How High Is America’s Health Care Cost Burden?

By Sara R. Collins, Munira Gunja, Michelle M. Doty, Sophie Beutel
The Commonwealth Fund, November 20, 2015

Toplines

*  Health care costs are unaffordable for 25% of privately insured working-age people

*  53% of privately insured people with low incomes have unaffordable health care costs

Abstract

One-quarter of privately insured working-age adults have high health care cost burdens relative to their incomes in 2015, according to the Commonwealth Fund Health Care Affordability Index, a comprehensive measure of consumer health care costs. This figure, which is based on a nationally representative sample of people with private insurance who are mainly covered by employer plans, is statistically unchanged from 2014. When looking specifically at adults with low incomes, more than half have high cost burdens. In addition, when privately insured adults were asked how they rated their affordability, greater shares reported their premiums and deductible costs were difficult or impossible to afford than the Index would suggest. Health plan deductibles and copayments had negative effects on many people’s willingness to get needed health care or fill prescriptions. In addition, many consumers are confused about which services are free to them and which count toward their deductible.

Exhibit 4

How easy or difficult is it for you to afford your deductible?

<200% FPL:  51% very difficult or impossible, or somewhat difficult

200%-399% FPL:  51% very difficult or impossible, or somewhat difficult

>400% FPL:  32% very difficult or impossible, or somewhat difficult

http://www.commonwealthfund.org/publications/issue-briefs/2015/nov/how-high-health-care-burden

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Comment:

By Don McCanne, M.D.

This update using the Commonwealth Fund Health Care Affordability Index demonstrates that health care remains unaffordable for one-fourth of privately insured adults and for over half of privately insured adults with incomes below 200% of the federal poverty level (FPL).

Of the several statistics in this report, one of the more telling is the percentage of people who find that their deductibles are unaffordable. Half of those with incomes below 400% FPL found their deductibles difficult to afford, but, perhaps more astonishingly, one-third of those with incomes above 400% FPL did as well ($46,680 for an individual or $95,400 for a family of four).

This is yet one more report that confirms that “Affordable Care Act” is a misnomer. Single payer please.

UnitedHealth May Quit Obamacare in Blow to Health Law

By Zachary Tracer
BloombergBusiness, November 19, 2015

The biggest U.S. health insurer is considering pulling out of Obamacare as it loses hundreds of millions of dollars on the program, casting a pall over President Barack Obama’s signature domestic policy achievement.

UnitedHealth Group Inc. has scaled back marketing efforts for plans sold to individuals this year and may quit the business entirely in 2017.

While millions of Americans have gained coverage under Obamacare since new government-run marketplaces for the plans opened in late 2013, in UnitedHealth’s case they haven’t been the most profitable. Customers the company has added have tended to use more medical care. UnitedHealth also said today that some people are signing up for coverage, getting care and then dropping their policies.

“We cannot sustain these losses,” Chief Executive Officer Stephen Hemsley told analysts on a conference call. “We can’t really subsidize a marketplace that doesn’t appear at the moment to be sustaining itself.”

UnitedHealth said it expects as much as $500 million in losses on the Obamacare plans in 2016.

While UnitedHealth has been slower than some of its rivals to sell Obamacare policies, the announcement may indicate that other insurers are struggling, said Sheryl Skolnick, an analyst at Mizuho Securities.

“If one of the largest and presumably, by reputation and experience, the most sophisticated of the health plans out there can’t make money on the exchanges, then one has to question whether the exchange as an institution is a viable enterprise,” Skolnick said.

Anthem and Aetna have said they’ll be patient as the exchange business develops, and that they expect it to eventually become profitable.

“It’s way too early to call it quits on the ACA and on the exchanges,” Aetna CEO Mark Bertolini said on an Oct. 29 conference call. “We view it still as a big opportunity for the company.”

Still, Bertolini said the market “remains challenging,” and Aetna reduced the number of states where it sells coverage to 15 for next year from 17.

Anthem said in late October that the company may need to wait until 2017 or 2018 for the individual exchange business to improve.

http://www.bloomberg.com/news/articles/2015-11-19/unitedhealth-may-pull-out-of-obamacare-marketplace-stock-slides

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Comment:

By Don McCanne, M.D.

