PNHP

Having health insurance doesn’t mean mental health care access. Insurance companies make certain of that.

Having health insurance doesn’t mean mental health care access. Insurance companies make certain of that.

Insurers often maintain minimal lists of in-network providers, loaded with meaningless names and numbers.

By J. Wesley Boyd, M.D., Ph.D.
NBC News, July 3, 2019

Most well-insured individuals assume that, if they ever need psychiatric care, they will be able to get it.

They are wrong.

The reason that they are wrong is that insurance companies are in the business of making money, and they make money when the folks they “insure” don’t actually receive care. Although this is the basic business model of insurers, they can’t be too obvious about that fact. And so, insurers seemingly employ subtle ways to make it more difficult than is necessary for folks to receive care when it is needed.

I am a psychiatrist at a public hospital that treats a multiethnic, diverse patient population, and for years I have seen firsthand the way these tactics are utilized by insurers.

One way that insurance companies make it difficult to obtain mental health care is to require clinicians to obtain prior authorizations before patients can be admitted to inpatient psychiatric facilities. Several years ago, my colleagues and I conducted a small study and found that clinicians spent an average of 38 minutes on the phone with insurers obtaining authorization to admit someone to the hospital, even after the clinicians had deemed these individuals dangerous enough to either themselves or someone else that a psychiatric hospitalization was needed. A follow-up study with a larger sample found clinicians spending an hour on the phone for each authorization.

Given that these requests are essentially all approved if the clinician spends the time, insurance companies obviously hope that the sheer time-consuming hassle of having to make the call will dissuade clinicians from seeking to admit folks to psychiatric facilities.

It is important to note that psychiatric care is singled out for this kind of profiteering and scrutiny. By comparison, if a woman is in labor, her obstetrician does not have to spend time on the phone getting permission to admit her. If a child needs an emergency appendectomy, the pediatrician or surgeon is not required to call the parent’s insurance company.

Accessing outpatient psychiatric care isn’t much easier, even if it doesn’t require preauthorization. Insurers often maintain minimal lists of in-network providers, effectively punishing patients who choose to see a provider who is not in their network by making them pay more out-of-pocket (if the insurance company covers any of the cost at all). And the lists of in-network providers that insurers do maintain are often loaded with meaningless names and numbers.

I have to date conducted three different studies looking at availability of three different kinds of outpatient psychiatric services: clinics; adult psychiatrists; and pediatric mental health care. In each of these studies my co-authors and I used the Blue Cross Blue Shield database and posed as patients — or as the parent of a child — and called either clinics or individual providers seeking appointments. Although we were using a list of supposedly in-network providers, we were scarcely able to obtain appointments.

When we called Boston-area clinics, we were able to secure appointments only 12 percent of the time, even when we told them we had BCBS insurance. When we called adult psychiatrists, we could only obtain appointments only 26 percent of the time. For pediatric appointments, our success rate was even lower. Over and over in these studies we would simply not receive calls back, even though we left two separate messages approximately a week apart asking for calls back. Additionally, many phone numbers in the databases provided by BCBS were simply wrong (and included a McDonald’s restaurant and a jewelry store) and many of the practices we called were full and not accepting new patients.

I used to think the inadequacy of the BCBS database of providers was unintentional. But given how chronic the problem is — even in the face of scrutiny by state attorneys general and others — I now feel otherwise. After all, if a person who seeks mental health care is unable to access it, the insurance company pockets money that would otherwise go pay for its customers’ treatment.

Since I first started researching these issues, publishing our results and getting the attention of regulators, insurance companies have begun to send out letters to providers on their in-network lists asking them to update their contact and practice information; I have received a number of these requests myself. One insurer asks providers to go to a website and check all of their practice locations for accuracy and says that if all of the information is accurate, no further action is required. Another insurer sends a letter with the provider’s information printed on it and says that if one doesn’t respond within 45 days the insurer “will assume that your contact and practice information listed below is correct.”

The obvious problem with either such method of supposed due diligence is that the insurance companies have no way of knowing if their letters are delivered to the intended providers and, even if they are, whether they are ever opened. Additionally, there are no penalties for providers who fail to update their information — and I do not know of any physician who has been kicked off an insurance panel because he or she did not verify the accuracy of their information.

In conclusion, given their profit motive, accessing mental health care when it is needed — whether inpatient or outpatient — will remain difficult at best as long as insurers are in the mix. Implementing a not-for-profit single payer health care system would, I wager, improve access to mental health care and allow those who need mental health care to actually receive it.

Dr. J. Wesley Boyd is an associate professor of psychiatry at Harvard Medical School, a faculty member in the school’s Center for Bioethics and a staff psychiatrist at Cambridge Health Alliance.

https://www.nbcnews.com…

New declaration: Health care is an unalienable right

By Ean Bett, M.D.
The Columbus (Ohio) Dispatch, July 3, 2019

Our country’s most indelible document introduces its citizens to their “certain unalienable Rights,” which most Americans would quickly identify when pressed as being “life, liberty, and the pursuit of happiness.” But what many of us likely do not remember, or perhaps never learned, is that our Declaration of Independence identifies those three rights as being “among” our unalienable rights, not encompassing them.

In their wisdom, our country’s founding generation understood that not only were there other unalienable rights, but that as the United States of America matured, others would be defined.

Thankfully, our country is beginning to awaken to the realization that health care is one of those unalienable rights. Perhaps even more importantly, as is pointed out by the American scholar and Harvard professor Danielle Allen, there is more to the introductory sentence of our nation’s founding document that not only supports the groundswell for health care as a right in this country, but also provides a road map by which to achieve it:

“That to secure these rights, governments are instituted among men, deriving their just powers from the consent of the governed, — that whenever any form of government becomes destructive of these ends, it is the right of the people to alter or to abolish it, and to institute new government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their safety and happiness.”

