Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs

By Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
Annals of Internal Medicine, Ideas and Opinions, February 21, 2017

Although Republicans’ proposals seem unlikely to achieve President Trump’s triple aim — more coverage, better benefits, and lower costs — single-payer reform could. Such reform would replace the current welter of insurance plans with a single, public plan covering everyone for all medically necessary care — in essence, an expanded and upgraded version of the traditional Medicare program.

Savings Available to Expand and Improve Coverage Under Single-Payer Reform, 2017

$ (billion)

220.0 – Insurance overhead and administration of public programs
149.3 – Hospital administration and billing
75.3 – Physicians’ office administration and billing
503.6 – Total administration

113.2 – Outpatient prescription drugs

616.8 – Total administration plus outpatient prescription drugs

This morning (Feb 21) AIM decided to allow free access to this article:
http://annals.org…

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Single-payer reform is ‘the only way to fulfill the president’s pledge’ on health care: Annals of Internal Medicine commentary; Researchers estimate administrative savings at $504 billion annually

Physicians for a National Health Program, Press Release, February 21, 2017

Proposals floated by Republican leaders won’t achieve President Trump’s campaign promises of more coverage, better benefits, and lower costs, but a single-payer reform would, according to a commentary published today [Tuesday, Feb. 21] in Annals of Internal Medicine, one of the nation’s most prestigious and widely cited medical journals.

Republicans promised to repeal the Affordable Care Act on the first day of the Trump presidency. But the health reform effort has stalled because Republicans in Congress have been unable to come up with a better replacement and fear a backlash against plans that would deprive millions of coverage and raise deductibles.

In today’s Annals commentary, longtime health policy experts Drs. Steffie Woolhandler and David Himmelstein warn that the proposals by Speaker Paul Ryan, R-Wis., and Secretary of HHS Tom Price would slash Medicaid spending for the poor, shift the ACA’s subsidies from the near-poor to wealthier Americans, and replace Medicare with a voucher program, even as they would cut Medicare’s funding and raise the program’s eligibility age.

Woolhandler and Himmelstein review evidence that, in contrast, single-payer reform could provide comprehensive first-dollar coverage to all Americans within the current budgetary envelope because of vast savings on health care bureaucracy and profits. The authors estimate that a streamlined, publicly financed single-payer program would save $504 billion annually on health care paperwork and profits, including $220 billion on insurance overhead, $150 billion in hospital billing and administration and $75 billion doctors’ billing and paperwork. They estimate that an additional $113 billion could be saved each year by hard bargaining with drug companies over prices. A table in the paper summarizes these savings.

The savings would cover the cost of expanding insurance to the 26 million who remain uninsured despite the ACA, as well as “plugging the gaps in existing coverage – abolishing copayments and deductibles, covering such services as dental and long-term care that many policies exclude.”

The lead author of the commentary, Dr. Steffie Woolhandler, is an internist, distinguished professor of public health and health policy at CUNY’s Hunter College, and lecturer in medicine at Harvard Medical School. She said: “We’re wasting hundreds of billions of health care dollars on insurance paperwork and profits. Private insurers take more than 12 cents of every premium dollar for their overhead and profit, as compared to just over 2 cents in Medicare. Meanwhile, 26 million are still uninsured and millions more with coverage can’t afford care. It’s time we make our health care system cater to patients instead of bending over backward to help insurance companies.”

Dr. David Himmelstein, the senior author, is a primary care doctor and, like Woolhander, a distinguished professor at CUNY’s Hunter College and lecturer at Harvard Medical School. He noted: “We urgently need reform that moves forward from the ACA, but the Price and Ryan plans would replace Obamacare with something much worse. Polls show that most Americans – including most people who want the ACA repealed, and even a strong minority of Republicans – want single-payer reform. And doctors are crying out for such reform. The Annals of Internal Medicine is one of the most respected and traditional medical journals. Their willingness to publish a call for single payer signals that it’s a mainstream idea in our profession.”

The Annals of Internal Medicine is the flagship journal of the American College of Physicians (ACP), the nation’s largest medical specialty organization with 148,000 internal medicine physicians (internists), related subspecialists, and medical students. In 2007, the Annals published a lengthy policy article in which the ACP said a single-payer system was one pathway to achieving universal coverage. In early 2008, the journal published a study showing 59 percent of U.S. physicians support “government legislation to establish national health insurance,” a leap of 10 percentage points from five years before.