The Affordable Care Act was designed by the nation’s largest insurers to serve the interests of the nation’s largest insurers. It was almost as if the patients were not much more than a necessary nuisance, required only because an insurance market requires patients to purchase their plans. How is it working out for the insurers?

The largest insurer in the nation – UnitedHealth  – has scaled back their marketing of ACA exchange plans and is considering totally exiting the exchanges by the end of next year. Two of the other largest insurers – Anthem and Aetna – have yet to profit from the exchanges and are waiting to see if the exchange business will improve before they decide about the future.

It is no secret what happened. The insurers had to agree to crucial reforms in the insurance market. They had to accept higher cost individuals with preexisting disorders; they had to cover ten categories of health care benefits; they had to limit excess administrative costs and profits by agreeing to minimum medical loss ratios, and they had to submit higher premium increases to insurance regulators for greater public scrutiny.

In other words, they had to agree to market basic insurance products to anyone who was eligible for them. With these requirements, premiums would be unaffordable for all but the wealthy. Thus ACA was crafted to keep premiums down by making lower actuarial value plans the standard – requiring greater cost sharing by patients, though with government subsidies for lower-income individuals. ACA also was crafted to provide government subsidies for the premiums to assist lower-income individuals with the purchase of these plans. That still was not enough so they used the leverage of narrow provider networks to contract for cheaper medical services, and they increased the deductibles, shifting more of their costs to patients.

Guess what. It isn’t working – for the insurers or the patients. Congress dumped on us an administratively complex system that has made it almost impossible for the insurers to offer a product with affordable premiums that still meets the basic plan elements required by the legislation. For the patients, the premiums and deductibles are not affordable for the average family, and they have had to give up their health care choices because of the narrow networks selected by the insurers.

Congress and the Obama administration did this one for the insurers. Yet the insurers are beginning to back out now. That’s just fine because it will allow us to replace them with a financing plan that is designed for patients instead. A well designed single payer national health program would make health care affordable for everyone while returning to them their choices in health care delivery.

New Health Plans Offer Discounts For Diabetes Care

By Michelle Andrews
Kaiser Health News, November 17, 2015

Talk about targeted. Consumers scrolling through the health plan options on the insurance marketplaces in a few states this fall may come upon plans whose name — Leap Diabetes Plans — leaves no doubt about who should apply.

Offered by Aetna in four regions next year, the gold-level plans are tailored for the needs of people with diabetes. They feature $10 copays for the specialists diabetics need such as endocrinologists, ophthalmologists and podiatrists, and offer free blood sugar test strips, glucose monitors and other diabetic supplies. A care management program with online tools and coaching helps people manage their condition day-to-day. The plans also offer financial incentives, including a $50 gift card for getting an A1c blood test twice a year to measure blood sugar levels and a $25 card for hooking up a glucometer or biometric tracker to the Aetna site.

It’s unclear whether the diabetes plans are a good buy for people with diabetes. The cut rates for specialist visits only apply if they’re related to diabetes care, not for other conditions someone may have. Meanwhile, coverage for medications, which may cost consumers hundreds of dollars every month, is no different in the diabetes plans than in other gold plans.

This isn’t the first time that an insurer has designed a health plan for people with diabetes, but it appears to be the first on the health insurance marketplaces. They are part of a new line of plans Aetna is introducing, called leap plans, aimed at helping Aetna build its retail business. Aetna says they are simpler to use and will have more personal customer service.

http://khn.org/news/new-health-plans-offer-discounts-for-diabetes-care/

Aetna Innovation Health Leap Gold Diabetes Plan

http://innovation-health.s3.amazonaws.com/SBC_2016_VA_GoldDiabetes_ON.pdf

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Comment:

By Don McCanne, M.D.

Private insurers use innovation to maintain a competitive marketplace presence for their insurance products. Health care costs are so high that premiums become unaffordable without the introduction of innovations. Two ubiquitous examples are lower-cost narrow networks of providers, and shifting health care costs to patients through higher deductibles. Now Aetna is introducing an innovative plan targeted to one specific disorder – diabetes. How does this work, and who benefits?

