermont Davis Center in Burlington, Vermont at 12 noon. If there ever was a day to drop what you are doing and come, this is it. There will be national and local media there. We need hundreds of people to come from all over New England and New York. We urge health professionals to come and bring your white coats and stethoscopes.

For more information email Deb Richter
vthca@sover.net
Call 802-371-7764
www.savevermonthealhcare.org

NOTE: The Davis Center is on Main Street but its entrance faces into the campus.

Ideas for signs:

The Marginalized Majority Wants Single Payer

Yes we can! Support single payer bills H100/S88 (Vermont) and HR 676 (US Congress)

Single payer = $billions in savings and health care for all

Private insurance = high costs and millions uninsured

Health care is a public good — support single payer

Health care is a public good, not a commodity

Take the profit out of health care — support single payer

Single payer-the Most Fiscally Conservative Plan

We are NOT # 1 but could be with Medicare for All

You want to help the middle class? Pass single payer

You want to help business? Pass single payer

You want to help the economy ? Pass single payer

Obama says single payer is the best option

It is our money . We want it to pay for health care not health insurance

We can afford health care for all, not health insurance for all

Doctors want single payer

Nurses want single payer

Americans want single payer

PR: Single-payer health reform supporters to rally at March 12 White House-sponsored forum in Dearborn, Mich.

Physicians and 'Medicare for All' reform advocates decry outsized role of corporate interests at regional meeting on health reform

MEDIA ADVISORY
March 10, 2009

Contacts:
Johnathon Ross, M.D., PNHP
Bob Sisler, LMSW, chairman of Local 6000 UAW Retirees S.E. chapter
Mark Almberg, PNHP, (312) 782-6006, mark@pnhp.org

What
Press conference and rally to express support for single-payer health reform and to protest the “marginalization of majority opinion” at Thursday’s White House Forum on Health Care Reform at the Ford Conference Center in Dearborn, Mich., at 1 p.m. EDT, and at other presidential health forums.

Spokespersons for Physicians for a National Health Program (PNHP) and other advocates of single-payer national health insurance, sometimes called an improved Medicare for All, will decry the outsized role of the private health insurance industry, Big Pharma, and other representatives of corporate medicine at the White House-sponsored forum, one of five that are being across the country. Rally organizers charge the guest list is heavily laden with for-profit interests who care more about safeguarding their profits than delivering health care.

While acknowledging that a very small number of single-payer supporters have been invited to the forum, physicians wearing their white coats and other health reform advocates will assert that national health insurance is being accorded a minor, marginalized role at the forum, even though surveys show two-thirds of Americans and 59 percent of U.S. physicians support it. They will also present forum conveners with letters signed by members of Detroit-area churches in support of H.R. 676, the U.S. National Health Care Act, a single-payer bill sponsored by Rep. John Conyers Jr. (D-Mich.).

Rally participants will demand that the single-payer model be “on the table” as a full-fledged option and given pride of place, given its proven effectiveness in providing universal, comprehensive care; its ability to contain costs; and the fact that its annual savings in administrative costs — $400 billion — will mean that it will require no increase in health spending.

Who
Johnathon Ross, M.D., an internist at St. Vincent Mercy Medical Center, a 500-bed teaching hospital in Toledo, Ohio, who has many patients in Michigan. He is also an associate professor of medicine at the University of Toledo, and a past president of Physicians for a National Health Program, a national organization of 15,000 doctors who support single-payer national health insurance.

James Mitchiner, M.D., emergency physician and St. Joseph Mercy Hospital in Ann Arbor and immediate past president Washtenaw County Medical Society.

Representatives of labor and faith communities.

When
1 p.m. EDT, Thurs., March 12

Where
Ford Conference Center, 1151 Village Rd., Dearborn, Mich., immediately outside main entrance.