Today’s commentary is believed to be the first full-length call for single payer, or national health insurance, that the journal has published in its 90-year history.

https://www.pnhp.org…

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Comment:

By Don McCanne, M.D.

There are two reasons why this article from the Annals of Internal Medicine is so important.

As the Democrats proved with ACA and the Republicans are now learning by coming up essentially empty handed in their search for reform that would meet President Trump’s goal of more coverage, better benefits, and lower costs, building on our fragmented multi-payer system cannot possibly meet these goals. This article explains why the Republicans, working with the Democrats, need to turn to the single payer model if they wish to achieve President Trump’s admirable goals (“insurance for everybody… much less expensive and much better,” Washington Post, January 15, 2017). With the reform process currently taking place, this article could not be more timely.

The other reason this is important is that it represents an acknowledgement of the editors of the Annals of Internal Medicine – a publication of the American College of Physicians – that single payer needs to be a prominent part of the national dialogue on reform. In fact, today (Feb 21) the article was featured as a banner headline on the opening page of the journal’s website. Those who read the major medical journals regularly understand what a breakthrough this is.

Today is the day. The time has come to steamroller all of the other vacuous policy proposals on health care reform and mount the flag of health care justice for all in America. Begin by distributing widely the article, “Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs,” (link above).

Actuarial Challenge: Announcement of Round One Results

Robert Wood Johnson Foundation

The Actuarial Challenge, sponsored by the Robert Wood Johnson Foundation (RWJF), brings actuaries together to explore approaches to stabilize the individual health insurance market. The Challenge is administered by Milliman, Inc. and actively promoted by the American Academy of Actuaries and the Society of Actuaries. Support for the Actuarial Challenge is being provided by the Robert Wood Johnson Foundation.

The Challenge kicked off in late September. Almost 70 participants registered, comprising 20 teams. Initial papers were submitted by December 9th. The papers each presented a proposal of various ways in which the individual health insurance market could be reformed. The proposals were not intended to be comprehensive, but to offer ideas on different ways to improve certain aspects of the current system. A panel of five judges (all actuaries) reviewed each paper and ultimately selected five papers to move on to the next round. Round Two involves the selected teams working with Milliman to model their proposals to illustrate the potential financial impact on the individual health insurance market.

Round Two Proposals

Individual Market Redux
Revises rating to allow a wider premium range by age (5-to-1) and limited consideration of an enrollee’s health status in setting premium rates via an automated process (up to an additional 50% of premium). Uses contributions to individual health savings accounts for mid/low income consumers to replace premium and cost sharing subsidies. Revises risk adjustment methodology and restores a reinsurance mitigation program. Uses Medicaid reimbursement levels and increases health cost transparency. Increases penalties for not obtaining health insurance, but allows more benefit plan design flexibility. Reduces mandated benefits based on scientific evidence and use of an independent board. Incentivizes payment reform, integration of healthcare information, implementation of clinical best practices, and value-based care.

Why Not BE HIP?
Establishes a nationwide Basic Essential Health Insurance Plan (BE HIP) covering a core set of services/benefits set by federal regulation. Allows purchase of state regulated standardized supplemental plans (benefit riders) to offset cost sharing (i.e., upgrade to richer benefits). Automatic enrollment and/or penalty of full cost of basic plan if not enrolled. Uses a risk adjustment program and reinsurance to protect insurers. Premium equalization process to account for socioeconomic variations between insurers in a given market. Premium subsidies use similar methodology as the Patient Protection and Affordable Care Act (ACA), although percentages may differ.

The Simplifiers
All residents receive a fully publicly-funded preventive plan and must purchase an insurance plan for non-preventive services. Insurers must offer a standard plan but may offer additional plans subject to state regulations such as actuarial soundness, minimum coverage levels and loss ratios. Premiums will be limited to significantly lower and more affordable levels. A simplified, permanent publicly funded risk mitigation program based on reinsurance formulas will result in reduced premium. Hospital costs will be reduced by payment at Medicare reimbursement levels. Drug costs will be lowered by allowing purchase from qualified international locations. Simplified low-income premium discounts will be available. Penalties equal to the lowest cost insurance plan will apply for non-coverage. Lifetime universal Medical ID cards will be used to monitor enrollment, provide electronic medical records, and act as low-interest credit cards to pay for premiums and out-of-pocket medical expenses. Exchanges will act simply as informational websites.