This is a somewhat bizarre innovation since insurers traditionally have used various devious strategies to try to avoid selling their products to individuals anticipated to have higher health care costs. Diabetics certainly fall into this category. So what are they doing here that makes this a rational strategy?

It should be noted that the Aetna Innovation Health Leap Gold Diabetes Plan is a gold plan with an actuarial value of 80 percent (the individual pays 20 percent of the average costs of covered services). Lower-income individuals who would be eligible for subsidies for their covered out-of-pocket expenses must buy a silver plan (70 percent actuarial value) to qualify for those subsidies. So this plan is designed for individuals with higher incomes that would disqualify them for the out-of-pocket subsidies – individuals who would be more capable of paying higher premiums and greater out-of-pocket expenses anyway – the carriage trade.

So how can Aetna keep these plans affordable if they are deliberately marketing them to individuals with diabetes? First of all, they do increase the premium paid for the plan since patients would think that it is worth the difference because they are getting a plan that is customized to take better care of their diabetes. The insurers also use other innovations to keep spending under control. For example, although they include in their networks enough providers to take care of diabetes, they can keep the rest of the network as narrow as possible, thereby impairing access to care beyond their diabetes.

So how well is diabetes covered under this plan? In the example given – routine maintenance of well-controlled type 2 diabetes – for $5,400 of allowed costs, the plan pays $2,720 and the patient pays $2,680 – almost half. However, Aetna includes the disclaimer that “Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.”

For individuals with significant disorders such as diabetes, out-of-network care is common and may be unavoidable. The deductible for an individual for out-of-network care in this Aetna plan is $20,000 ($40,000 for a family) and only allowed charges apply. The patient is also responsible for a coinsurance of 50% after the out-of-network deductible is met. Thus if the patient is charged $50,000 for out-of-network care, and the charge allowed by the insurer is $20,000, the patient must pay the entire $50,000 charge, and Aetna pays nothing.

Suppose the out-of-network charges are $50,000 but the insurer’s allowed charges are $30,000. In this case the patient pays the $20,000 deductible, $5,000 of the remaining allowed charges, and the $20,000 balance that was not allowed – a total of $45,000. The insurer pays $5,000 or a mere 10% of the bill.

Other features of the plan are of concern. The plan uses tiering of pharmacy benefits, and the patient could end up with very large out-of-pocket costs for their essential diabetes medications. Weight loss programs and bariatric surgery are specifically excluded even though many diabetics could benefit from these services. Several out-of-network services require precertification or the patient pays not only the $20,000 deductible and the 50% coinsurance, but would also have a penalty of a 50% reduction in the meager allowed benefits, up to $400. And so on.

So who gains? A diabetic patient might be better off if the only care received is for diabetes,  but diabetics have a high incidence of serious concomitant disorders. Under this plan care for conditions other than diabetes could be restricted by narrower networks, higher cost sharing, and other restrictions of the plan. Plus the premium paid is higher. The insurer can benefit by providing a product that might have market appeal for a given sector (diabetics), resulting in greater enrollment. However, the insurer does bear some risk. The additional premium and the restrictions and cost sharing in the plan may not be enough to offset the additional costs of care that diabetics require, not to mention that an increase in insurer profits might not be realized.

Perhaps the most fundamental flaw with this proposal is that one condition is selected for better coverage whereas all other conditions have offsetting direct or indirect reductions in coverage, which goes one step further in disrupting the risk pooling that is essential in well functioning insurance programs. It is moving away from the direction in which we should be headed.

Just think of how single payer would eliminate these issues without having to play the games devised by the private insurers for their own benefit.

The Future of Public Health

By Thomas R. Frieden, M.D., M.P.H.
The New England Journal of Medicine, October 29, 2015

The Role of Government

A responsive government can maintain that people are responsible for their own health while also taking public health action that changes default choices to make it easier for people to stay healthy. Key public health actions do one of three things, all of which are now well accepted but were initially controversial. The first is to promote free and open information — such as truth-in-advertising laws and nutrition-facts panels. The second is to protect people from harm caused by others — for example, by detecting adulterated food, prohibiting alcohol-impaired driving, and protecting workers and the public from second-hand smoke. Legal and policy changes in this area often both reflect and accelerate changes in social norms. The third is to implement societal interventions when individuals cannot efficiently or effectively protect their own health through such policies as vaccination mandates, clean air regulations, water fluoridation, micronutrient fortification of food, and elimination of lead in paint and gasoline — interventions that have all greatly improved the health of Americans.

