PNHP

Jost and Pollack’s proposals to strengthen ACA

Jost and Pollack’s proposals to strengthen ACA

Key Proposals to Strengthen the Affordable Care Act

By Timothy Stoltzfus Jost and Harold Pollack
The Century Foundation, December 15, 2015

The ACA undertook from the beginning an ambitious reform agenda, but some of its approaches have turned out to be ineffective, poorly targeted, or not ambitious enough to address deeply rooted problems.

Many of the remaining challenges in health care reform reflect the inherent complexities and path-dependency of the American system and were beyond the reach of any politically feasible reform. Perhaps the most serious problem — which this report will address repeatedly — is the inadequacy of the ACA’s subsidies and regulatory structures to address the problems of low-income Americans, for whom merely meeting the costs of day-to-day essentials is a continuing challenge, and for whom even modest monthly insurance premiums and cost-sharing are often serious barriers to health coverage and care.

This report identifies problems and suggests potential solutions. Some solutions would require federal legislation. Others could be implemented by the administration, state law, or by private parties.

In all, we propose nineteen steps that could help fix recognized flaws in the ACA as well as build on its accomplishments. Taken together, these proposals would further improve the access and affordability of health care under the ACA, create more robust provider networks, enhance competition among insurers, improve the consumer experience, and strengthen the Medicaid program. We understand that in the current political climate, improvements to the ACA that require congressional action are unlikely.

1. Expanding Access to Health Coverage for Moderate-Income Americans

*  Fix the Family Glitch.

*  Reduce Complexity in the Tax Credit Program.

*  Increase Credits for Moderate- and Middle-Income Families.

2. Making Health Care Affordable

*  Reduce Cost-sharing and Out-of-Pocket Limits and Improve Minimum Employer Coverage Requirements.

*  Increase Use of Health Savings Accounts for Moderate-Income Americans.

*  Allow Use of Health Reimbursement Accounts to Purchase Health Insurance.

*  Incorporate Value-based Insurance Design to Support Coverage for High-Value Services.

*  Improve State Regulation of Network and Formulary Adequacy.

*  Improve Protection from Balance Billing.

3. Improving the Consumer Marketplace Experience

*  Actively Guide Consumers in Coverage Selection.

*  Improve Network and Formulary Transparency.

*  Standardize Insurance Products.

4. Improving Medicaid for Low-Income Americans

*  Have the Federal Government Permanently Assume the Entire Cost of the Medicaid Expansion Population.

*  Constrain 1115 Waivers.

*  Eliminate Medicaid Estate Recoveries from the Expansion Population.

*  Improve Medicaid Payment Rates.

*  Ensure a Judicially Enforceable Right to Adequate Access to Medicaid Providers and to Adequate Medicaid Payment Rates.

*  Reconsider a “Public Option” Early Medicare Coverage within Health Insurance Marketplaces.

*  Raise or Eliminate Medicaid and Supplemental Security Income Asset Limits for People Living with Disabilities.

From the Conclusion

This report offers a number of proposals for building on the ACA, to make health coverage and health care even more affordable, accessible, and understandable for Americans. We understand that in the current political climate, improvements to the ACA that require congressional action are unlikely. Yet an administration committed to improving access could take some of the actions we recommend without new legislation, while other proposals could be implemented by the states, marketplace, or simply by insurers.

http://www.tcf.org/assets/downloads/TCF_KeyProposalstoStrengthenACA.pdf

***

Comment:

By Don McCanne, M.D.

Congress is divided on what to do about our expensive but highly dysfunctional health care system. Congressional opponents of the Affordable Care Act (ACA) today will vote for the 62nd time to repeal the Act without offering any replacement, and President Obama will veto the legislation. In contrast, supporters of health care reform would like to improve the system so that it works better for everyone.

There are two approaches to improving the system: either build on ACA and the existing financing system, or replace it with a single payer system. Today’s report is by two highly respected professors who are personally dedicated to health care justice – Timothy Stoltzfus Jost and Harold Pollack – and they would build on ACA. Thus today’s report represents the best of the “repair and improve” approach.