The safety and happiness of most Americans is intimately entwined with their health or the health of their loved ones. The growing discussion around health care reform, with recent bills introduced in both the House and Senate, has brought health care once again to the main stage of American politics. And for good reason.

When the safety and happiness of our people are jeopardized, as they are by surprise out-of-pocket costs, ridiculously high private insurance deductibles, unaffordable pharmaceutical pricing and unexpected illness, all of which lead to crushing medical debt, the people of this country should turn back to our founding generation’s greatest gift — the understanding that “we the people” are able to form and effect our own safety and happiness.

Making health care fair is the essence of a Medicare-for-all universal health care platform; it is in principle an acknowledgement of the unalienable right to health in this country, and by proxy, health care. Each and every American at some point in his or her life will need the assistance provided by a robust, technologically advanced and universal health care system.

Therefore, if we are to truly recognize our rights as American citizens, we must insist that our governance provide a health care infrastructure that is universal, affordable and equitable. These characteristics will help provide a just and fair health care system.

We remain as the lone developed and technologically advanced society in the world without a guaranteed right to health care for all of its inhabitants, exposing a vast majority of Americans to insurmountable debt when illness strikes. Or even while they try to maintain their state of health with chronic diseases. Nearly 70% of Americans now believe that Medicare for all is the solution to our nation’s health care crisis, and is in effect a plan to bring all Americans one step closer to the safety and happiness our forefathers constructed for us.

Life, liberty and the pursuit of happiness have been the roots from which our modern American rights have grown; the passage of time and maturation of our great nation have brought us women’s rights, civil rights and gay rights in the past 100 years.

As Independence Day approaches, we should continue to harken back to our founding generation’s greatest gift and push for the establishment of our health care rights and a universal health care system by supporting local and national leaders who understand our government derives its power from the consent, and wishes, of the governed.

Dr. Ean Bett is a family medicine physician in Columbus.

https://www.dispatch.com…

The Business Case for Universal Health Care

A Portland physician details six goals that Oregon businesses consider critical in health care reform.

By Samuel Metz, M.D.
Oregon Business, July 3, 2019

Before business owners do battle against a dysfunctional health care system, they need common goals. And health care is indeed a big battle — Oregonians spend more on health care ($70 billion) each biennium than the U.S. military did in the Persian Gulf War ($61 billion).

One part of the battle was the Oregon Legislature’s 2013 authorization of a study of health care financing options (published by the RAND Corporation as “Oregon’s Options for Financing Health Care”).

Charged with gaining business input, I spoke to business owners to determine what they sought most from health care reform. Here are six goals they considered critical:

1. “Get me out of health care benefit management.” One owner said, “I know a lot about sheet rock. I don’t know anything about the health care needs of my employees’ children.” Owners want to focus on their business, not on congressional policy or the latest in evidence-based medical practice.

2. “Keep my employees healthy.” Whether an employee is part time or full time, productivity is lost when they call out sick. Healthy employees mean better business.

3. “Remove health care benefits from my labor negotiations.” Health care benefits are the leading cause of labor disputes. U.S. employers tolerate this as normal, but employers in other industrialized nations do not. Only the U.S. holds business owners accountable for choosing an employee’s insurance company, benefits and providers.

4. “Whatever I pay for employee health care, it can’t be more than my competitors.” Employer health care costs should be equitable. The advantage should not fall on business owners who can afford expensive attorneys to best game a wilderness of business laws.

5. “Whatever benefits my employees receive, they can’t be worse than my competitors.” If two competing businesses spend the same amount on employees’ health care, their employees should receive comparable benefits.

6. “Keep my health care costs stable and predictable.” If every year brings changes to employer health care costs, long-term planning becomes impossible.

These six goals should guide health care reform.

Our health care system misses all of them. And however well-intended, the Affordable Care Act (ACA) produced little change. This massive legislation (at 380,000 words, the ACA is shorter than War and Peace but longer than Moby Dick) was not a giant step forward — it was a great leap in place.

Health care still baffles most business owners.

Employers in competing nations are free of these burdens. They pay less for health care (on average, half — some only 40%) yet enjoy broader coverage with better outcomes. Notably, international employers don’t choose insurance companies, benefits or providers on behalf of their employees. Employees choose their own.

Our toxic bond between employers and health care cripples U.S. competitiveness in international markets. Businesses in other nations enjoy lower health care costs and healthier employees. This is not a level playing field.

How do other nations provide better care to more employees at lower cost without the bond between business and health care benefits?

They use universal health care. Each format is different, but (contrary to talk-show hosts) “socialized medicine” is rare and private insurance is common.

How does this approach lower cost? Despite differences, universal-care systems have these characteristics in common:

  • Everyone participates in a health care plan. No exclusions. No opting out.
  • Every policy is comprehensive. This does not mean unlimited; it means treatable conditions receive a treatment.
  • Employees can see any provider. And provider payment reflects value of service, not value of employee insurance policy.

Most importantly, these systems separate benefits from employment.

This combination (in insurance talk, “single-risk pool, single-benefit schedule, single network”) generates enormous administrative efficiency.

How much? Americans pay more than $1 trillion annually in administration ($7 billion in Oregon), about 30% of all health care spending. International competitors pay one quarter of that. Where does this administrative spending go?