The Future

In the future, clinical medicine could see costs increase without substantial improvement in health outcomes. Alternatively, new delivery models and technology could substantially increase healthy life expectancy. The public health field, for its part, may not be able to keep pace with changing risks and increased opposition to core public health actions that promote healthy living — or it could expand its past successes to further reduce tobacco and alcohol use, control persistent infectious diseases, increase physical activity, improve nutrition, and reduce harms from injuries and other environmental risks.

By working more closely together, clinical medicine and public health can help each other improve health maximally — and emphasize society’s responsibility to promote both healthy environments and consistent, high-quality care. Public health organizations can publicize information on health outcomes and risks that clarifies the need for, or achievement of, substantial progress. Clinical experts can identify and validate preventable harms and effective interventions to protect patients.

The involvement of many parts of society, including government agencies, health organizations, nongovernmental organizations, clinicians, the private sector, and communities, is increasingly important for success. Everyone benefits when people are healthier.

Accountability for outcomes is essential — public health’s obsession with denominators can reduce the number of people missed by interventions that improve health and save lives. Working together, clinical medicine and public health can ensure that people live active and productive lives far longer than was ever thought possible.

(Thomas R. Frieden, MD, MPH, is the Director of the Centers for Disease Control and Prevention [CDC])

http://www.nejm.org/doi/full/10.1056/NEJMsa1511248

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Public Health’s Falling Share of US Health Spending

By David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH
American Journal of Public Health, November 12, 2015 (online ahead of print)

Abstract

We examined trends in US public health expenditures by analyzing historical and projected National Health Expenditure Accounts data. Per-capita public health spending (inflation-adjusted) rose from $39 in 1960 to $281 in 2008, and has fallen by 9.3% since then. Public health’s share of total health expenditures rose from 1.36% in 1960 to 3.18% in 2002, then fell to 2.65% in 2014; it is projected to fall to 2.40% in 2023. Public health spending has declined, potentially undermining prevention and weakening responses to health inequalities and new health threats.

Discussion

An analysis of the economic and political forces driving public health funding is beyond the scope of this brief report, but it is clear that public health funding has languished over the past decade. It is projected to continue falling as a share of overall health spending, although, like any projection, this should be interpreted cautiously.

The Affordable Care Act originally promised a $15-billion boost in public health funding. However, a 2012 law cut funding for the Affordable Care Act’s Prevention and Public Health Fund by $6.25 billion. Sequestration, which cut federal spending across the board beginning in 2013, reduced it even further; fiscal year 2015 appropriations are less than half the $2 billion originally budgeted.

Meanwhile, many state and local governments — the main source of public health dollars — have faced fiscal challenges. Whereas state medical care spending has continued to increase, public health spending has not.

There is no absolute measure of the optimal level of public health spending. However, an Institute of Medicine panel recently concluded that public health agencies are markedly underfunded, and that US health spending is out of balance, with spending for clinical care disproportionately high compared with spending for “population-based activities that more efficiently and effectively improve the nation’s health.” The current trajectory of health spending seems unlikely to close the funding gap identified by the Institute of Medicine panel.

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302908

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Comment:

By Don McCanne, M.D.

A century ago life expectancy was 54. Today it is 79. Public health has played a much greater role in realizing this gain than has clinical medicine. Although most health funds are being directed to clinical services, public health services will need support to continue and to expand the gains that have been more important to society as a whole.

Government must remain responsive to the nation’s health needs. Recognizing that, Congress included in the Affordable Care Act a $15 billion boost in public health funding. However, that was reduced in 2012 legislation by $6.25 billion, and then further reduced by sequestration. Public health appropriations for 2015 are less than half of the $2 billion budgeted.