Take a close look at the nineteen recommendations by these two revered individuals who really care about our health care system, and then think about what impact these recommendations would have. Most of the them would hardly qualify as tweaks, though several of them would certainly be beneficial if we were to support the perpetuation of the current system. But what they do not do is to provide a new financing infrastructure that we would need to improve efficiency, equity, universality, access, quality, comprehensiveness, affordability, portability, and to reduce the administrative burden through public administration – features of a single payer national health program.

We can be thankful that we have individuals like Timothy Jost and Harold Pollack who have dedicated themselves to improve what we have. Until we can enact a single payer system, we need their efforts to continue. Yet they concede that “improvements to the ACA that require congressional action are unlikely.” That is the same reason given for not advocating for a single payer system – it supposedly is not politically feasible. But you don’t compromise policy for politics. You change politics so that you can achieve optimal policy.

Unfortunately Harold Pollack has a problem with PNHP. He has written, “I happen to dislike PNHP leaders’ unhelpful stance in the current debate,” and “I wish the group would talk and act rather differently in this debate,” and “Indeed its leaders denigrate important provisions of ACA that expand access for 32 million people and protect millions against catastrophic financial risks.” In fact, we have supported the beneficial gains of ACA as important transitional improvements until we can move the political process to achieve single payer. This matters because this abrasiveness has reduced the framing to incremental changes or nothing, when the framing should be incremental changes or single payer.

From the list in this report, the proposed incremental changes are far too feeble when compared to the need. I feel certain that Timothy Jost would be on board if there were a politically feasible path to single payer. I just wish Harold Pollack would join us as well.

https://pnhp.org/blog/2015/07/09/seidman-and-pollack-aca-versus-medicare-for-all/

Jost and Pollack’s proposals to strengthen ACA

Key Proposals to Strengthen the Affordable Care Act

By Timothy Stoltzfus Jost and Harold Pollack
The Century Foundation, December 15, 2015

The ACA undertook from the beginning an ambitious reform agenda, but some of its approaches have turned out to be ineffective, poorly targeted, or not ambitious enough to address deeply rooted problems.

Many of the remaining challenges in health care reform reflect the inherent complexities and path-dependency of the American system and were beyond the reach of any politically feasible reform. Perhaps the most serious problem — which this report will address repeatedly — is the inadequacy of the ACA’s subsidies and regulatory structures to address the problems of low-income Americans, for whom merely meeting the costs of day-to-day essentials is a continuing challenge, and for whom even modest monthly insurance premiums and cost-sharing are often serious barriers to health coverage and care.

This report identifies problems and suggests potential solutions. Some solutions would require federal legislation. Others could be implemented by the administration, state law, or by private parties.

In all, we propose nineteen steps that could help fix recognized flaws in the ACA as well as build on its accomplishments. Taken together, these proposals would further improve the access and affordability of health care under the ACA, create more robust provider networks, enhance competition among insurers, improve the consumer experience, and strengthen the Medicaid program. We understand that in the current political climate, improvements to the ACA that require congressional action are unlikely.

1. Expanding Access to Health Coverage for Moderate-Income Americans

*  Fix the Family Glitch.

*  Reduce Complexity in the Tax Credit Program.

*  Increase Credits for Moderate- and Middle-Income Families.

2. Making Health Care Affordable

*  Reduce Cost-sharing and Out-of-Pocket Limits and Improve Minimum Employer Coverage Requirements.

*  Increase Use of Health Savings Accounts for Moderate-Income Americans.

*  Allow Use of Health Reimbursement Accounts to Purchase Health Insurance.

*  Incorporate Value-based Insurance Design to Support Coverage for High-Value Services.

*  Improve State Regulation of Network and Formulary Adequacy.

*  Improve Protection from Balance Billing.

3. Improving the Consumer Marketplace Experience

*  Actively Guide Consumers in Coverage Selection.

*  Improve Network and Formulary Transparency.

*  Standardize Insurance Products.

4. Improving Medicaid for Low-Income Americans

*  Have the Federal Government Permanently Assume the Entire Cost of the Medicaid Expansion Population.

*  Constrain 1115 Waivers.

*  Eliminate Medicaid Estate Recoveries from the Expansion Population.

*  Improve Medicaid Payment Rates.

*  Ensure a Judicially Enforceable Right to Adequate Access to Medicaid Providers and to Adequate Medicaid Payment Rates.