In the U.S., insurance administrators evaluate every health care bill to determine if the patient, treatment and physician were all included in benefits. U.S. health insurance administrators process 4 billion claims each year.

These insurance costs do not include the additional costs to physicians attempting to collect from insurance companies (U.S. physicians spend $82,000 annually on insurance billing) or costs to employers paying for additional HR personnel to manage health care benefits.

These costs add up quickly. The simplified billing of universal care with one risk pool, one benefit schedule and one network cuts administrative costs by half. These recovered payments fund expanded benefits for all employees without compromising outcomes.

Universal care suffers a bad rap in the U.S. Advocates promote it to families as a way to protect access, reduce costs and prevent medical bankruptcies. While these claims are correct, advocates neglect to emphasize business benefits.

A universal-care plan addresses the six health care goals that businesses seek: Employers are free from health care benefit management; all employees, full and part time, enjoy health care access; labor negotiations are free from benefit conflicts; all businesses pay equally for health care; all employees share equal benefits; and business health care costs become stable and predictable.

For employers seeking a more functional and competitive health care system, universal health care is the gold standard.

Dr. Samuel Metz is a Portland physician.

https://www.oregonbusiness.com…

People will give up private insurance if they can keep their doctors and hospitals

Majority Backs ‘Medicare for All’ Replacing Private Plans, if Preferred Providers Stay

Reduced support for single-payer overcome by assurance that Americans would not lose their doctor and hospital

By Yusra Murad
Morning Consult, July 2, 2019

Though the dividing line between Democratic presidential candidates on “Medicare for All” concerns the elimination of the private insurance market, new Morning Consult data suggests that anxiety among voters may be misplaced fear about losing their providers rather than their private plans.

According to a Morning Consult/Politico survey conducted after the first Democratic presidential primary debates, support among voters for Medicare for All falls to 46 percent from 53 percent when respondents are told the government-run health system would diminish the role of private insurers — but rises back to 55 percent when voters learn that losing their private plans would still allow them to keep their preferred doctors and hospitals.

“These numbers only affirm what the senator has said many times: people don’t like insurance companies, they like their doctors and their hospitals,” Sanders’ campaign said of the data in an email to Morning Consult. “Despite what the pharmaceutical and insurance industries will tell you, Medicare for All is the only proposal that gives Americans the freedom to control their own futures — change jobs, start a family, start a business — and keep their doctor.”

Several polls have demonstrated that support for Medicare for All plummets when Americans learn the system would replace employer-sponsored coverage with one sweeping plan, forcing single-payer supporters to go on the defensive to alleviate concerns from voters. But as candidates attempt to persuade voters that Medicare for All would not require diminishing the role of private insurers — further adding to confusion among the electorate about what exactly the system would entail — the new data suggests that the consequences of that argument can be mitigated by clarifying that losing private insurers would not affect access to preferred providers.

The June 29-July 1 survey of 1,472 voters found that explanation to be especially effective in quelling skepticism among Democrats and independents. Among independents, 56 percent back a Medicare for All system that nixes the private market but allows people to keep their doctors — a 14-point increase over the share that only hears about the diminished role of private insurers. The poll had a margin of error of 3 percentage points.

Previous Morning Consult polling has also indicated Americans who are against Medicare for All on the grounds that it would reduce the role of insurance companies may be inadvertently conflating their payers and providers. Among adults who said they opposed the system, 62 percent said they are more likely to support the plan if they could keep their doctors and hospitals.

https://morningconsult.com…

National Tracking Poll #190675

Morning Consult + Politico, June 29 – July 1, 2019

Do you support or oppose a ’Medicare for All’ health care system, where all Americans would get their health insurance from the government?

53% – Support
30% – Strongly support
23% – Somewhat support
36% – Oppose
13% – Somewhat oppose
23% – Strongly oppose
11% – Don’t know/No opinion

Do you support or oppose the public health insurance option, a system in which Americans can choose to purchase medical coverage either entirely from a federally-run health program, entirely from private insurers, or a combination of both?

68% – Support
33% – Strongly support
35% – Somewhat support
17% – Oppose
9% – Somewhat oppose
8% – Strongly oppose
16% – Don’t know/No opinion

Do you support or oppose the 2010 Affordable Care Act, sometimes referred to as Obamacare?

48% – Support
24% – Strongly support
24% – Somewhat support
41% – Oppose
11% – Somewhat oppose
30% – Strongly oppose
10% – Don’t know/No opinion

As you may know, during the Democratic presidential primary debates some candidates advocated for installing a ’Medicare for All’ system that would diminish the role of private insurers. Would you support or oppose ’Medicare for All’ if it diminished the role of private insurers?

46% – Support
24% – Strongly support
22% – Somewhat support
35% – Oppose
9% – Somewhat oppose
26% – Strongly oppose
18% – Don’t know/No opinion

As you may know, during the Democratic presidential primary debates some candidates advocated for installing a ’Medicare for All’ that would diminish the role of private insurers but allow people to keep their preferred doctor and hospital. Would you support or oppose ’Medicare for All’ if it diminished the role of private insurers but allowed you to keep your preferred doctor and hospital?

55% – Support
31% – Strongly support
24% – Somewhat support
31% – Oppose
9% – Somewhat oppose
22% – Strongly oppose
14% – Don’t know/No opinion

https://morningconsult.com…

Comment:

By Don McCanne, M.D.

It appears that when individuals polled are told that they would lose their private insurance if a Medicare for All were enacted, they may have conflated that with losing their doctors and hospitals. This poll removed that confusion: “… support among voters for Medicare for All falls to 46 percent from 53 percent when respondents are told the government-run health system would diminish the role of private insurers — but rises back to 55 percent when voters learn that losing their private plans would still allow them to keep their preferred doctors and hospitals.”

