PNHP

Forty percent churn in the ACA exchanges

Forty percent churn in the ACA exchanges

Member Turnover Challenges Public Exchange Markets

By Jose Diaz
Express Scripts, December 20, 2016

In the current discussions about the advantages and disadvantages of the Affordable Care Act (ACA), one important challenge that goes unnoticed is the topic of member turnover. For every 10 Americans who enroll in the public exchanges, only six will re-enroll during annual open enrollment. The remaining 40% fall into member “churn,” meaning that they will enroll in Medicaid, Medicare or employer-sponsored coverage, or perhaps forgo health insurance altogether. This does not include members who stay within the public exchanges but switch to a new plan – another factor that exacerbates the issue of member turnover for health plans.

With some health plans leaving the public exchange market and an incoming administration looking to repeal the ACA, high member turnover is expected to continue into the 2017 enrollment period. Health plans, yet again, potentially face a membership churn of higher than 40%, leading to member care disruption and limiting a health plan’s ability to recoup costs over a patient’s tenure.

http://lab.express-scripts.com…

***

Comment:

By Don McCanne, M.D.

Each year forty percent of enrollees leave the insurance exchanges established by the Affordable Care Act, and this does not even include the numbers who move to different plans within the exchanges during the open enrollment period. This churning is yet one more of a multitude of design flaws resulting from the fact that our legislators decided to build on our highly dysfunctional, fragmented health care financing infrastructure instead of replacing it with one that is far more effective in meeting reform goals.

Churning has serious consequences. Because health plans do not use the same provider networks, enrollees often lose their choices of their health care professionals and sometimes their hospitals. Networks tend to have even fewer choices of specialists, depriving patients of affordable access to specialized care that may be more appropriate for their circumstances. The practice locations of the network providers may be inconvenient, adding transportation issues to the complexity of obtaining care within our system. Drugs that are commonly used by patients with more serious, chronic conditions are frequently placed in tiers with very high coinsurance, often making those drugs unaffordable, not to mention discouraging those patients from enrolling in the plans in the first place.

Another problem is that insurers have less incentive to cover programs that will improve the long term health of their enrollees since a forty percent churn rate means that very few of the current enrollees will be there in even three years.

It is also more difficult for patients to select the best plan since they have to weigh the differences in plan premiums, the size of the deductible, the differences in copayments and coinisurance, the composition of the provider networks, the geographic accessibility of the physicians and hospitals, and perhaps splitting up integrated primary care for the family when some are covered by other plans. Churning is also compounded by “life events” which force a change in coverage outside of the open enrollment period.

This instability was built into the ACA reform model knowing that patients would not fare as well in such a system, but it was designed to ensure that private insurers would have a viable market for their plans. As it turns out, the model does not work well for insurers either, as we see them increase their premiums, further limit their networks, reduce benefits, and many are pulling out of the markets because it is simply not a good deal for them.

What is really curious is that we are not seeing more of a demand to eliminate this dysfunctional market of private plans and replace it with a model that prevents or corrects these many defects – a well designed, single payer national health program – an improved Medicare for all. Do people just not understand the magnitude of the benefits of making the change?

Ethics of CMS experiment on special enrollment

Fact Sheet: Pre-Enrollment Verification for Special Enrollment Periods

Centers for Medicare and Medicaid Service (CMS), December 2016

The Centers for Medicare and Medicaid Services (CMS) is committed to making sure that Health Insurance Marketplace special enrollment periods are available to those who are eligible for them, and equally committed to avoiding any misuse or abuse of special enrollment periods. Over the last year, we have taken a number of steps to balance these commitments. Today, we are announcing a pilot program starting in 2017 that will test the impact of pre-enrollment verification of special enrollment period eligibility through HealthCare.gov on compliance, enrollment, continuity of coverage, the risk pool, and other outcomes.

The Pre-Enrollment Verification Process:

‱ CMS will pilot pre-enrollment verification in all states and all counties served by the HealthCare.gov platform.

‱ All special enrollment period types will be subject to enhanced verification in some form, whether through the pilot or through other enhanced procedures. In particular, applications based on loss of minimum essential coverage will be included in the pilot.

‱ The pilot will begin in June 2017 and CMS anticipates basing future decisions about special enrollment period verification procedures on the results of the pilot.

‱ 50 percent of new applications with relevant special enrollment periods will be part of the pilot and applicants will be required to submit documents before their coverage begins. Applications will be randomly selected for the pilot.

‱ Consumers included in the pilot will still be able to submit their application and select a plan, with a coverage effective date determined by the date of plan selection. However, the Marketplace will “pend” the consumer’s enrollment until the consumer submits documents that establish their eligibility for a special enrollment period.

‱ Consumers will be given 30 days to provide document. They can upload documents into their account on HealthCare.gov or send their documents in the mail. The Marketplace Call Center will be able to provide consumers with information on the status of their documents.