*  Reconsider a “Public Option” Early Medicare Coverage within Health Insurance Marketplaces.

*  Raise or Eliminate Medicaid and Supplemental Security Income Asset Limits for People Living with Disabilities.

From the Conclusion

This report offers a number of proposals for building on the ACA, to make health coverage and health care even more affordable, accessible, and understandable for Americans. We understand that in the current political climate, improvements to the ACA that require congressional action are unlikely. Yet an administration committed to improving access could take some of the actions we recommend without new legislation, while other proposals could be implemented by the states, marketplace, or simply by insurers.

http://www.tcf.org/assets/downloads/TCF_KeyProposalstoStrengthenACA.pdf

Congress is divided on what to do about our expensive but highly dysfunctional health care system. Congressional opponents of the Affordable Care Act (ACA) today will vote for the 62nd time to repeal the Act without offering any replacement, and President Obama will veto the legislation. In contrast, supporters of health care reform would like to improve the system so that it works better for everyone.There are two approaches to improving the system: either build on ACA and the existing financing system, or replace it with a single payer system. Today’s report is by two highly respected professors who are personally dedicated to health care justice – Timothy Stoltzfus Jost and Harold Pollack – and they would build on ACA. Thus today’s report represents the best of the “repair and improve” approach.

Take a close look at the nineteen recommendations by these two revered individuals who really care about our health care system, and then think about what impact these recommendations would have. Most of the them would hardly qualify as tweaks, though several of them would certainly be beneficial if we were to support the perpetuation of the current system. But what they do not do is to provide a new financing infrastructure that we would need to improve efficiency, equity, universality, access, quality, comprehensiveness, affordability, portability, and to reduce the administrative burden through public administration – features of a single payer national health program.

We can be thankful that we have individuals like Timothy Jost and Harold Pollack who have dedicated themselves to improve what we have. Until we can enact a single payer system, we need their efforts to continue. Yet they concede that “improvements to the ACA that require congressional action are unlikely.” That is the same reason given for not advocating for a single payer system – it supposedly is not politically feasible. But you don’t compromise policy for politics. You change politics so that you can achieve optimal policy.

Unfortunately Harold Pollack has a problem with PNHP. He has written, “I happen to dislike PNHP leaders’ unhelpful stance in the current debate,” and “I wish the group would talk and act rather differently in this debate,” and “Indeed its leaders denigrate important provisions of ACA that expand access for 32 million people and protect millions against catastrophic financial risks.” In fact, we have supported the beneficial gains of ACA as important transitional improvements until we can move the political process to achieve single payer. This matters because this abrasiveness has reduced the framing to incremental changes or nothing, when the framing should be incremental changes or single payer.

From the list in this report, the proposed incremental changes are far too feeble when compared to the need. I feel certain that Timothy Jost would be on board if there were a politically feasible path to single payer. I just wish Harold Pollack would join us as well.

https://pnhp.org/blog/2015/07/09/seidman-and-pollack-aca-versus-medicare-for-all/

This is the right thing to do

By Mark A. Krehbiel, M.D.
Salina (Kan.) Journal, Jan. 6, 2016

The divisiveness in the world today seems very troubling to me. Information technology gives us the ability to respond immediately to situations that arouse our emotions. The “oh my gosh!” or “can you believe that?” are common utterances that feed our senses to join the bandwagon, laugh it away, become upset or even angry.

Of course, there are exceptions to every rule, but I truly believe that as humans we have core values that most of us can agree upon. We believe in individuality, equality and the right to be comfortable and work hard to achieve goals. Most would agree that volunteerism and helping those in need are strong core values.

We are entering a new year with many questions and fewer answers about how to solve our differences. I find it interesting that our president’s low approval rating is very similar to President George W. Bush’s rating at the same point in his administration. Although both men had different styles and different agendas, I believe they both have similar core values and tried their best to do the right thing for our country and the world. Apparently, there are many Americans who think things could be better. We forget how blessed we are to live in this country of opportunity and freedom.

Many of us think our health care system needs improvement. The Affordable Care Act was an attempt to get more uninsured Americans better access to health care. I laud Barack Obama’s attempt, but disappointing facts remain. Many of us, insured, underinsured and uninsured, are not happy with the system.