So the message that we have to pound home until it becomes a meme: Under Medicare for All you can always keep the same doctors and hospitals, but you would lose that freedom of choice under private insurers and their restricted provider networks.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The manufacturing of biased framing on reform

Parroting the Right

How media and polling company adoption of insurance industry spin warps democracy

National Economic & Social Rights Initiative

Mainstream media and public-opinion polls commonly state that the country has a choice between government and private insurance. This portrayal is inherently biased because it invokes government control while rendering insurance companies invisible, warping democratic discourse and policy-making. As leaked memos and decades of news reports and polls reveal, most journalists and pollsters only adopted this framing after the health insurance industry crafted it and, along with partisan strategists and right-wing think tanks and media, pressed it into common use. To balance their reporting, nonpartisan media, polling, and policy organizations must drop the insurance industry’s biased framing and instead contrast private with public insurance or name the role of both government and insurance companies in the health care system.

In the first section of this report, we trace how this biased framing was strategically constructed by the health insurance industry and mainstreamed by the industry along with other business lobbies, Republican strategists, and right-wing think tanks and media. In the second, we reveal how the mainstream media and public-opinion polls adopted this language following the insurance industry’s messaging campaign. In the third, we offer specific recommendations on how journalists, editors, and public-opinion pollsters can balance their language.

Any use of the word “government” as an adjective therefore invariably activates negative associations in people’s minds. Who would want to eat government food or go on a government-run vacation? It is no surprise that when polling companies ask people if they want “government-run health care” most people say no, even as large majorities of people celebrate Medicare and the Veterans Administration and support Medicare for All.

Recommendations

  1. Pair equivalent subjects: There are two choices: name the actors on both the public and private sides of the health insurance and health care systems or leave them both out. If describing “private” insurance or insurers, stick with “public” insurance and insurers. If naming “government-run insurance plans” or the role of “government,” point to “corporate-run insurance” or “insurance companies” too.
  2. Pair equivalent verbs: Today “government” is often paired with the verbs “run” and “controlled,” which in comparison to softer verbs like “administered,” “financed,” “managed,” “offered,” operated,” “provided,” and “sponsored,” imply a loss of control for the individual. Whichever tone of verb is used should be used on both sides of the comparison.
  3. Pair equivalent sentence structures: Sentence constructions that turn a noun into an adjective, such as “government-run program” or “government plan,” imply more control than a passive sentence construction like “a program run by the government.” Whichever construction is used should be employed on both sides of the comparison.
  4. Be careful about personalizing administrative mechanisms: Using possessives (“your” insurance, “their” plan, etc.) tends to individualize, personalize, and convey a misleadingly sense of ownership of the administrative mechanism through which an individual’s care is presently covered and payed for. When public-opinion polls personalize private insurance as “your insurance” or “your plan,” they introduce a bias that skews their results. If you are specifically asking about an individual’s current coverage, use another phrase (“the insurance plan you are enrolled in,” for example) or if using a possessive, use it for both private and public insurance.

Conclusion

Journalists, editors, and pollsters play a hugely important role in society, and these days especially are under a great deal of strain. Health care is also an enormously complicated economic sector with competing stakeholders, making it difficult to understand and even harder to reform. Yet as this report has shown, well-intentioned professionals in media, polling, policy, and academia who strive to explain how the health care system works now and the choices the country faces moving forward have been manipulated. Through a well-funded, highly orchestrated campaign, the insurance industry and its allies have manipulated the media and public-opinion polls, and thereby warped American democracy. In light of the findings of this report, independent media, polling, and policy organizations have an obligation to drop the insurance industry’s spin. They must present a balanced picture of American health care by comparing private and public insurance (and health care, programs, etc.) and, when naming government as the public insurer, must also name insurance companies.

https://parrotingtheright.org

Comment:

By Don McCanne, M.D.

This report reveals the staggering amount of funds that have been used to introduce simple but politically charged words into our common parlance on health care reform. Particularly, they have shown that using the term “government” or “government-run” in referring to a public health care financing program elicits a negative response when that is paired with “private,” as in private insurance. Reading the full report can provide you with an understanding as to why and how that came about.

The recommendations of the report are quite straightforward. Use “public” instead of “government” when contrasting with “private” insurance. On the other hand, when “government-run” is used, contrast that with “corporate-run” insurance.

However, we need to look at the question that was asked during the debates of the Democratic presidential candidates. “Who here would abolish their private health insurance in favor of a government-run plan?” Here not only was there the bias of pairing “government-run” with “private,” but there was introduced the additional bias of having your private insurance taken away from you. Regardless of how the candidates may have stumbled over their rehearsed responses, the national audience certainly was hit with two negatives on public insurance (“government-run” and “abolish” choice) along with the positive of “private,” giving them a triple reason to reject the government-run model. Even several of the candidates who had cosponsored single payer Medicare for All legislation declined to raise their hands in the affirmative. Not only did this confirm the finding of the report that showed that journalists and pollsters have adopted the framing of the right, whether intentionally or not, but it also shows how effective this campaign has been (read the full report to understand).