‱ Once a consumer has submitted appropriate documents, the Marketplace will send their enrollment to the issuer. The consumer will be able to pay their premium, and their coverage will begin, generally with the original coverage effective date.

‱ CMS will evaluate the impact of pre-enrollment verification on the risk pool, using data on 2017 claims that will become available in the spring of 2018. CMS will also evaluate the impact of the pilot on enrollment and other metrics on an ongoing basis.

Prior Special Enrollment Period Program Integrity Actions:

Earlier this year, CMS added warnings to HealthCare.gov to discourage the inappropriate use of special enrollment periods. We have also eliminated several special enrollment periods that were no longer needed and tightened the eligibility rules for certain special enrollment periods.

We have begun to learn about how the Special Enrollment Confirmation Process is affecting the Marketplace. Since implementing this process in June, we have seen a 20 percent reduction in the number of consumers enrolling through special enrollment periods, compared to 2015, with every week since the implementation of the confirmation process in 2016 showing lower enrollment than the corresponding week in 2015.

The early results of the Special Enrollment Confirmation Process also suggest that younger consumers are disproportionately likely to fail to complete the verification process. A preliminary snapshot of consumers selected for review showed that 73 percent of applications with a household contact ages 55-64 submitted documents after initial outreach, but only 55 percent of those ages 18-24 did so.

https://www.cms.gov…

***

New Special Enrollment Rules Will Shift Paperwork Burden To Consumers

By Michelle Andrews
Kaiser Health News, December 20, 2016

People who want to sign up for a policy on healthcare.gov after the annual open enrollment period ends Jan. 31 may have to produce a paper trail proving that they qualify for a “special enrollment period” before their coverage can begin, according to details of a pilot program described last week by federal officials. But the verification measures, long sought by insurance companies, may deter the very consumers the marketplace needs to attract: healthy people who may not bother signing up if doing so is a hassle.

The insurance needs of many of the shoppers who use the health marketplaces don’t fit neatly into the three-month annual open enrollment period. For example, nearly 30 million people — workers plus their families — lose employer-sponsored coverage every year outside of open enrollment, researchers at the Urban Institute found. But they estimated that only about 5 percent of those eligible for a special enrollment period signed up for marketplace coverage in 2015.

“We have a lot of experience that eligible consumers faced with [documentation requirements] will drop out of the process,” said (Stan Dorn, a senior fellow at the Urban Institute).

http://khn.org…

***

Comment:

By Don McCanne, M.D.

The policy community has gone out of its way to initiate studies that would enhance the business outcomes of the private insurers, almost regardless of any negative impact on patients. This study on special enrollment periods being initiated by CMS is no exception and may actually violate standards of ethics in research.

For most of the year individuals are prohibited from enrolling in ACA exchange plans in order to prevent individuals from signing up only when they need care and dropping out after receiving it. Obviously this is designed to protect insurers from excessive losses though it does so at a cost of reducing patients’ access to health insurance.

People do experience “life events” that require a change in their insurance. For this reason, special enrollment periods are offered on an individual basis. The insurers claim that many people “abuse” this process and simply wait until they need coverage. To reduce this “abuse,” one-half of special enrollment applicants will be required to submit documentation of the qualifying event or their pending coverage will be rejected. They will be compared with the other half who still have to meet the same requirements but will not have to provide documentation.

We already have a few facts at hand. Many people eligible for the exchange plans never apply for them, and some will remain uninsured. Since rules for the special enrollment periods were tightened earlier this year, the enrollment rate has dropped 20 percent. We know that people eligible for programs will drop out of the process when faced with sometimes burdensome documentation requirements. We do not need another study to show that those facing documentation requirements will enroll at a lower rate. Many of them will remain uninsured, with potential adverse health and financial outcomes.

This study will harm patients. It is a violation of medical and health policy ethics to institute a study in which harm to patients is an expected outcome.

Besides, we do not need this study. Instead, we need a health care financing system in which everyone is enrolled, automatically, for life.

We need a new ethical principle and that is that it is a violation of ethics to establish policies that benefit private insurers at a cost of the physical and financial well-being of patients. But under such a principle the business model of private insurers would fail because they would lose all of their patient-unfriendly innovations that have made the insurers such a business success.

That is why we need to replace them with our own single payer national health program – an improved Medicare for all. Such a public service model would eliminate the perversities of the insurers’ private business model. It’s a matter of ethics.

Remove profit motive from U.S. health care system

By Philip Caper, M.D., and Julie Pease, M.D.
Portland (Maine) Press Herald, Letters, Dec. 20, 2016

Maine AllCare has received many responses to the Dec. 5 Maine Voices column “Trump’s health care policy appears heavy on complexity, light on mercy.” One respondent correctly observed that not every industrialized country has a “single-payer” system.