As it turns out, the insurance companies and pharmaceutical companies are the big winners. Insurance coverage costs are rising. Insured customers are not using their insurance because of high deductibles. There are still millions who cannot get the care they need. Our nation still ranks very low in infant mortality and other health care outcomes. If you live in Canada or Cuba, your life expectancy is longer than if you live in the U.S.

As one of only a few industrialized countries in the world that does not have universal coverage for all of its citizens, now is the time to continue reaching for that goal. The insurance companies and pharmaceutical companies need to be taken out of the driver’s seat. Let doctors and hospitals do their jobs without worrying about payment.

There are now more employees working in billing and administration than there are the number of beds in U.S. hospitals. In contrast, there are three people working in billing at one large Toronto, Canada, hospital.

The solution is one insurance company. A single-payer system or Medicare for all would achieve truly universal care, affordability and effective cost controls. By taking private insurance companies and administrators out of the equation, it is estimated we would save $400 billion (that is with a “B”) annually.

Many are concerned about another government-run system. The fact is that regulations now exist from the Centers for Medicare and Medicaid Services that basically tell hospitals and physicians what they need to provide, what they can charge and how much they get paid. The insurance companies just take a percentage off the top.

Some states are thinking of trying this system. Colorado, Oregon, Massachusetts and Vermont have all been discussing this. Although admirable, we need the whole country behind such a change. More than 60 percent of physicians are in favor of such a system. Other polls have shown that two-thirds of Americans would favor this.

The system as described would cover all doctor visits, deductibles, medications, hospital charges, nursing home services and ancillary health care needs. It would be paid for by a tax that for most of us would be less than we now pay for insurance.

If you agree with any part of a single-payer system, would like to take the hassle out of deciding on your health insurance annually, or just need some health care and a way to afford it, just check out legislation already before Congress. H.R. 676, the Expanded and Improved Medicare for All Act, has more than 60 sponsors. It explains how this would work.

In this politically charged environment and election year, this might seem to be an insurmountable task. However, I truly believe that with enough groundswell of support, like many past, slow-moving social change events, this will become a reality. There are many reasons for covering the basic needs of health care for all of us Americans. Mostly, I believe, because it is the right thing to do.

Dr. Mark A. Krehbiel has practiced medicine in Salina for nearly 37 years.

http://www.salina.com/opinion/columns/this-is-the-right-thing-to-do/article_7c052d0b-47a6-5715-a5ea-b5edb1d44ae2.html

The Trouble with For-Profit Healthcare: Even the Insured Face Mountains of Debt

New data outlines ‘wide range of consequences and sacrifices’ made by insured Americans who face burdensome medical bills

By Deirdre Fulton
Common Dreams, Jan. 5, 2016

For one in five Americans, just having medical insurance isn’t enough to forestall the damaging consequences of the nation’s for-profit healthcare system.

A comprehensive new poll from the Kaiser Family Foundation and the New York Times finds that while an unsurprising 53 percent of people who are uninsured face problems with medical bills, a whopping 20 percent of working-age Americans who do have insurance also report having medical debt that causes serious financial challenges and changes in employment and lifestyle.

According to a Kaiser Foundation statement, people with insurance who faced the burden of medical debt reported “a wide range of consequences and sacrifices during the past year as a result,” including:

* delaying vacations or major household purchases (77%),
* spending less on food, clothing and basic household items (75%),
* using up most or all their savings (63%),
* taking an extra job or working more hours (42%),
* borrowing money from family or friends (37%),
* changing their living situation (14%), and
* seeking the aid of a charity (11%).

In addition, insured people with medical debt reported skipping or putting off other health care in the past year because of the cost, such as postponing dental care, skipping doctor-recommended tests or treatments, or not filling a prescription.

The report shows that for people with insurance, such consequences loom as large as—or in some case, larger than—they do for uninsured people with problem medical bills. Indeed, a full 62 percent of those who had medical debt say the bills—stemming from co-pays, deductibles, unexpected claim denials, and more—were incurred by someone who had health coverage at the time.

“These financial vulnerabilities reflect the high costs of health care in the United States, the most expensive place in the world to get sick,” wrote Margot Sanger-Katz for the Times, where individuals shared how medical debt had affected them.