Nurse’s insurance nightmare makes her a single-payer advocate

By Michael Vitez
Philadelphia Inquirer
Sat, Mar. 7, 2009

Marilyn Cawthon has been a nurse for 30 years. “All my life I provided health care to people,” she said recently. “I thought when I needed it, it would be there and wouldn’t drive me broke or crazy.”

It nearly did both.

Cawthon got the heart care she needed, but insurance refused to pay – and she was billed $24,000.

Now an intensive care nurse at Lower Bucks Hospital in Bristol Township, Cawthon, 57, ultimately got her insurer to pay – four years later.

Her experience turned her into a foot soldier in the fight to bring single-payer universal health care to the United States.

She will be handing out literature today when U.S. Rep. John Conyers (D., Mich.), sponsor of H.R. 676, a bill to create a single-payer system, holds a town-hall meeting at 10:30 a.m. at Thomas Jefferson University, 11th and Locust Streets.

Conyers will be at the University of Pennsylvania Newman Center, 3720 Chestnut St., at 1 p.m. for a second town meeting.

“Trying to talk to insurance companies, sending certified letters, calling on the phone, talking to people who said they’d take care of this only to have them never take care of this,” Cawthon explained, “I felt like I was in a maze.”

“When people are sick,” she added, “the last thing they should be worrying about is money. They should be worrying about getting better. The way it is now . . . people are worried about how they are going to pay for it. And that shouldn’t be.”

Single payer is a dramatic change favored by millions of Americans and thousands of health-care professionals, but not supported by President Obama. He is determined to bring about health-care reform this year, but says the United States isn’t ready for that option.

Under a single-payer plan, Americans would contribute to a health-care trust fund through a variety of means, such as a payroll tax, and this fund would pay doctors, hospitals and nursing homes for care. Patients could still choose doctors. There would be no need for insurers.

“The president said, if we were starting from scratch, that would be an excellent way to go,” said Melody Barnes, head of Obama’s Domestic Policy Council, “but at this point, we have to build on our current employment-based system to move forward.”

Obama said Thursday, “I think most of us would agree that if we want to cover all Americans, we can’t make the mistake of trying to fix what isn’t broken. So if somebody has insurance they like, they should be able to keep that insurance.”

Opponents of the single-payer plan say it will result in longer waits to get into hospitals and to see specialists. Since health care will appear to be free, they say, demand will rise, and the government will ration care to control costs, leading to a chronic shortage of physicians.

Cawthon is undaunted. Understanding what she went through might explain why.

Roll back to 2000. Cawthon was a single mother, divorced, supporting two children.

She was suffering from shortness of breath. Her father died of a heart attack at 45, so she knew not to mess around. She went for a stress test in September. Positive.

That day, she quit smoking.

She needed a cardio-catheterization – doctors would go in and check the arteries and valves of her heart, looking for blockages. She scheduled the test for January 2001. She didn’t want to have it before then, because her older daughter was expecting a baby.

In December, a month before the procedure, Cawthon left her job in home health with Jefferson, where she had Personal Choice insurance coverage.

In her new job as a contract nurse, she wouldn’t have insurance. So she thought about keeping her coverage through Jefferson for 18 months, as allowed by the federal COBRA law. She would just pay the premiums out of pocket, rather than having Jefferson pay.

But on Dec. 18, Cawthon called Blue Cross and asked about an individual plan.

About 170 million Americans get group insurance through their jobs. About 17 million buy insurance through individual plans on the open market.

In Pennsylvania, if a person is healthy, individual plans can be cheaper than paying to continue coverage under a group plan through COBRA.

As a single mother, Cawthon was always looking for ways to economize, she said. She signed up.

She wanted to make sure that if she switched plans, she’d still be covered for her surgery.

A letter from Independence arrived Jan. 2, the day before her procedure.

“The requested service has been approved.”

Another paragraph began:

“This letter is not a determination of eligibility or a guarantee of payment.”

Did these mean opposite things? She was confused.

She went ahead the next day and the procedure went well. Her doctor found a clogged artery, did angioplasty to unblock it, put in a stent. She is grateful and thinks this prevented a heart attack.