This observation misses the forest for the trees. Indeed, many countries employ private insurance companies. But they are overwhelmingly nonprofit, heavily regulated public utilities.

Insurance companies process Medicare claims, but most of the time Medicare, not the insurance companies, underwrites the costs of care. There is a reason for this. Having a for-profit health insurance system sets the tone for behavior throughout the system.

The United States is the only country in the world where for-profit insurance and other products and service companies are central to its health care system. It is also the only society where profiteering and wealth extraction from sick, frightened and essentially powerless patients by insurance, pharmaceutical, medical device and other corporate providers of health care products and services (some of them nominally nonprofit) are not only tolerated and permitted, but also often celebrated.

In other countries, the mission of the health care system is facilitating the delivery of health care. Instead, our for-profit system often erects financial and other barriers to care (insurance companies), or prices their products out of reach of most Americans (pharmaceutical, medical device companies and corporate service providers), all in the cause of maximizing profitability.

We offer access to the most profitable services to those able to pay for them, often without regard to their clinical necessity or merit, leading to well-documented over-treatment, sometimes with disastrous results.

In other wealthy countries, health care is a right, not a privilege to be purchased by those with the means to do so, and is considered a public service, not a way to get rich quick. This was the column’s central point, and one worth repeating over and over again.

Philip Caper, M.D., and Julie Pease, M.D., are members of the board of directors of Maine AllCare, www.maineallcare.org.

http://www.pressherald.com…

Frakt: Don’t expect much from price transparency

Price Transparency Is Nice. Just Don’t Expect It to Cut Health Costs.

By Austin Frakt
The New York Times, December 19, 2016

Lack of price transparency in health care has been cited as one of the reasons we spend too much on it. It’s easy to overpay. Health care prices vary tremendously. And there is no established relationship with quality.

Over half of the states have passed laws that either establish websites with health care prices or require plans, doctors and hospitals to disclose them to patients.

But improved transparency isn’t working as well as hoped. Health care pricing apps and websites don’t always help patients spend less.

That’s the conclusion from a study published this year in The Journal of the American Medical Association. It investigated the effect of the Truven Treatment Cost Calculator, a website available to more than 21 million workers and their family members.

The study found that price transparency did not reduce outpatient spending, even among patients with higher deductibles or who faced higher health care costs because of illness.

Study after study has showed the same thing.

If there’s one thing we’ve learned time and again, it’s that there’s no single best way for reducing health care spending. Price transparency may be part of the answer, but it clearly isn’t the entire answer.

http://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

One of the reasons given for using high deductibles in health plans is that they supposedly reduce spending by encouraging patients to shop for lower health care prices. Austin Frakt shows us that the impact of price transparency on spending has been relatively trivial.

What little benefit it has is not worth t ahe cost in the form of causing patients to forgo beneficial health care and in exposing patients to financial hardship because of out-of-pocket spending.

Frakt repeats what many others have said, “there’s no single best way for reducing health care spending.” But that assumes that we keep our current flawed financing infrastructure in place and merely tweak it with a few innovations – primarily from the private insurance industry.

In contrast, a single payer system would reduce administrative waste by a few hundred billion dollars and would set the health cost trajectory on a lower path (“bending the curve”). That is the single best way of controlling health care spending. We should do it.

Media legitimizing GOP’s ‘universal’ health plan that doesn’t exist

By Michael Corcoran
Fairness and Accuracy in Reporting, FAIR.org, Dec. 19, 2016

Members of the GOP leadership were likely jubilant when they read the New York Times (12/15/16) and saw the following headline: “GOP Plans to Repeal Health Law with ‘Universal Access.’”

The Times’ decision to include the words “universal,” “health” and “plan” in the headline was extremely misleading and irresponsible. It gave readers the distinct—and deceptive—impression that Republicans have something resembling a “universal” health plan, and will use it to replace the Affordable Care Act (ACA).

It appears that the same corporate media who misled us into the Affordable Care Act (ACA) (Extra!, 4/10) are now misleading us out of it—and the Times’ reporting  on the GOP’s health care agenda is a particularly egregious example of this.

Republicans haven’t determined what, if any, plan will be enacted to “replace” the ACA after it is repealed. Donald Trump’s brief 7-point campaign proposal (3/16) does not even contain the word “universal.” There are several other conservative proposals from prominent organizations and politicians, including House Speaker Paul Ryan (6/22/16), the Cato Institute (7/4/12), the Heritage Foundation (10/13, 11/22/16) and various legislative efforts vetoed by President Obama (Health Affairs, 1/9/16). There is nothing in any of these plans approaching universality—not as a goal, a result or a guiding principal.