The rhetoric discussed here is quite simplistic, but it can certainly have a major impact. The lesson seems to be that we need to become acutely rhetoric-aware so that the truth is always communicated. We can’t let bad policy be driven by subliminal communications of those without a single pristine soul amongst them.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Medicare for All Explained Podcast: Episode 15

Interview with Stephanie Nakajima

July 1, 2019

Stephanie Nakajima, Director of Communications at Healthcare-NOW!, details her personal experiences with the health care systems in Japan and Denmark, and contrasts them with the failures of U.S. health care. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Trump Administration’s proposed public charge immigration rules likely to harm millions of children: JAMA Pediatrics study

The study is the first to examine the impact of the proposed change on children with significant medical needs

Contact:
Leah Zallman, M.D., M.P.H.: (917) 520-8918, lzallman@icommunityhealth.org
Steffie Woolhandler, M.D., M.P.H.: (617) 312-2766, swoolhan@hunter.cuny.edu

A proposal by the Trump administration to deny legal permanent residency status to immigrants who legally use public benefits like food assistance and Medicaid may prevent health care and nutrition aid from reaching millions of children, according to a new study by researchers from Harvard Medical School and the City University of New York at Hunter College that was published online today in JAMA Pediatrics. Currently, enrollment in public food, housing, and health insurance programs are not counted against immigrants applying for permanent residency, also known as “green cards.”

The study is the first to examine the impact of a proposed change in the U.S. Department of Homeland Security’s ‘public charge’ rule on children with significant medical needs. Researchers found that between 0.8 million and 1.9 million such children currently enrolled in public health insurance and the Supplemental Nutrition Assistance Program (food stamps), may lose these benefits, endangering their health. Most of these children are citizens living in households with a non-citizen immigrant parent or other family member. 

Using data from the Medical Expenditure Panel Survey, the authors estimated the number of children who need medical care and who live in families that may disenroll from public benefits. They also estimated the number of children in need of medical care, e.g., kids with asthma, who may lose benefits due to the proposed rule change.

In 2015, 8.3 million children enrolled in Medicaid and the Children’s Health Insurance Program or who received Supplemental Nutrition Assistance Program benefits lived with adults who may disenroll their families from benefits due to fear or confusion caused by the proposed rule, even if the rule does not technically apply to them. Of these children, 5.5 million had medical needs, including 615,842 with asthma; 53,728 with epilepsy; 3,658 with cancer; and 583,700 with disabilities or functional limitations. The article concludes that this policy would threaten the health and wellbeing of millions of children, most of whom are U.S. citizens.

“Most children who lose Medicaid or CHIP due to this proposed rule will become uninsured, and are likely to skip needed care,” said lead author Dr. Leah Zallman, Director of Research at the Institute for Community Health at Cambridge Health Alliance/Harvard Medical School, where she is also an Assistant Professor of Medicine. “For many children, skipping care will lead to long-term medical problems, increased health care costs and school absenteeism. It also means that their parents — many of whom play vital roles as caregivers in nursing homes and home care — will be forced to skip work. The proposed public charge policy will threaten the health of millions of children and have negative repercussions for generations to come.”

The DHS proposal would affect both green card applications and applications for admission to the U. S. It would not apply to other immigrants, including: refugees; asylees; survivors of trafficking, domestic violence, or other serious crimes (T or U visa applicants/holders); VAWA self-petitioners; special immigrant juveniles; and certain people paroled into the U.S. Immigrants who already hold green cards are also exempt from public charge requirements when applying for U.S. citizenship.

The DHS proposal is one of several regulatory policy changes experts expect to dissuade lawfully-present immigrants and their families from using health and social services programs. Other Trump Administration regulatory proposals contributing to this “chilling effect” have been proposed by the U.S. Department of Housing and Urban Development, U.S. Department of Agriculture’s Food and Nutrition Service, U.S. Department of State (which processes visa applications abroad), the Social Security Administration, and a draft proposal by the U.S. Justice Department.

“Punishing children by denying them medical care and nourishment is a gross violation of medical ethics and common decency. But that’s what President Trump’s proposed immigration policy changes will do to millions of innocent children,” said Dr. Steffie Woolhandler, Distinguished Professor of Public Health at the City University of New York at Hunter College and Lecturer in Medicine at Harvard.

“Implications of changing public charge immigration rules on children who need medical care,” Leah Zallman, M.D., M.P.H., Karen Finnegan, P.h.D, David Himmelstein, M.D., Sharon Touw, M.P.H., Steffie Woolhandler, M.D., M.P.H., JAMA Pediatrics, July 2019.

Drs. Woolhandler and Himmelstein are co-founders of Physicians for a National Health Program (PNHP) which advocated single-payer health reform.  PNHP had no role in the funding or designing the research, which was partially funded by a grant to Dr. Zallman from the California Health Care Foundation.

The truth behind the lies about Medicare for all

By James Binder, M.D.
The Cincinnati Enquirer, July 1, 2019

The private insurance industry cannot reasonably defend CEO salaries of $100,000 a day, wasting $ 500 billion dollars a year on excessive bureaucracy, denying care to sick and dying patients, restricting care to small networks, charging $5,000 deductibles, so they go on the attack. They attack single-payer Medicare for all with lies.

These are felony lies because many lives would be saved with an improved single-payer Medicare for all. Allowing the private insurance to restrict and deny care results in tens of thousands of unnecessary deaths a year due to uninsurance (and underinsurance), according to a 2009 Harvard study. I say unnecessary deaths because a single-payer, improved Medicare for all program would cover everyone automatically, provide comprehensive care (dental, mental, eye, long-term care) for life, allow free choice of doctors and hospitals and cost no more than what we are currently paying into the system.

Myths about single-payer Medicare for all are perpetuated daily by politicians and uninformed media. It is crucial to expose these myths, because they are the biggest obstacle to establishing a just, equitable and humane health care system in the U.S.

Myth: It will be expensive and lead to a large increase in taxes.