On Jan. 22, three weeks later, Cawthon received a one-page form letter from Temple University Hospital. It read:

“We have been notified by Blue Cross that your claim for benefits has been DENIED. The reason for this denial is: claim was denied for pre-xcondition. This bill, in the amount of $24,471.82, is now your responsibility.”

Cawthon lit a cigarette.

Here is what happened:

When an American is covered in a group plan through an employer, the insurer cannot deny coverage because of a preexisting condition.

But when a person seeks an individual plan, in Pennsylvania and 43 other states, coverage can be denied for a preexisting condition.

One trigger allowing an insurer to deny coverage is a lack of insurance in the previous two years.

Before Cawthon worked at Jefferson, she’d gone through February, March and April of 2000 without insurance. That allowed Independence to look at her medical history, see she had a heart ailment, and deny her coverage.

Hence, the $24,000 bill.

The confusing letter she received the day before her procedure confirmed that she needed help, but also said coverage couldn’t be guaranteed. Cawthon said she didn’t understand.

It gets more complicated.

The law gave Cawthon 63 days after she left Jefferson to get covered under COBRA.

Temple sent Cawthon the bill. But she didn’t get an official denial from the insurer for nine months – too late to go back and get the surgery covered under COBRA. She was stuck with a $24,000 bill she said she couldn’t pay.

The debt ruined her credit rating. The interest rate of her car loan was 16 percent.

On Nov. 20, 2004, she read a newspaper story about G. Fred DiBona, president and chief executive officer of Independence, and his fight with cancer and determination to live.

Cawthon wrote him that night. She hoped he would beat the cancer. She also told him, “I counted on your insurance company to help me out, and it’s been a nightmare.”

A letter came back, signed by Fred DiBona. He said he’d look into it. He died soon after. But he had been good to his word.

On Jan 19, 2005, a letter came from the insurer: “A decision has been made to … have the claim reprocessed for payment. . . . This . . . is a one-time exception.”

Marilyn cried that day.

She interprets the letter as: “In honor of Fred, we’re going to give you a break.”

Elizabeth Williams, an Independence spokeswoman, said that wasn’t the reason. The denial “was accurate,” Williams said, “but the period between when she had the surgery and October, when she got that letter, that’s an unnecessary delay.”

All this led Cawthon to support a single-payer plan, she said, to hand out literature today. Every day, she helps save lives. Only now, she often wonders, “Are these patients going to go through the same thing I went through?”

“The whole thing is about quality of life,” she said. “You don’t want to give patients another heart attack when you start pummeling them with bills.”

http://www.philly.com/philly/hp/news_update/20090307_Nurse_s_insurance_nightmare_makes_her_a_single-payer_advocate.html

AHIP's phony epiphany

Insurers’ commitment to healthcare reform is only skin-deep

The industry claims to have had a change of heart, but its position hasn’t changed at all.

By Michael Hiltzik
Los Angeles Times
March 9, 2009
In December, the industry’s trade group, AHIP (for America’s Health Insurance Plans) revealed that it had experienced an epiphany and decided for the first time to support the principle of universal healthcare — insuring everyone in America, regardless of health condition.
It described its change of heart as the product of three years of sedulous soul-searching by AHIP’s board of directors, who claimed to have “traveled the country and engaged in conversations about healthcare reform with people from all walks of life.”
As a connoisseur of health insurance lobbying practices, however, I withheld judgment until I could scan the fine print. What I found by reading AHIP’s 16-page policy brochure was that its position hadn’t changed at all. Its version of “reform” comprises the same wish list that the industry has been pushing for decades.
Briefly, the industry wants the government to assume the cost of treating the sickest, and therefore most expensive, Americans. It wants the government to clamp down hard on doctors’ and hospitals’ fees. And it wants permission to offer stripped-down, low-benefit policies freed from pesky state regulations limiting their premiums.
… AHIP Chief Executive Karen Ignagni (told) the Obama summit: “You have our commitment to play, to contribute and to help pass healthcare reform this year.”
Ignagni can afford to be gracious because no specific reform plan is yet on the table. But veterans of the last reform battle warn that the moment concrete proposals appear, the insurance industry will deploy in force to kill anything that threatens its profitability and freedom of movement, such as an expansion of public insurance programs or tighter federal regulations.
Veterans of earlier healthcare battles justly wonder if the industry is merely trying to get in front of the parade, the better to lead it into a dead end.
“It might be that they think reform is inevitable,” says (Jonathan Oberlander, a healthcare reform expert at the University of North Carolina), observing that the industry made very similar noises at the outset of the Clinton effort, before the slaughter started. “I’d say buyer beware. We’ve been there before with them.”
http://www.latimes.com/business/la-fi-hiltzik9-2009mar09,0,4220704.column