Panoptic
Uses auto enrollment into newly defined catastrophic plans to enforce participation, and combines the individual and small group markets (with no self-funding allowed in the small group market). Consumer can add benefits through purchase of supplemental benefit riders. Block funds for subsidies provided from federal to state for the state to administer. Elimination of dual regulation to reduce expenses. Allows wider rating for age (5-to-1) and lowers or eliminates minimum medical loss ratios. Continues risk adjustment and restores reinsurance for up to five years. The equivalent of cost-sharing reduction (CSR) funds would be deposited into a consumer’s health savings account (HSA), if eligible. Use reference-based benefit pricing for provider fees. Encourages risk contracting with both upside and downside risk to the provider. Eliminates direct-to-consumer advertising. Eliminates grandfathered and transitional business. Focuses on consumer accountability by providing consumers with improved cost transparency and other resources to help them make educated decisions regarding their healthcare.

King of Carrot Flowers
Creates three pools in the individual market: (1) Over 250% FPL (federal poverty level) with state regulated underwritten market, (2) Under 250% FPL with federally funded underwritten and subsidized market, and (3) Special Needs (High Risk) Pool with a federally-funded, highly-subsidized market for individuals with persistent high costs or uninsurable conditions. Guarantee issue, but requires continuous enrollment. Incentivizes providers to manage care. Encourages tax parity between individual and group market by capping group tax deductions. Allows more tax-favored health savings account contributions.

Milliman will work with these five selected teams to model their proposals in February and March. The five Round Two teams will be able to incorporate the modeling results in their final papers.

Other Proposals

Nine other teams have the opportunity to refine their papers for possible exposure on the Actuarial Challenge website (which is hosted by the American Academy of Actuaries) or as decided by the RWJF at the end of the Challenge.

The Mod Squad
Increases incentives to first-time enrollees, but with significant penalties for not obtaining coverage after first year…

JHU Actuarial Club
Provides enhanced benefits (e.g., gym membership, fitness classes, preventive services, etc.) in insurance coverage to encourage younger individuals to purchase…

Policy Proposal for Healthy Behavior Incentive (“HBI”) Plans
Healthy Behavior Incentive Plans encourage a partnership between the insured, insurer, and health care provider to maintain well-being rather than just reimbursement for expenditures…

Underwriting and Premium Rating using Risk Adjustment
Focuses on improving market stability through increased enrollment of lower cost individuals by revising the rating basis to better align with expected costs…

Team DC
Increases individual market penalties to encourage more enrollment by young and healthy uninsured, and mitigate developing anti-selection spiral in the individual market…

Team ACA Version 2.0
Proposes changes to the subsidy and risk adjustment programs…

Consulting Actuaries for Sustainable Healthcare
Insurance reforms to improve actuarial soundness, and provider price & quality reforms, to address unsustainable underlying healthcare spending…

True Health
Develops actuarial incentive compensation for physicians who are effective at addressing the underlying cause of patient health conditions by using the “food as medicine” concept…

A Social Insurance Solution To Health Care Finance
Proposes to use a social insurance model to replace all current health insurance (across all markets). Covers all legal residents in the program through a payroll tax for funding. Insurance plan would cover preventive care and catastrophic care (exceeding 7.5% of income). Low income families would receive additional assistance similar to Supplemental Nutrition Assistance Program (SNAP) benefits. Routine care would be funded by individuals, but administered through a central fund, billing patients as with a credit card. Administrators must negotiate with providers, but must make all fees available to the public.

http://challenge.actuary.org…

About the Actuarial Challenge:
http://challenge.actuary.org

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Comment:

By Don McCanne, M.D.

In designing a health care financing system that is efficient and effective in ensuring affordable access to health care, it seems that the nation’s actuaries should be up to the task. So it is informative to see what recommendations were elicited when the Robert Wood Johnson Foundation, assisted by Milliman, Inc., issued the Actuarial Challenge, calling for an exploration of approaches to stabilize the individual health insurance market.

Of the proposals submitted, five were selected to move into the second round to work with Milliman to model their proposals to illustrate the potential financial impact on the individual health insurance market. Although some proposals would introduce improvements into the individual insurance market, they all would increase administrative complexity and none would ensure affordable coverage for all participants in the individual market.