Single-payer programs in other nations, such as Canada, Taiwan, and Australia show that it is possible to provide high quality for everyone at about one-half the cost, per capita, that the U. S. is spending now. This is accomplished by eliminating the costs of a wasteful, complex private insurance bureaucracy, negotiating fair prices from Big Pharma through the power of a monopsony, and operating hospitals with a global budget, just like fire departments and public schools operate now.

Medicare has an overhead of about 2%; private insurers have a 12-14 % overhead. The only way the enemies of single-payer can argue against this type of basic economic fact is to use scare tactics and cite false information.

There would be a 2% increase in income taxes for individuals if single-payer Medicare for all was adopted. Since there would be no premiums, deductibles, and co pays, the net result for 95% of people would be to pay less for health care, yet get full, comprehensive care. Only the wealthy would pay more than they pay now.

Myth: The government will run it poorly. There will be rationing and long waits to see a doctor.

There are many parts of our government that run well, such as the CDC, NIH, and Social Security system. Many private companies run poorly. I’d rather have a committee of health professional and informed citizens with oversight responsibilities making health care decisions than CEOs responding to investors.

Remember, we are talking about the financing of health care; the delivery of health care will remain private. The clinician-patient relationship would become sacred once again, since the intrusion of private insurers would be removed.

Finally, we already have rationing of health care. We ration on the basis of ability to pay, and that is unjust. No one will be excluded in a single-payer Medicare for all program. We have a large capacity in the U.S. The flow of patients will be readily managed, just as it was when 19 million senior citizens were suddenly covered by Medicare in 1966.

Myth: It will take away patient choices of doctors and hospitals.

The truth is, patients would have free access to any doctor or hospital they wanted with single-payer Medicare for all. The narrow networks are the creation of the private insurance industry. People with employment health insurance often find that their coverage is not so great when they actually need to use it. Deductibles and copays are very high and specialists are frequently out of network. In addition, they forego other employment benefits, like salary increases, in order to have these limited health care benefits.

Myth: It will lower innovation for new treatments and worsen our health care.

Most health research is financed through the National Institutes of Health (NIH). Private companies become involved only after the public has paid for the development and clinical trials for new treatments.

Myth: It would be better to simply add a public option and retain the hundreds of private insurance companies. Examples: Medicare -X and Medicare for America.

This is a con. The private health insurers are trying to avoid elimination. They provide no value to the system or to the patient. They just add costs and complexity. The huge cost savings gained from eliminating the wasteful health insurance bureaucracy would be lost if we simply added a public option. Public option plans have been tried and tried and failed every time. It is time to move to a solution that has been shown to work in countries throughout the world.

Support single-payer improved Medicare for all.

Dr. James Binder is co-founder of the Cincinnati Chapter-Physicians for a National Health Program.

https://www.cincinnati.com…

Sources of inertia in health plan choice

Sources of Inertia in Health Plan Choice in the Individual Health Insurance Market

Presenter: Coleman Drake
Co-Authors: Conor Ryan; Bryan Dowd
8th Conference of the American Society of Health Economists, June 23-26, 2019

Inertia, the tendency to stay enrolled in a health plan from one year to the next, is a well-documented phenomenon in the health insurance literature. Handel and Kolstad (2015), among others, find that consumers are willing to pay hundreds of dollars per month to avoid switching health plans. However, it is less clear why consumers exhibit inertia. In this paper, we separately identify three separate reasons consumers may exhibit inertia: (1) tastes for continuity of care from in-network providers and insurers; (2) hassle costs; and (3) inattention resulting from choice frictions. While the literature has begun to explore these different sources of inertia, it has not incorporated them into a single model. We do so using a novel combination of Abaluck and Adams’s (2018) default-specific consideration model and a random parameters mixed logit model. This model allows us to separately examine inattention in plan choice and plan choice among attentive households. Our data are household-level 2014-2018 enrollment data from Covered California, California’s State-based Health Insurance Marketplace. Covered California is the nation’s largest Marketplace; it covers roughly 1.4 million enrollees each year. Preliminary results suggest that the mean household is willing to pay $77 per month to avoid the hassle of plan switching (conditional on being aware of plan characteristics) and $282 per month for continuity of care. Inattention increases total switching costs by an additional $150 per month. Tastes for continuity do not directly reduce consumer welfare – consumers may derive utility from staying with the same health care provider – but they could limit the benefits of competitive insurance markets. Choice frictions and hassle costs, in addition to having the same anti-competitive effects, reduce welfare through sub-optimal choices. Policymakers seeking to improve consumer welfare should therefore focus on reducing consumers’ choice frictions and hassle costs. Potential remedial policies include increasing outreach from insurance navigators and funding programs to educate consumers about the benefits of active health plan choice.

https://ashecon.confex.com…

Comment:

By Don McCanne, M.D.

Because of its technical nature, this is a report that only an economist can love, but it does have an important lesson for single payer supporters.

Enrollees in health plans tend to be reluctant to change plans at the policy anniversary. This inertia can be due to: “(1) tastes for continuity of care from in-network providers and insurers; (2) hassle costs; and (3) inattention resulting from choice frictions.” Although hassle costs are an important factor, even more important is the reluctance to risk continuity of care that stems from changes in provider networks. This inertia can result in additional insurance costs of $509 per month ($77 + $282 + $150).

Every time that you hear the opponents of single payer Medicare for All say that people want to keep the insurance they have, you can feel confident that they don’t really want to pay an extra $509 per month. It has been said many times, it is not the insurance that they want to keep, it is their choice of health care professionals and institutions that they value highly.