How can these reductions be justified? The need for austerity? Not based on the billions of dollars being fed into the coffers of the wealthiest amongst us. Less need for government public health services? Not unless we are willing to accept a surge in preventable disease epidemics and injuries from public hazards. Can we justify these reductions based on the ideological principle that the responsibility for health should be shifted from the government to the individual? Even ideologues can suffer or die from uncontrolled epidemics, from uncorrected public hazards, or because of a lack of beneficial interventions that were not implemented.

In addition to these important public health actions, we would also benefit by adopting a government-run health care financing system – a single payer national health program. The failure to act makes our Congress one of the greatest public health hazards that we face. Electing the right people to Congress may be the most important single measure that we could take to maintain and improve the health of our nation.

Many Say High Deductibles Make Their Health Law Insurance All but Useless

By Robert Pear
The New York Times, November 14, 2015

Obama administration officials, urging people to sign up for health insurance under the Affordable Care Act, have trumpeted the low premiums available on the law’s new marketplaces.

But for many consumers, the sticker shock is coming not on the front end, when they purchase the plans, but on the back end when they get sick: sky-high deductibles that are leaving some newly insured feeling nearly as vulnerable as they were before they had coverage.

In many states, more than half the plans offered for sale through HealthCare.gov, the federal online marketplace, have a deductible of $3,000 or more, a New York Times review has found. Those deductibles are causing concern among Democrats — and some Republican detractors of the health law, who once pushed high-deductible health plans in the belief that consumers would be more cost-conscious if they had more of a financial stake or skin in the game.

In Miami, the median deductible, according to HealthCare.gov, is $5,000. (Half of the plans are above the median, and half below it.) In Jackson, Miss., the comparable figure is $5,500. In Chicago, the median deductible is $3,400. In Phoenix, it is $4,000; in Houston and Des Moines, $3,000.

In employer-sponsored health plans, deductibles have also been rising as companies shift costs to workers. Still, the average annual deductible in employer plans, $1,320 for individual coverage according to the Kaiser Family Foundation, is considerably less than the deductibles in many marketplace plans.

Sara Rosenbaum, a professor of health law and policy at George Washington University who supports the health law, said the rising deductibles were part of a trend that she described as the “degradation of health insurance.”

Insurers, she said, “designed plans with a hefty use of deductibles and cost-sharing in order to hold down premiums” for low- and moderate-income consumers shopping in the public marketplaces.

http://www.nytimes.com/2015/11/15/us/politics/many-say-high-deductibles-make-their-health-law-insurance-all-but-useless.html

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Comment:

By Don McCanne, M.D.

The deductibles are out of control. The anecdotes in the full article (link above) demonstrate that many people find that their insurance is “all but useless” simply because they cannot afford to pay the deductibles. Anecdotes do not constitute a scientifically valid study, but they certainly do tell us what is happening to individuals out in the real world.

Insurers needed to keep premiums affordable in order to maintain a viable market of private plans. They do that by shifting costs to patients through ever higher deductibles. This was inevitable through the reform model selected for the misnamed Patent Protection and Affordable Care Act. Because of the large deductibles, actual health care is not affordable for individuals with modest incomes and thus patients do not have the protection that they need.

The three trillion dollars that we are already spending on health care is enough to provide all essential health care services for everyone. With a properly designed financing system there is no need to erect financial barriers to care since cost containment can be achieved through patient-friendly policies such as those of a single payer national health program.

Without proper reform, “degradation of health insurance” will progress. People will face greater financial hardship because of medical bills. People will suffer more because of forgone health care. People will die.

This isn’t right. We need an improved Medicare that includes everyone.

Medicaid coverage improves access to health care and chronic disease control: American Journal of Public Health study

Physicians for a National Health Program, November 12, 2015

Low-income Americans with Medicaid insurance have more awareness and better treatment of chronic diseases, such as high blood pressure, than their uninsured counterparts, a group of Harvard researchers said today. People with Medicaid are also five times more likely to see a doctor than those with no health insurance.