Nine other proposals were selected for possible posting on the Actuarial Challenge website, although they do no move into round two. They too are quite disappointing except for one proposal – A Social Insurance Solution To Health Care Finance – that seems to acknowledge the importance of a universal system. Though even that proposal requires cash payments for all routine care except preventive care and catastrophic care charges exceeding 7.5% of income. We have plenty of studies to show that the excessive out-of-pocket costs of this model would leave too many people broke and without the care they need.

Except for the social insurance model, the authors of the proposals limited themselves to solutions for the individual market – a relatively small sector of health care – which is understandable since that was the challenge they were given.

There are two predominant disappointments with the submissions for this challenge. The first is that it should be intuitive that the problems of the individual market cannot be resolved with patches limited to that market. The solutions require a fundamental change of the financing infrastructure of our entire health care system, and the actuaries should acknowledge that in their proposals.

The other disappointment is in the nature of the various recommendations. They seem to lack a sensitivity to the imperative to address issues of health care justice, ensuring an equitable system to bring affordable care to everyone, whether just in the individual market or throughout the entire system – the latter actually being the moral imperative.

The model that would work is already well understood – a single payer national health program, aka an improved Medicare for all. Maybe we can teach the actuaries something, though it would be difficult. I will say that I once was a speaker at a national meeting of actuaries, and I did find that there was some insight amongst the members, but that didn’t translate into policy recommendations.

Scheme Tied to UnitedHealth Overbilled Medicare for Years, Suit Says

By Mary Williams Walsh
The New York Times, February 16, 2017

UnitedHealth Group, one of the nation’s largest health insurers, is accused in a scheme that allowed its subsidiaries and other insurers to improperly overcharge Medicare by “hundreds of millions — and likely billions — of dollars,” according to a lawsuit made public on Thursday at the Justice Department’s request.

The accusations center on Medicare Advantage, a program through which people 65 or older agree to join private health maintenance organizations, or H.M.O.s, whose costs the government reimburses.

The program was created in 2003 after UnitedHealth and other insurers said that managed care could help contain the overall cost of Medicare, which has strained the federal budget by rising faster than the rate of inflation.

Instead of slowing Medicare costs, UnitedHealth may have improperly added excess costs in the billions of dollars over more than a decade, according to the lawsuit, which was unsealed in Federal District Court in Los Angeles.

The newly public accusations were first made in 2011, when a former UnitedHealth executive, Benjamin Poehling, filed a complaint under the False Claims Act, a federal law that allows private citizens to take legal action when they believe a government program has been defrauded.

The Justice Department’s court notice that it was joining the case involving UnitedHeath was filed by Chad Readler, a lawyer who joined the agency’s civil division as part of the Trump administration.

Mr. Poehling was finance director for UnitedHealthcare Medicare and Retirement, a subsidiary that works with the Medicare Advantage program. His complaint describes “a corporate culture that demands and rewards financial success from its employees,” including initiatives to increase a billing practice known as “risk adjustment.”

Mr. Poehling said that he and other employees were given “risk adjustment” targets and their performance was evaluated based on how well they achieved them.

Attached to his complaint was an email message from his division’s chief financial officer, Jeffrey J. Knutson, urging staff members “to really go after the potential risk scoring that you have consistently indicated is out there.”

“Let’s turn on the gas!” Mr. Knutson wrote. “What can we do to make sure we are being reimbursed fairly for the members and risk we take on more than what we are currently doing.

“When we meet next on our steering committee, I’d like to see what it would take to add another $100M to our 2008 revenue from where we are. What would be doable? What resources would you need? What technology would you need?”

Medicare initially paid the H.M.O.s a fixed rate per member, no matter what chronic conditions members had. That made the H.M.O.s avoid signing up unhealthy people, because they required more care, reducing the companies’ profits.

The approach changed in 2003, when the Centers for Medicare and Medicaid Services added a “risk adjustment factor” to its reimbursement schedules for managed care. That made H.M.O.s more willing to sign up unhealthy people, but it also gave them a new incentive: to make people appear sicker than they were. UnitedHealth had a unit that helped its subsidiaries and other insurance companies perform risk adjustment calculations.

Medicare Advantage’s rules require that for patient care to qualify for risk adjustment factors, a patient’s condition must be verified in person on a regular basis by a qualified professional.