The phrase “universal access” sounds nice, but is a meaningless slogan clearly aimed to confuse the status quo, in which healthcare is a commodity, with everyone actually being able to get the medical treatment they need. “Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,” one anonymous GOP aide told the Times (12/15/16). Of course, the right to “buy coverage” has never been in question—the more than 30 million Americans who currently lack insurance can “choose” to buy coverage today. And when that number swells by another 20 million or so, which the Congressional Budget Office (12/3/15) predicts will happen if the ACA is repealed, they will all be allowed to buy coverage then too. Using this flawed logic, the Times could just as well amplify nonexistent GOP plans to provide “universal access” to housing, childcare and transportation, too.

But not a single critic was quoted in the Times article. The only quotes were from the anonymous Republican aide, Paul Ryan and a federal judge who ruled against some ACA subsidies. Not even a token response from the Democratic leadership was included, let alone an independent policy expert or advocate for true universal care. This omission occurs despite the article being 853 words and 20 paragraphs long—25 column inches, to use old print vernacular, and not a solitary clause devoted to a critical response.

But misleading coverage from the dominant newspaper is hardly surprising on this topic. In addition to spreading nonsensical and unchallenged arguments made by Republicans, major media outlets also routinely rely on current or former industry executives as sources or op-ed contributors.

Politico, for instance, has relied on Heritage Foundation health analyst and former Pfizer executive Ed Haismaier as their go-to expert. Haismaier, who co-authored the Heritage repeal plan, has been cited or mentioned in 22 Politico articles since the passage of the ACA, including six times in November 2016. This included more than 20 minutes in a Politico podcast (11/28/16). This, it would turn out, was just 10 days before he was announced (Politico, 12/7/16) to be part of Trump’s Department of Health and Human Services (DHS). Yet more evidence of how, according to the Wall Street Journal (11/25/16), “Heritage has become a hybrid of an administration-in-waiting for Mr. Trump” and “a policy factory for the new Republican-led Congress.”

The Washington Post (12/7/16) recently published an op-ed from Marilyn Tavenner that advanced the agenda of private insurers whom she represents as CEO of America’s Health Insurance Plans (AHIP). “There is no single ‘silver bullet’ to ensure that people get and stay covered,” Tavenner wrote, advancing the notion that universal health care is virtually impossible. Of course, despite using the word “single,” she ignores a policy that is used in almost every industrialized nation to “ensure that people get and stay” covered: a single-payer system (or a similarly structured public plan).

This is hardly a surprise. The corporate media have long allowed partisan power brokers in Washington, funded heavily by the health industry, to frame the debate in the narrowest of terms, treating the commodification of healthcare as a default setting that can never be changed (Extra! Update, 6/94; FAIR.org, 5/11/11, 1/20/11).

While the industry and Heritage/Trump staffers all get to have their say about what should replace Obamacare, finding an advocate for single-payer in these outlets is far more difficult. For instance, the only mention of Physicians for a National Health Program (PNHP) in Politico is a reference to a failed health reform effort in Vermont (12/20/14). In fact, PNHP compiles a list of major articles that advocate for single-payer, and with the exception of two articles from the Hill (11/16/16, 11/30/16), and one letter to the editor in the Times (11/16/16), since Trump’s stunning victory, the only articles advocating a national health system are from small local papers or independent news sites.

This problem existed during the Obama presidency as well, when the media portrayed the ACA, which was a “market solution” once promoted by Heritage (7/20/90; Forbes, 10/20/11), as the furthest acceptable “left” solution to the healthcare crisis. Single-payer, and even the far less transformative public option, were largely dismissed (FAIR.org, 5/11/11, 1/20/11).

Further, the media published a great deal of hyperbole from partisan liberals about the ACA, falsely portraying the law as a groundbreaking path to universal coverage as a human right (Washington Post, 11/23/13; Politico, 1/1/16). This portrayal further enforced the doctrinal notion that only market solutions were worthy of consideration, thereby undermining legitimate critiques of the ACA and its shortcomings (Truthout, 6/9/16).

The Times story uncritically advancing GOP talking points, just as the party prepares to take a hacksaw to what little safety net already exists in the United States, is a worrisome sign that the media’s flawed coverage of health policy will not be improving anytime soon.  In terms of the coming repeal of the ACA, it seems the public will have “universal access” to the narrow viewpoints of a small group of power brokers in Washington, and little in the way of critical dialogue.

Michael Corcoran is a journalist based in Boston. He has written for the Boston Globe, The Nation, the Christian Science Monitor, Extra!, NACLA Report on the Americas and other publications. Follow him on Twitter: @mcorcoran3.

http://fair.org…

U.S. is on fast track to health care train wreck

By Richard D. Lamm and Vince Markovchick, M.D.
The Denver Post, Dec. 17, 2016

With the impending repeal of Obamacare, America is headed toward a public policy train wreck.

Three seemingly unstoppable trends in America are on collision course: 1) the inventiveness of the promoters of medical technology; 2) health care insurers and providers’ excessive costs; and (3) the health care expectations of the American public.