These are among the chief findings of a new study by a team of researchers led by Dr. Andrea Christopher, a fellow at Harvard Medical School, published today in the American Journal of Public Health. The study is based on data gathered from 4,460 poor Americans in national surveys conducted by the Centers for Disease Control and Prevention.

https://www.pnhp.org/news/2015/november/medicaid-coverage-improves-access-to-health-care-and-chronic-disease-control-amer

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Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured

By Andrea S. Christopher, MD, Danny McCormick, MD, MPH, Steffie Woolhandler, MD, MPH, David U. Himmelstein, MD, David H. Bor, MD, and Andrew P. Wilper, MD, MPH
American Journal of Public Health, November 12, 2015 (Online ahead of print)

Abstract

Objectives. We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care.

Methods. Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485).

Results. Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia.

Conclusions. Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.

From the Introduction

The Affordable Care Act (ACA; Pub L No. 111—148) expanded Medicaid insurance for people with low incomes (<138% of the federal poverty level [FPL]) in 31 states. However, whether Medicaid coverage improves health outcomes remains controversial. Several studies described differences in chronic disease prevalence and control between uninsured persons and those with Medicaid, but have not been designed or powered to explore whether Medicaid coverage might cause these differences.

Recently, the Oregon Health Insurance Experiment (OHIE), a randomized, controlled trial, found that Medicaid coverage increased health care use, improved patients’ financial security and self-reported health, lowered depression rates, and raised diabetes diagnosis rates. However, the OHIE did not find improvements in other important health outcomes such as control of other chronic diseases, fueling Medicaid’s critics.

The rigorous design of the OHIE provides strong evidence on the impact of Medicaid in the Portland, Oregon, metropolitan area where it was conducted. However, Portland’s relatively robust medical safety net for the uninsured may have attenuated the potential for health improvements from Medicaid expansion compared with other locales, or the United States as a whole.

From the Discussion

Our findings suggest that, nationally, Medicaid was associated with improved access to outpatient medical care, as well as awareness and control of important chronic conditions. Medicaid recipients visited health care providers much more frequently than comparable uninsured individuals, and were more likely to be aware of their hypertension and overweight. In addition, Medicaid recipients were more likely to have their blood pressure controlled, a clinical goal known to reduce all-cause mortality by as much as 17%. However, we found no differences in the diagnosis or control of diabetes, and only nonsignificant differences among those with hypercholesterolemia. We theorize that the lack of findings for diabetes may be because control requires more significant diet and lifestyle changes compared with other chronic conditions, and these changes may not be easily remedied through access to medical care.

Our findings differ from those in the OHIE. First, in the Oregon study, outpatient visits among uninsured individuals averaged 5.5 per year, whereas we found that more than 60% of uninsured individuals nationally had zero or 1 outpatient visit per year. Second, whereas the OHIE observed a 50% increase in outpatient visits among the Medicaid population, we found substantially larger national effects (a 5.0-fold increased odds). Despite methodological differences that preclude exact comparisons with the OHIE data (the NHANES coded outpatient visits into categories), our results suggest that outpatient health care use by the uninsured nationally is probably lower than that of the OHIE’s control population and the boost from Medicaid somewhat bigger. Third, the OHIE found significantly increased detection of diabetes but not hypertension or obesity, and did not show improvement in any physical health measures.

For states that expanded Medicaid under the ACA, enrollment began only 1 year ago; several states are considering expanding Medicaid in the future. Thus, it will likely take several years before nationally representative data become available on the ACA’s impacts. Our data on the association of Medicaid coverage with both outpatient visit frequency and chronic disease care in the pre-ACA era help inform projections of the impact of the largest expansion of Medicaid since its founding.

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302925

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Comment:

By Don McCanne, M.D.

Opponents of the Affordable Care Act have been using the Oregon Health Insurance Experiment (OHIE) to supposedly show that Medicaid does not improve health outcomes even though the study was not powered to demonstrate such. Thus this new study is important because it does show that Medicaid improves access, improves awareness of important chronic conditions, and improves control of hypertension. The OHIE trial did show that “Medicaid coverage increased health care use, improved patients’ financial security and self-reported health, lowered depression rates, and raised diabetes diagnosis rates.”