But Mr. Poehling said that coding specialists would instead mine patient records, looking for hints of a possible long-term condition. When they found one, they would request the higher payment without going through the required in-person evaluation.

The realization that medical records could be mined for extra money appears to have given rise to a cottage industry of consulting firms offering to screen patient histories and look for indications of long-term health problems that could be used to increase Medicare reimbursements.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Innumerable studies that we’ve written about have shown that the private Medicare Advantage plans have gamed the system at the expense of taxpayers by surreptitiously selectively enrolling healthier, less costly patients, and then, when risk adjustment was introduced to correct for this favorable selection, the plans upcoded to qualify for higher payments by making the patients appear sicker than they really were.

Finally, the legal system has caught up with them. First a whistleblower suit was filed under the False Claims Act, and now, under the Trump administration, the Justice Department has joined in that action.

UnitedHealth contends that they complied with the program rules. Technically, that may be true. The Bush and Obama administrations along with Congress were complicit with efforts to ensure success of the private Medicare Advantage plans as a first step toward eventually privatizing the Medicare program. Insurance innovation has been praised by the privatizers. In this instance, innovation is enhanced by interpreting quite loosely the federal regulations on favorable selection and risk adjustment.

We need a little perspective here. There is no question that the insurers manipulated the system to gain a greater return than the actual health of their enrollees warranted. But private for-profit corporations have a responsibility to their shareholders to do precisely that – maximize returns – and they will every time.

Whether or not there is a technical violation of the regulations, it is the insertion of a rent-seeking intermediary that is the fundamental flaw here. Gaming favorable selection and risk adjustment does not occur in the traditional Medicare program. Gaming the system is expensive because it requires more administrative efforts to pull it off. The private plans have about five times the administrative costs of the traditional Medicare program, and we taxpayers are footing the bill.

The inferiority of the private Medicare plans is not a newly discovered fact. My very first Quote of the Day (before I realized what I was starting) was Congressman Pete Stark’s response to Karen Ignagni of AAHP (precursor to AHIP) who was boasting about Medicare + Choice plans (precursor to Medicare Advantage). She said that the the early results of the plans provided proof that the private sector could provide higher quality at lower costs. (In fact the evidence was the opposite in that Medicare + Choice plans soon began to pull out of the market because they could not deliver on that promise. But the market was saved by converting to Medicare Advantage on terms much more favorable to the insurers.) Pete Stark, not known for mincing words, responded to Ignagni’s praise of private Medicare plans by saying, “She’s full of more s*** than a Christmas goose.”

Obviously the insurers violated what should have been the intent of the laws and regulations. But they will always do that if it accrues to their benefit. The solution is simple: throw them out, fix Medicare, and then expand it to include all of us. An immediate benefit is that it would also end discussion of all of the flawed policies being considered under repeal and replace.

National Health Expenditure Projections, 2016–25: Price Increases, Aging Push Sector To 20 Percent Of Economy

By Sean P. Keehan and colleagues at the CMS Office of the Actuary
Health Affairs, February 15, 2017

Abstract

Under current law, national health expenditures are projected to grow at an average annual rate of 5.6 percent for 2016–25 and represent 19.9 percent of gross domestic product by 2025. For 2016, national health expenditure growth is anticipated to have slowed 1.1 percentage points to 4.8 percent, as a result of slower Medicaid and prescription drug spending growth. For the rest of the projection period, faster projected growth in medical prices is partly offset by slower projected growth in the use and intensity of medical goods and services, relative to that observed in 2014–16 associated with the Affordable Care Act coverage expansions. The insured share of the population is projected to increase from 90.9 percent in 2015 to 91.5 percent by 2025.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Over this decade, with no further changes in our health care financing system, national health expenditures are expected to increase to one-fifth of our GDP. Unfortunately, our current health care financing system remains incapable of containing health care costs.

Perhaps more alarming is that this decade will reduce the numbers of uninsured by only six-tenths of one percent. Eight and one-half percent of the population will remain uninsured in 2025. Without change, our system will continue to fail to ensure that health care is a right for all.

On a personal note, our daughter-in-law is in Taiwan – her native country – where today she had major surgery for cancer. All went well.

Our son just sent a photo of the mission statement that is posted on the wall of her post-op room.