America is sleeping as this collision draws nearer. As Winston Churchill warned us 70 years ago, democracies always seem to wake up 20 years too late. We believe that even if America awoke tomorrow, it would be too late to avoid many aspects of the coming collision.

But what an opportunity! If we spent what other developed nations spend on health care, we could balance the budget and fund a myriad of other important public needs.

In 2015 we spent $3.2 trillion on health care, which was $10,000 per person in the U.S., ($25,000 for a typical American family). This is 17.5 percent of the U.S. gross domestic product (GDP). To put this in perspective, this is more than twice what most other developed nations spend on health care while insuring all of their residents. This year we are on track to exceed that amount with it being 18 percent of GDP.

Even with the implementation of the Affordable Care Act, we still have 28 million people with no health insurance, and many more are under-insured due to rising co-pays and deductibles. Most families are unaware of the magnitude of spending since their employer pays most of their $17,000 family annual health insurance premiums. Because most do not need to be hospitalized, they are unaware of the extremely high cost of medical care.

Of the $3.2 trillion health spending, 70 percent goes directly to fund the cost of our healthcare. The remaining 30 percent is spent on administration and profit, which is more than twice that of any other nation. In 2014, studies published by the Institute of Medicine, Rand Corporation, and the Center for Medicare/Medicaid Services estimated that out of total health care spending, as much as $900 billion, or about one-third of our total spending, can be attributed to waste, fraud and abuse.

Over the past 25 years, health care inflation has been three to four times the rate of overall inflation. This has forced employers to pay more and more for health insurance, which is one of the major causes of wage stagnation during this period. During this same period employees have had to pay a higher share of their health insurance premiums as well as higher co-pays and deductibles.

This current system is unsustainable, but who will tell the American public? We suggest that the solutions to the real problems of health care are hardly being talked or written about.

The ideal health insurance system is one that: provides free choice of hospitals and doctors; provides insurance coverage to all at all times (i.e., not tied to an employer); is affordable and will remove all risk of medical bankruptcy. This system should have an administrative cost of less than 5 percent and have everyone in the risk pool, thus making premiums affordable. We have such a system now: Medicare covers all persons over 65, those on total disability, and all renal dialysis patients.

Currently 20 percent of the population accounts for 80 percent of our total health care spending, most of this coming from Medicare and Medicaid. Medicare should be improved by allowing the government to negotiate for prescription drug prices, and to pay directly for prescription drugs, thus eliminating the private health insurance prescription drug coverage. This improved Medicare will eliminate the need for costly Medicare supplemental insurance and the large subsides to Medicare Advantage private insurers. It will also dramatically reduce waste, fraud and abuse. It would be funded by an increase in the Medicare tax and by cost savings.

Medicare, with all the fraud and other issues, still operates with about 3 percent to 4 percent overhead. That is much less than the profit and overhead added by U.S. health insurers, which is instead 15 percent to 20 percent. In addition, Obamacare, Veterans Affairs and Medicaid each add another entire layer of expensive bureaucracies. All these, along with the government being unable to bid for drugs purchased under Medicare, add up to unnecessary cost and waste in our system.

These costs would be dramatically reduced if the VA and Medicaid coverage could be put under Medicare instead, and if drugs could be bid for on a competitive basis. Similarly, there would be tremendous cost savings if under Medicare as a single payer, it is authorized to negotiate for hospital care on a more cost-efficient and more comparable basis across the nation.

This is where we need to go to avoid the looming disaster that we face in the future.

Dr. Vince Markovchick is president of the Healthcare for All Colorado Foundation. Richard D. Lamm is former governor of Colorado.

http://www.denverpost.com…

Want to Get Rid of Obamacare? Be Careful What You Wish For

By Robert H. Frank
The New York Times, Economic View, Dec. 16, 2016

With Donald J. Trump’s choice of Tom Price to head the Department of Health and Human Services, it’s clear that Republicans have a good chance of fulfilling their pledge to repeal Obamacare. In January, Republican majorities passed a measure similar to the one now proposed, which President Obama promptly vetoed. But with control of the presidency, they can prevail.

The prospect portends one of the biggest political backlashes in recent history. On Monday, a search of The New York Times archives since 1981 turned up 344 articles containing the phrase “Be careful what you wish for.” As the repeal effort gathers steam, expect that number to grow sharply.

Opponents of the Affordable Care Act have denounced it bitterly for more than six years, so it is not surprising that, despite the program’s successes, public opinion about it would be divided. Even so, a repeal would unleash the awesome power of loss aversion, among the more deeply rooted human tendencies known to behavioral scientists. Their consistent finding: The amount of effort people will expend to resist being stripped of something they already possess is significantly larger than the effort they will devote to acquiring something they don’t already have.