Clearly Medicaid is of benefit. However, as a chronically underfunded welfare program, Medicaid does have significant deficiencies. Last week, a UC Davis study reported that cancer care is worse for Medicaid patients than for other insured patients. The question is, what should we do about it?

Some conservatives would convert Medicaid into a block grant to the states, limiting federal contributions, likely compounding the problem of underfunding. Other conservatives would eliminate Medicaid and place everyone in high-deductible private plans, perhaps with some federal contributions to health savings accounts for low-income individuals. Narrow networks and cost sharing would surely limit access for this population.

A much better solution would be to replace our fragmented health care financing system with a single payer national health program, eliminating cost sharing and network barriers. Since the program would cover all of us, chronic underfunding for a sector of us would not be tolerated.

Support for National Health Insurance Seven Years Into Massachusetts Healthcare Reform: Views of Populations Targeted by the Reform

By Sonali Saluja, Leah Zallman, Rachel Nardin, David Bor, Steffie Woolhandler, David U. Himmelstein, and Danny McCormick
International Journal of Health Services, OnlineFirst – November 3, 2015

Abstract

Before the Affordable Care Act (ACA), many surveys showed majority support for national health insurance (NHI), also known as single payer; however, little is currently known about views of the ACA’s targeted population. Massachusetts residents have had seven years of experience with state health care reform that became the model for the ACA. We surveyed 1,151 adults visiting safety-net emergency departments in Massachusetts in late 2013 on their preference for NHI or the Massachusetts reform and on their experiences with insurance. Most of the patients surveyed were low-income and non-white. The majority of patients (72.0%) preferred NHI to the Massachusetts reform. Support for NHI among those with public insurance, commercial insurance, and no insurance was 68.9%, 70.3%, and 86.3%, respectively (p < .001). Support for NHI was higher among patients dissatisfied with their insurance plan (83.3% vs. 68.9%, p 1⁄4 .014), who delayed medical care (81.2% vs. 69.6%, p<.001) or avoided purchasing medications due to cost (87.3% vs. 71.4%; p1⁄4.01). Majority support for NHI was observed in every demographic subgroup. Given the strong support for NHI among disadvantaged Massachusetts patients seven years after state health reform, a reappraisal of the ACA’s ability to meet the needs of underserved patients is warranted.

From the Methods

The survey included questions about demographics, health status, knowledge about health insurance, and experiences obtaining and using insurance. One question assessed patients’ preferences regarding reform of the health care system. This question, adapted from a prior Washington Post-ABC News poll question, asked patients to choose one of two health care systems: “the current Massachusetts system — which includes a mixture of insurance types, requires that most people pay copays and premiums and mandates that people obtain coverage — or a single national health insurance program — which would be run by the government, paid for by taxes, cover all residents, and not require co-pays or premiums.”

From the Discussion

Our study is the first to directly compare preferences for the MA health reform to NHI. Our findings are not intended to be generalizable to all residents of MA, most of whom are affluent, white, and commercially insured. Our purpose was not to gauge statewide support for NHI, but instead to understand such support in the key policy-relevant populations of patients who were the main target of the health reform — MA residents who are socioeconomically disadvantaged and racial and ethnic minorities.

NHI has been proposed for many years; however, this option is often regarded as unrealistic because it lacks support of key stakeholders, especially the pharmaceutical and insurance industries. Yet, our results suggest a disconnect between the health care financing system that exists in MA (and now nationally) and the system underserved patients prefer.

http://joh.sagepub.com/content/early/2015/10/30/0020731415615314.abstract

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Comment:

By Don McCanne, M.D.

Many polls and surveys have shown that the majority of United States residents would prefer a single payer national health program. This survey is an important addition since it shows that individuals specifically targeted by reform in Massachusetts – individuals who theoretically would be satisfied with the system if reform met their needs – would still prefer to have a single national health insurance program.

Since the reform design of the Affordable Care Act (ACA) was based on the reforms in Massachusetts, it would be safe to say that the response nationally to ACA reforms would be quite similar. So reforms were not adequate for the population they were primarily designed to serve, nor were they adequate for the majority of us who believe that health care should be accessible and affordable for all. ACA falls short of those goals, whereas single payer would meet them. We should go for it.