It begins,

Objective: To promote the basic human right of health

If only President Trump and his colleagues in the District of Columbia truly supported that concept and would act upon it…

CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018

Centers for Medicare & Medicaid Services (CMS), Press release, February 15, 2017

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients. This proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements; and announces upcoming changes to the qualified health plan certification timeline.

“Americans participating in the individual health insurance markets deserve as many health insurance options as possible,” said Dr. Patrick Conway, Acting Administrator of the Centers for Medicare & Medicaid Services. “This proposal will take steps to stabilize the Marketplace, provide more flexibility to states and insurers, and give patients access to more coverage options. They will help protect Americans enrolled in the individual and small group health insurance markets while future reforms are being debated.”

The rule proposes a variety of policy and operational changes to stabilize the Marketplace, including:

Special Enrollment Period Pre-Enrollment Verification:  The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the HealthCare.gov platform. This proposed change would help make sure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. This will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.

Guaranteed Availability:  The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This will incentivize patients to avoid coverage lapses.

Determining the Level of Coverage:  The rule proposes to make adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.

Network Adequacy:  The proposed rule takes an important step in reaffirming the traditional role of states to serve their populations. In the review of qualified health plans, CMS proposes to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy. States are best positioned to ensure their residents have access to high quality care networks. Also plans will now be required to include only one0fifth of essential community providers (ECPs) within their networks, removing from the patient the option of receiving care from the other four-fifths of ECPs.

Qualified Health Plan (QHP) Certification Calendar:  In the rule, CMS announces its intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.

Open Enrollment Period:  The rule also proposes to shorten the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, we propose an open enrollment period of November 1, 2017, to December 15, 2017. This proposed change will align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare, and help lower prices for Americans by reducing adverse selection.

https://www.cms.gov…

CMS Proposed Rule:
https://s3.amazonaws.com…

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Comment:

By Don McCanne, M.D.

CMS today released a new proposed rule allegedly designed to “protect patients” by stabilizing the plans offered in the ACA insurance exchanges. A cursory reading of the press release would tend to confirm this intent, but a careful reading of the release and especially the executive summary of the proposed rule will reveal that the rule is designed to improve the market for the insurers with a detrimental impact on potential enrollees of the insurance plans.

Revising the CMS rhetoric to match more accurately the actual impact on patients:

* Special Enrollment Period Pre-Enrollment Verification: Qualifying categories for special enrollment will be reduced, and documentation requirements increased. This will reduce the number of individuals with greater needs that the insurers would be required to accept outside of open enrollment – reducing adverse selection, but it will prevent many individuals who missed open enrollment because of the administrative burden from becoming insured.

* Guaranteed Availability: Insurers may apply premiums paid as a credit against unpaid premiums for the prior year, and then deny coverage because of non-payment for the current year. This will protect insurers from individuals who have difficulty paying the premiums, but at a cost of leaving individuals uninsured in spite of a good faith effort to pay current premiums.

* Determining the Level of Coverage: The insurers will be allowed greater flexibility in the variation of the actuarial values for the metal tiers. This greater flexibility will likely translate into less generous benefits for the beneficiary.

* Network Adequacy: The responsibility for regulatory oversight of network adequacy would be further shifted to the states. Although that would reduce the regulatory burden for the insurers, it would also threaten the adequacy of provider networks in states that have relaxed standards of how many physicians and hospitals would have to be included in the networks. Patients may find access to be impaired.

* Qualified Health Plan (QHP) Certification Calendar: Insurers would be allowed more time to incorporate benefit changes and maximize the number of coverage options available to patients. Allowing insurers more time to manipulate the benefits would allow them to reduce services more likely needed by the beneficiaries while increasing coverage for those services less likely to be used.

* Open Enrollment Period: The open enrollment period will be terminated six weeks earlier. This will protect insurers from many individuals with greater health care needs who often enroll later in the open period. This reduces adverse selection for the insurers but at a cost of leaving uninsured more individuals who have greater needs.

It is not only CMS that is catering to the insurers. Right now Congressional staff members are negotiating with representatives of the insurance industry to help write the replace and repair provisions promised by the politicians. It appears that the legislative proposals will be designed to protect and enhance the market for insurers, though at a cost of reducing the adequacy of coverage for the patients.

Why are we taking such good care of the insurers? We don’t even need them. We need a program that takes good care of patients – all patients. That would be an improved Medicare that includes everyone.