And…

In Divide Over Health Care Overhaul, 2 Major Unions Withdraw From a Coalition

By Robert Pear
The New York Times
March 6, 2009
Two labor unions have pulled out of a broad coalition seeking agreement on major changes in the health care system. The action, by the American Federation of State, County and Municipal Employees and the Service Employees International Union, shows the seeds of discord behind the optimistic talk at a White House conference on health care this week.
The most active participants in the coalition include Karen M. Ignagni, president of Americaā€™s Health Insurance Plans, a trade group, and Billy Tauzin, president of the Pharmaceutical Research and Manufacturers of America, which represents drug companies.
http://www.nytimes.com/2009/03/07/us/politics/07health.html?ref=washington

In December, when America’s Health Insurance Plans (AHIP) released their new report indicating that they were fully committed to reform that would cover everyone, I responded in a Quote of the Day (12/4/08) with the following: “You could not possibly describe a proposal that would better serve the interests of the private insurance industry. They would create a standard of underinsurance, require all of us to purchase their products, and pretend to address affordability issues through tax credits.”
Michael Hiltzik has provided for us a great service by actually reading AHIP’s report – carefully. He confirmed that this industry, which has been so destructive to health care reform efforts in the past, hadn’t changed its position at all.
Yet Washington has rolled out the red carpet for Karen Ignagni, AHIP’s president. She appears at almost every forum on reform and is presented with the microphone with some fanfare, even if she was not scheduled in the agenda. The intensity of the efforts to keep the private insurance industry in control of the process might best be exemplified by President Obama’s Health Care Summit. In closing remarks, President Obama handed the microphone off to Karen Ignagni so that she could express for the national audience AHIP’s phony epiphany.
Robert Pear’s report on the split in a major coalition on reform exposes the sharp contrast between AHIP’s sick-sweet public rhetoric on cooperation, and its back-stabbing, cut-throat, behind-the-scenes negotiations on the specifics of reform.
AFSCME and SEIU, the two unions that pulled out of the negotiations, serve as a proxy that represents the only special interest that really matters – the patients. After half a year of intensive negotiations with AHIP, PhRMA, the United States Chamber of Commerce, and others, it was clear that the insurance industry would not compromise its business interests for the benefit of patients. AFSCME and SEIU had to walk out.
The coalition plans to issue recommendations later this month in a report that reflects “the lowest common denominator,” undoubtedly more sick-sweet rhetoric crafted by AHIP.
(Theoretically the consumers were represented by Ronald Pollack of Families USA, but he has lost all credibility because of his years of insistence that we follow a strange-bedfellows strategy – a process which tragically has only perpetuated health reform inertia. Jonathan Oberlander cautions that “we’ve been there before with them,” but Ronald Pollack’s learning curve is flat. )
Michael Hiltzik is to be praised for his leadership. We can only hope that other influential members of the media follow his example. All they need to do is carefully read AHIP’s own report on its change of heart, and see what it really says. (Hint: I couldn’t find a heart anywhere in the report.)
AHIP’s phony epiphany:
http://www.americanhealthsolution.org/assets/Uploads/healthcarereformproposal.pdf