Obamacare Not as Egalitarian as It Appears

By Tyler Cowen
The New York Times, November 6, 2015

The Affordable Care Act has generated an enormous amount of partisan rancor, but with more access to data, it is worth taking stock of how it has actually been working.

We can safely say that the policy is costing less than anticipated, perhaps 20 percent less, according to a Congressional Budget Office estimate, and that it has reduced the number of Americans without insurance. But the numbers also suggest that by some measures, the Affordable Care Act has had only a limited impact on economic inequality. In fact, I view the policy as an object lesson in the complexity of reducing the harmful consequences of inequality in the United States.

The act has many parts, but let’s focus on the mandate, a core feature that requires those without insurance to buy it. It was intended to help millions of Americans who did not have health care coverage. Under the program, government subsidies are available for the needy, and there is clear evidence that the poorest people, who receive the largest subsidies, are better off under the health reform law.

In that sense, the program has been a success. But whether other individuals subject to the insurance mandate — those who qualify for lower subsidies or for none at all — are also better off is much harder to say, some recent research has found.

Of course, this question may seem simple if you consider health care coverage to be an essential component of a good human life, and perhaps of social justice as well. If you begin with those assumptions, you might conclude that when you require people to buy insurance coverage you are improving their lives — even if they are not willing to pay for the insurance without prompting from the government.

But there is another way of looking at it, one used in traditional economics, which focuses on how much people are willing to pay as an indication of their real preferences. Using this measure, if everyone covered by the insurance mandate were to buy health insurance as the law dictated, more than half of them would be worse off.

This may seem startling. But in an economic study, researchers measured such preferences by looking at data known as market demand curves. Practically speaking, these demand curves implied that individuals would rather take some risk with their health — and spend their money on other things — partly because they knew that even without insurance they still would receive some health care.

One implication is that the preferences of many people subject to the insurance mandate are likely to become more negative in the months ahead. For those without subsidies, federal officials estimate, the cost of insurance policies is likely to increase by an average of another 7.5 percent; even more in states like Oklahoma and Mississippi. The individuals who are likely losers from the mandate have incomes 250 percent or more above the federal poverty level, the paper said. (That figure is $29,425; the federal poverty level is $11,770 for a single person, more for larger families). They are by no means the poorest Americans, but many of them are not wealthy, either. So the Affordable Care Act may not be as egalitarian as it might look initially, once we take this perspective into account.

It is a matter of philosophy whether we should help people even if they may not want to bear the costs, or instead should honor their individual preferences, but either way there is a sustainability problem. Consider that the health law was enacted to replace an unsustainable system in which uninsured people relied on last-ditch emergency room care. Yet enrollment projections suggest that the Affordable Care Act’s insurance mandate may face sustainability issues of its own.

In short, while numerous government programs redistributed income toward the poor successfully in the past, successive improvements, as exemplified by the Affordable Care Act, have become harder to accomplish, as many of the easiest and most efficient opportunities have already been exploited. We have ended up at margins where political divisions and interest group capture make further progress harder to carry out, no matter how good the proposed policies may seem on the drawing board.

(Tyler Cowen is a professor of economics at George Mason University.)

http://www.nytimes.com/2015/11/08/upshot/obamacare-not-as-egalitarian-as-it-appears.html

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Comment:

By Don McCanne, M.D.

Is our health care system under Obamacare (ACA) an egalitarian system? Although ACA includes numerous policies designed to improve health care equity, it still falls far short. Conservative economist Tyler Cowen agrees, although his proposed solutions may be somewhat different from ours.

For a health care system to be egalitarian, it must be equitable. A well designed single payer system would achieve that equity. As an example, the financial burden on middle-income families that Tyler Cowen and many others have described would be lifted.

In the past, Cowen has supported “a Singapore-style system, with single payer on the catastrophic side rather than mandates for private insurance purchase.” Thus he would move us toward a more egalitarian system as well. But the many problems created by moving to the requisite health savings accounts would threaten health care equity, and, thus, threaten egalitarianism itself.

Single payer is the way to go, but let’s make sure that the system design maximizes egalitarianism.