When the possession in question is an insignificant material object, such as a coffee mug, people must be offered roughly twice as much to part with it as they would have been willing to pay to acquire it initially. If the possession relates to health or safety, that ratio becomes drastically larger.

In one experiment, subjects who were asked to imagine having been exposed to a rare fatal disease — there was a 1 in 1,000 chance they had caught it — were willing to pay only $2,000 for the only available dose of the antidote. The same subjects said that, under the same conditions, they would pay roughly 250 times as much to avoid any exposure to the disease if there was no available antidote.

The asymmetry is striking, since in both cases, people would be buying a one-in-a-thousand chance at reducing their likelihood of death. The findings suggest that people would fight hundreds of times harder to retain the health benefits they currently possess than they would to acquire those same benefits if they lacked them.

The scale of the losses at stake for Obamacare is staggering. A study by the Urban Institute estimates that a repeal would result in almost 30 million Americans losing their health coverage. Research on loss aversion thus suggests that the repeal would precipitate a political firestorm of epic proportions.

Republicans have promised to replace Obamacare with something better. Everyone, Mr. Trump included, insists that any plan must require insurers to offer affordable coverage to people with pre-existing health conditions. But that’s not possible financially unless the insured pool includes predominantly healthy people. And because many healthy people won’t buy insurance unless they are required to do so, no developed country relegates its health coverage entirely to unregulated private insurance markets.

The same logic explains why private/government hybrid programs — like Obamacare, and its predecessor in Massachusetts, Romneycare — include an individual mandate. Opponents of the mandate argue that it limits individual freedom, which of course it does. But traffic lights and homicide laws also limit individual freedom; everyone celebrates liberty, but sometimes we must choose among competing freedoms. Failure to include a mandate would eliminate the freedom of citizens to purchase affordable health insurance. In such cases, we must decide which of the competing freedoms is more important.

The third feature of Obamacare (and Romneycare) is that both provide subsidies for low-income people. You simply cannot require people to buy something they cannot afford.

In short, it’s logically impossible to cobble together a private-insurer-based replacement for Obamacare that offers affordable coverage to people with pre-existing conditions without also including an individual mandate and subsidies. That’s why, despite scores of House votes to repeal it, no one has come forward with a coherent proposal to replace it. Hence the dilemma currently facing Republicans.

Some hope they can sidestep it by enacting a “repeal and delay” bill — one that repeals the Affordable Care Act immediately while promising to replace it with an unspecified alternative several years hence. That won’t solve the problem. As numerous health economists have explained, repeal without immediate replacement would result in a speedy collapse of the Obamacare insurance exchanges.

Bad times are looming for health insurance. If Mr. Trump wants to avoid a political buzz saw, what might he do? Unlike Republican congressional leaders, he seems to have no ideological commitment to a largely unregulated, and hence untenable, private health insurance system. And he has already demonstrated that Republican base voters will side with him rather than their congressional leaders.

The upshot is that, unlike President Obama, he may actually have the political power to enact the most sensible system for providing basic universal health coverage: the single-payer approach taken by most other developed countries. Older Americans have been covered under a single-payer system since the 1965 enactment of Medicare, which delivers basic health coverage more cost effectively than private insurance plans can, and which they are of course free to supplement with private insurance.

But having just announced plans to phase out Medicare, Republicans are extremely unlikely to voluntarily embrace a single-payer insurance option for all Americans, and Mr. Trump’s true intentions are, to say the least, unclear.

So buckle up. Whatever happens, there’s a rough ride ahead.

Robert H. Frank is an economics professor at the Johnson Graduate School of Management at Cornell University. Twitter: @econnaturalist.

http://www.nytimes.com…

Look for inspiration from Taiwan’s health care system

By Suzanne Hagan, O.D.
St. Louis Post-Dispatch, Letters, Dec. 16, 2016

I don’t know what was said between Donald Trump and the head of the Taiwanese government, President Tsai Ing-wen. But since this is the season for wishing, my hope is that they discussed how medical care is delivered and paid for in our two countries.

If this was the topic of discussion, Trump was likely shocked to find out that a Harvard health economics professor designed Taiwan’s system, which is based on our Medicare program for senior citizens, with one exception: Taiwan’s program covers everyone. It is paid for by taxes and some government supplements, and has given them a system that covers 99 percent of their population. Since it is based on our traditional Medicare system, which has a very low administrative overhead and no profit motive, it can be administered quite efficiently.

This stands in stark contrast to medical care in the U.S., which, with the exception of traditional Medicare, is administered very inefficiently and expensively by for-profit insurance companies.

If Trump and the Congress want to repeal and replace the so-called Affordable Care Act, they need look no further than our own Medicare system. Expand it to cover everyone, improve it to get rid of co-pays, deductibles and lifetime limits, and the result would be a real gift for all Americans.