The spin masters keep telling us that polls show that people do not want Medicare for All if it means being deprived of their choice of private insurance. But what if the polls asked this question instead: Would you give up the insurance you now have if the new public plan was guaranteed for life, always providing you with your choice of physicians and hospitals, providing all essential benefits, including drugs, dental, eye, mental health, and long term care, had no out-of-pocket costs whenever accessing health care, and was paid for by taxes that you could afford because they are based on your ability to pay instead of being based on the high costs of care? That was a long question so let me ask that again…

The point is we need to step up our efforts to be sure that the public understands what they actually could have if we were to enact and implement the single payer model of Medicare for All.

Addendum:

By Don McCanne, M.D.

Although the comment states that inertia in changing health plans could result in additional insurance costs of $509 per month, that is unlikely since the amount was derived by adding three different thresholds for what a household would be willing to pay to avoid three specified reasons for inertia. In fact they should not be additive since exceeding any one of the three thresholds would likely overcome the inertia to change plans at the policy anniversary. But that does not change the fact that most people, if they were well informed on the single payer model of reform, would be much more satisfied with a new public plan that was “guaranteed for life, always providing you with your choice of physicians and hospitals, providing all essential benefits, including drugs, dental, eye, mental health, and long term care, had no out-of-pocket costs whenever accessing health care, and was paid for by taxes that you could afford because they are based on your ability to pay instead of being based on the high costs of care.”

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Single-Payer Advocates Seek to Reverse Doctors’ Lobby Opposition

By Alex Ruoff
Bloomberg, June 28, 2019

About a decade ago Phillip Verhoef left the American Medical Association because it wouldn’t back efforts to replace the nation’s private health insurance system with a public one. He was frustrated the group focused more on doctors’ pay than what saw as a flawed health system.

Verhoef, assistant professor of medicine and an intensivist at the University of Chicago, has spent the years since selling the idea of “Medicare for All” to medical students, fellow doctors, elected officials and anyone who will listen. He’s met with medical student organizations to explain how it might work and their role in changing people’s minds about the subject.

Now, he’s hoping to convince the AMA it’s time to join him.

“We won’t get single payer until we get a demand for it from a large body of physicians,” Verhoef said. “I believe we can do that.”

Verhoef, who serves on the Illinois board for Physicians for a National Health Program, an organization of about 20,000 doctors who advocate for a single-payer health system, is part of a collection of groups hoping to persuade the AMA to reverse its long-standing opposition to ending private health insurance in the U.S. They see the medical group as crucial to their goal of getting lawmakers—and the nation—to support Medicare for All because the AMA is the single largest organization representing doctors and has a long-standing presence on Capitol Hill.

“They’re on the wrong side of history and we want them to get on the right side,” Lori Clark, executive director of the Jane Addams Senior Caucus, said.

These groups are organizing rallies outside the AMA’s headquarters in Chicago and held a protest inside the group’s annual meeting early in June demanding the country’s largest doctors lobby support some type of Medicare for All legislation.

Their first demand is that the AMA end its association with the Partnership for American’s Health Care Future, a collection of hospital, doctors and insurance groups that works through a D.C.-based lobbying shop to oppose single-payer legislation.

Doctor groups have fought the growth of public insurance largely because it typically pays much less for their services than private insurance. Medicare can pay half or even a third as much for some common doctors services than private insurers.

Making Progress

The organizations pushing for single payer, including the National Nurses United, People’s Action, Democratic Socialists of America, and others, say they’re seeing progress.

AMA members voted down a measure to support a single-payer health system by 53% to 47% in June, the closest the group has ever come on such a vote.

Pramila Jayapal (D-Wash.), the lead sponsor of the House’s Medicare for All bill (H.R. 1384), celebrated the vote as a sign more doctors favor her idea.

“Doctors and the AMA are influencers in this debate and we want them lining up behind us,” she said. “It’s slower than we want, but it’s happening.”

The AMA vote came from the group’s Medical Student Section. “They’re the most interested in what we have to say,” Verhoef said.

However, the groups are also looking at the AMA’s finances and leadership, searching for ways to influence them, Clark said. She said the group has deep pockets, taking in more than $360 million in 2018, according to tax reports. It makes decisions about its lobbying positions based on votes cast by individual delegates.

AMA Stance

After the failed vote on a single-payer amendment, 83% of AMA delegates at that same meeting signed on to a report from the AMA Council of Medical Service calling for policies to “build upon and fix” the Affordable Care Act.

The AMA has fought most expansions of public health insurance programs, including the creation of Medicare in 1965.

The AMA spent nearly $20 million in 2018 on lobbying efforts, partly to fight the push toward Medicare for All, according to lobbying disclosure forms.

The AMA referred questions to the Partnership. Lauren Crawford Shaver, the executive director of the Partnership, said support for Medicare for All is waning, not growing.

“If you look at the polls, people are getting educated and realizing what it means,” Shaver said.

A June 18 poll from the Kaiser Family Foundation showed that most Americans are unaware of how dramatically a single-payer system would change the U.S. health care industry. About 40% of those Kaiser polled thought private insurance would continue in a single-payer system, something the Jayapal bill would nearly eliminate.

https://news.bloomberglaw.com…

Amanda Snead Cook County Testimony

Chicago-area medical student and SNaHP member Amanda Snead testified at a Cook County Board of Commissioners hearing on June 27, 2019 (testimony begins at 32:27). She was joined by other SNaHP students and members of National Nurses United, all of whom urged the County Board to support a resolution advocating single-payer reform. The resolution passed unanimously.