Suzanne Hagan resides in Ballwin.

http://www.stltoday.com…

Repeal Obamacare? But people actually like it!

By Jessica Schorr Saxe
The Charlotte (N.C.) Observer, Dec. 15, 2016

Repeal Obamacare? Really?

Repeal of the Affordable Care Act, also known as Obamacare, is a well-known priority of President-elect Trump and Republicans in Congress, bolstered by Trump voters.

But, while “yes or no” polling about the possible repeal of the ACA tells us something about Republicans’ antipathy to the law, more detailed polling questions reveal a complex picture.

A Kaiser Health Tracking poll in November reveals that, as expected, half of Trump voters would like to repeal the entire ACA and 29 percent would like to scale it back (compared with 26 percent of all Americans for repeal, 17 percent for scaling back, and 30 percent in favor of expansion).

However, when respondents were asked about individual provisions of the law, a different picture emerged.

Of Republicans, 82 percent have favorable opinions of allowing young adults to stay on their parents’ plans till age 26, 77 percent approve the free provision of preventive services, and 69 percent like closing the Medicare “doughnut hole” that decreases the cost of drugs. Similarly, 72 percent of Republicans like the health insurance exchanges, 67 percent approve of the insurance subsidies, 67 percent approve of Medicaid expansion, 63 percent approve of preventing denial of insurance for pre-existing conditions, and 63 percent approve of increasing the Medicare payroll tax for upper-income Americans.

The only two provisions that did not get favorable ratings from Republicans are the mandates: only 45 percent supported requiring employers to pay a fine for not providing health insurance and only 21 percent supported fining individuals who don’t get health insurance.

Notably the GOP respondents were in favor of the benefits, but not the law’s mechanisms for funding the benefits.

These findings should give the repealers pause.

In addition, a recent Urban Institute brief on the effect of partially repealing the ACA through the “reconciliation process” should also give the repealers pause. If this process is used, the budget provisions, such as the subsidies and the Medicaid expansion, could be repealed, but other provisions, such as guaranteed coverage to those with pre-existing conditions and essential health benefit coverage, could not.

The report’s authors estimate that the number of uninsured would rise by about 30 million. And, of these, 56 percent would be non-Hispanic whites and 80 percent of the adults would lack college degrees. These demographic sectors are well-known to be Trump supporters and are unlikely to be pleased at finding themselves uninsured.

The displeasure at losing health insurance would be exacerbated by skyrocketing premiums, thanks to the maintenance of the ACA’s benefits, which can’t be eliminated through reconciliation, combined with the cuts in their funding.

So, Republicans, take heed! One of the principal precepts of medical ethics is “First, do not harm.” If you don’t want to alienate your base in the first days of this administration, don’t mess with their health coverage. Instead, work on a bipartisan solution to protect and expand coverage for all.

Jessica Schorr Saxe, M.D., is chair of Health Care Justice – NC. Contact her at HCJusticeNC@gmail.com.

Read more here:
http://www.charlotteobserver.com…

Medicare for All no deal in Hawaii

By Bob Jones
MidWeek (Honolulu, Hawaii), Dec. 14, 2016

Psychiatrist Stephen Kemble, Punahou and Harvard Medical School alumnus, former president of Hawaii Medical Association and assistant professor at the UH medical school, has been advocating unsuccessfully for health care reform for at least 20 years.

He’d prefer single-payer, Medicare-for-all – or all-payer, where we’d retain insurance companies but they all would reimburse the same fees for medical services.

But in Hawaii – no deal. HMSA and the private insurers vote thumbs down and our governors and legislators sympathize with them.

A reform-mandated Hawaii Health Authority was created by the 2009 Legislature. Gov. Linda Lingle vetoed it, lawmakers overrode her, but Lingle refused to appoint members or release funds.

Gov. Neil Abercrombie appointed members in 2011, but Kemble says they started dropping out when the talk turned to dumping private insurance for a single-payer system. Then, he says, “Abercrombie tossed it under the bus.”

It hasn’t revived under Gov. David Ige and state health director Dr. Virginia Pressler.

Kemble says, “A fundamental reality is that competition among health insurance plans does not work to provide cost-effective health care. Competition creates perverse incentives and rewards health plans for avoiding coverage of sicker people, and denial of needed care and services.”

Kemble cites an international OECD study, which concluded that doctor visits and hospital days per capita in the U.S. are among the lowest of all industrialized countries, yet those others provide universal coverage while spending half of what we do per capita for health care.

Our total health care spending last year was $3.2 trillion, an average of $9,990 per person.

Would there be tax consequences under single payer? Yes. As The Washington Post put it: You can’t have all the good parts of universal coverage at affordable prices without mandates and regulations and large doses of subsidies. Anyone who says otherwise is peddling hokum.