Garnishing wages for medical debt

Prevalence and Characteristics of Virginia Hospitals Suing Patients and Garnishing Wages for Unpaid Medical Bills

By William E. Bruhn, BS; Lainie Rutkow, JD, PhD, MPH; Peiqi Wang, MD, MPH; Stephen E. Tinker, BS; Christine Fahim, PhD; Heidi N. Overton, MD; Martin A. Makary, MD, MPH
JAMA, June 25, 2019

An estimated 20% of US consumers had medical debt in collections in 2014. Medical debt has been increasing with direct patient billing, rising insurance deductibles, and more out-of-network care being delivered, even at in-network facilities. Bills sent directly to patients may use the undiscounted price of a hospital’s services and can result in financial hardship and avoidance of future medical care. Hospitals need to be paid for care delivered, but some bills are unpaid. Hospitals may negotiate, reduce, or write off payments. Some have begun adopting a range of aggressive strategies for collecting unpaid bills, including suing patients and garnishing their wages or bank savings. We examined garnishment legal actions among Virginia hospitals.

From the Discussion

Thirty-six percent of Virginia hospitals garnished wages in 2017, with a small number of hospitals accounting for most cases. Some characteristics suggest that hospitals with greater financial need (nonprofit, lower annual gross revenue) may be pursuing debt collection to the final stage of garnishment.

https://jamanetwork.com…

The Nonprofit Hospital That Makes Millions, Owns a Collection Agency and Relentlessly Sues the Poor

By Wendi C. Thomas
ProPublica, June 27, 2019

From 2014 through 2018, Methodist Le Bonheur Healthcare filed more than 8,300 lawsuits, according to an MLK50-ProPublica analysis of Shelby County General Sessions Court records.

Other hospitals in Memphis and around the country also sue patients. According to a study published Tuesday in the Journal of the American Medical Association, researchers found more than 20,000 debt lawsuits filed by Virginia hospitals in 2017.

Its handling of poor patients begins with a financial assistance policy that, unlike many of its peers around the country, all but ignores patients with any form of health insurance, no matter their out-of-pocket costs. If they are unable to afford their bills, patients then face what experts say is rare: A licensed collection agency owned by the hospital.

Lawsuits follow. Finally, after the hospital wins a judgment, it repeatedly tries to garnish patients’ wages, which it does in a far higher share of cases than other nonprofit hospitals in Memphis.

Its own employees are no exception. Since 2014, Methodist has sued dozens of its workers for unpaid medical bills, including a hospital housekeeper sued in 2017 for more than $23,000. That year, she told the court, she made $16,000. She’s in a court-ordered payment plan, but in the case of more than 70 other employees, Methodist has garnished the wages it pays them to recoup its medical charges.

Debt That Will Follow Her to the Grave

Judge Betty Thomas Moore called Carrie Barrett’s name again.

Barrett stood, and (hospital attorney Dewun) Settle asked the judge to set her payments at $100 a month.

The judge agreed, denying Barrett’s motion to pay $40 per month.

Months later, Barrett was still bothered by the outcome.

“If you know I can’t pay $40, why you think I can pay $100?” Barrett said.

Between February and May, Barrett managed to make her payments on time, by shorting other bills and relying on payday loans. But this month, she missed her payment due date.

If Methodist doesn’t add any interest to Barrett’s debt and she pays as ordered, she will pay it off in 330 months.

She will be 90 years old.

Not long after her day in court, Barrett filed her 2018 taxes.

She made $13,800.

“It’s in the hands of God now,” she said. “There’s only so much I can do.”

https://www.propublica.org…

When Hospitals Sue For Unpaid Bills, It Can Be ‘Ruinous’ For Patients

By Selena Simmons-Duffin
NPR, June 25, 2019

(Daisha) Smith is unflinching when she talks about Mary Washington and what happened to her after she went to the hospital in 2017.

At the time she didn’t have insurance. She was working part time at Walmart for $11 an hour. She doesn’t want to give the details about why she ended up at the hospital. “I was not myself,” she says. “So I walked myself into Mary Washington to get help — to get myself on track.” She says she was admitted for two weeks.

The hospital sued her for $12,287.68. She had a default judgement against her and did not realize she had been sued until she saw her paycheck mysteriously disappearing.

“When I looked at my pay stub, I’m like, ‘Why do I only have like $600-something in my account?’ ” She noticed “garnish” written on the bottom of her pay stub. “So I called my company and asked them, ‘Who’s garnishing my check?’ ” They told her it was Mary Washington.

With the garnishment, her take-home pay for a month of work comes to about $1,400. Her rent is $1,055. “I literally have no food in my house because they’re garnishing my check,” she says.

https://www.npr.org…

Comment:

By Don McCanne, M.D.

Even with insurance, our current health care financing system does not prevent medical debt for millions of workers and their families. For far too many, essential expenses such as housing, food, and transportation exceeds their incomes. What does adding to this the stresses of wage garnishment and taking out usurious loans from payday lenders do? Who benefits when the hole is only dug deeper?

Under a single payer Medicare for All program that eliminates premiums and cost sharing, no medical debt accrues since the health care system is prepaid through equitable taxes. Taxes should not create the same kind of financial burden since progressive taxes are based on the ability to pay.

Yet most of the Democrats in the presidential debate last evening want to protect the private, employer-sponsored insurance system that covers about half the population. They seem to feign obliviousness to the consequences of such a financing system including potential exposure to wage garnishment and usurious payday loans. Not that the Republicans are any better since they keep promising a better system but than never deliver.

Single payer Medicare for All removes financial barriers to care. It’s that simple.

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