In Canada, with health care income-tax-paid except for prescription drugs, dental care, ambulance services and prescription eyeglasses, claims are submitted to a single provincial health care agency for reimbursement, whereas here claims are submitted to the many insurance providers trying to squeeze out a profit or at least avoid a loss.

Colorado put single payer on the ballot last month and 80 percent voted “no” because it required a 10 percent hike in the state income tax.

The prevailing fight against single-payer systems seems to be led by the persistent lobbying of insurance providers listed as nonprofits but actually are Blue Cross and Blue Shield insurance affiliates.

However, the past five Hawaii Medical Association presidents, including the current Bernard Robinson, have favored the single-payer system.

Kemble says, “The private insurance business model aligns economic incentives against providers and recipients of health care, rewarding the denial of care.”

He adds: “It’s the paperwork, showing proof of no recurring illness, and prior authorization for certain drugs and medical services that drives our doctors nuts and out of private practice.”

Bob Jones, a MidWeek columnist, can be reached at BanyanTreeHouse@gmail.com.

http://midweek.com…

Fact-Checking Fact-Checkers on Privatizing Vets’ Health Care

By Suzanne Gordon
The American Prospect, Tapped Blog, Dec. 12, 2016

In the debate over the future of the Veterans Health Administration (VHA), no concept has attracted more controversy than “privatization.” Since wholesale privatization of the VHA is deeply unpopular among veterans and their advocacy organizations, groups like the Koch brothers-funded Concerned Veterans for America (CVA) argue that they do not support “privatization” of the VHA. As the CVA’s “Fixing Veterans Health Care” report, published earlier this year explains, the group just wants to give veterans “the same degree of choice that is available to other Americans,” with the federal government paying the tab.

Last week, The Washington Post entered the fray. Writing for the paper’s “Fact Checker” column, reporter Michelle Ye Hee Lee gave Senator Jon Tester of Montana and Representative Mark Takano of California, both Democrats, three out of a possible four Pinocchios (signifying “significant factual error and/or obvious contradictions”) for suggesting that the CVA and Trump transition team members support VHA privatization. According to Lee, the CVA’s position does not constitute privatization because, the “CVA has not proposed a wholesale transfer of VHA’s services over to the private sector—which is what ‘privatization’ usually describes.” 

Lee’s interpretation flies in the face of volumes of academic and policy research on the privatization movement that went mainstream in the 1980s, notably in the United States and Britain. As the Prospect’s Paul Starr wrote in a 1988 essay, privatization is “any shift of activities or functions from the state to the private sector; any shift of production of goods and services from public to private; including the wholesale of transfer of services from the public to the private sector or what Starr calls “privatization by attrition,” as furnishing costlier private-sector services lead to an underfunding of public ones.

Ironically, as Starr and other critics point out, the privatization movement decreases accountability and oversight of services currently delivered by the private sector by directing attention to poor government performance while deflecting attention from similar flaws in the private sector.

Privatization can erode public support for the belief that government plays a positive role in handling social needs. So CVA officials are keen to promote a counter-narrative: The VHA is broken. The group relies on stories from veterans who have had negative experiences at the VHA to support its claims. (One female veteran recently told me she’d sent in a story about her positive VHA experiences and never received any acknowledgment.) CVA allies like Florida’s Republican Representative Jeff Miller, the House Veterans Affairs Committee chairman and one of President-elect Donald Trump’s candidates for Veteran Affairs secretary, have also attacked agency employees and targeted the unions that represent them.

The CVA claims it wants to preserve the VHA, but its proposal would shift government funds to private-sector providers, depriving VHA doctors and other staff of the ability to maintain a high level of clinical and research expertise by treating the specific service-related problems of a large numbers of patients. Such a move would also drain resources for supporting current workers and recruiting new ones.

Moreover, the CVA promotes private-sector care even though such care would be more expensive. Like many proponents of privatization, the group supports shifting costs to veterans through out-of-pocket payments and mechanisms like interest-bearing health savings accounts. The CVA proposal would also limit eligibility for care in the private sector or in what remains of the VHA, to veterans with service-related conditions—a change that would hit low-income and indigent veterans the hardest.

CVA officials continue to claim that these moves do not constitute privatization. Some staff members like Darin Selnick, who was a member of the VA Commission on Care (and is now a member of Trump’s VA transition team), have supported eliminating the VHA as a care provider. Selnick was a coauthor of the Strawman Document that outlined a vision of a privatized VHA. In his dissent from the Commission’s final report, Selnick also proposed emulating military insurance programs like TRICARE, which would ultimately turn the VHA into just another insurer. So who really deserves the Pinocchios: two Democratic members of Congress, the CVA, or The Washington Post?

Suzanne Gordon is a journalist and co-editor of a Cornell University Press series on health-care work and policy issues. One of her latest books is “Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety.” Her website is www.suzannegordon.com.

http://prospect.org…