What’s more, the data highlights the problems inherent to a for-profit healthcare model.

As Sanger-Katz explained: “Since the late 1990s, insurance plans have begun asking their customers to pay an increasingly greater share of their bills out of pocket though rising deductibles and co-payments. The Affordable Care Act, signed by President Obama in 2010, protected many Americans from very high health costs by requiring insurance plans to be more comprehensive, but at the same time it allowed or even encouraged increases in deductibles.”

That’s why we need a different system, such as a uniform, single-payer national health program based on a Medicare-for-All model, advocates say.

What the Kaiser/Times statistics show is that “anyone short of Bill Gates is in big trouble if they get sick, even if they have insurance,” Dr. David Himmelstein, a co-founder of Physicians for a National Health Program (PNHP) and professor in the CUNY School of Public Health at Hunter College, told Common Dreams on Tuesday.

“A solution,” he continued, “would be real health insurance like people in the rest of the developed world have.”

Noting that residents of countries like Canada, France, and Germany don’t face the same gaps in coverage, out-of-network costs, co-pays, and “all those other things that leave Americans in trouble,” Himmelstein compared the average health insurance plan to a standard hospital gown—”it looks like you have coverage until you turn around and see what’s up in the back.”

National Nurses United policy director Michael Lighty echoed that call in an interview with Common Dreams. “Continued medical bankruptcy is inevitable because people simply can’t afford the out-of-pocket expenses that are inherent in the Affordable Care Act,” he said on Tuesday. “In that context, of course, the only solution is a system of guaranteed healthcare where we replace premiums with taxes and everyone has insurance and there’s never any possibility of bankruptcy due to healthcare needs.”

Under such a system, Lighty said, “out-of-pocket costs are virtually non-existent, you don’t have out-of-network costs because there’s a single network, and you have the ability to control costs without shifting the cost to the individual. You can’t do that under the current system. But you can do that under improved Medicare-for-All.”

Deirdre Fulton is a staff writer at Common Dreams.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

http://commondreams.org/news/2016/01/05/trouble-profit-healthcare-even-insured-face-mountains-debt

KFF/NYT survey demonstrating the burden of medical debt, even with insurance

The Burden of Medical Debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey

Prepared by: Liz Hamel, Mira Norton, Karen Pollitz, Larry Levitt, Gary Claxton and Mollyann Brodie
Kaiser Family Foundation, December 2015

Previous Kaiser surveys have found that about a quarter of people say they or someone in their household had problems paying medical bills in the past year, and a 2014 Kaiser report provided a qualitative look at some of the circumstances and consequences of unpaid medical bills through interviews with people who had sought credit counseling for medical debt. But to date, there has been little research providing a quantitative look at the causes of medical bill problems and the impacts they have on people’s families, their finances, and their access to health care.

To fill this gap, the Kaiser Family Foundation and The New York Times conducted an in-depth survey with 1,204 adults ages 18-64 who report that they or someone in their household had problems paying or an inability to pay medical bills in the previous 12 months.

Prevalence of problems paying medical bills among different groups

Insurance status has a strong association with medical bill difficulties, with over half (53 percent) of the uninsured saying they had problems paying household medical bills in the past year. However, as previous surveys have shown, insurance is not a panacea against these problems. Roughly one in five of those with health insurance through an employer (19 percent), Medicaid (18 percent), or purchased on their own (22 percent) also report problems paying medical bills. In fact, overall among all people with household medical bill problems, more than six in ten (62 percent) say the person who incurred the bills was covered by health insurance, while a third (34 percent) say that person was uninsured. Among those with private insurance (either through an employer or self-purchased), their plan’s deductible makes a difference in ability to afford health care bills, with those in higher deductible plans more likely to report medical bill problems than those in plans with lower deductibles (26 percent versus 15 percent).

To explore these relationships further, we used a statistical technique called logistic regression analysis to isolate which demographic characteristics are the strongest predictors of problems paying medical bills when holding other factors constant. In that analysis, income, insurance status, and all 3 measures of health status (being in fair or poor health and having a disability or chronic condition) had a significant and strong association with problems paying medical bills, even after accounting for the influence of the other demographic factors. Having a private insurance plan with a high deductible also remained a significant predictor, even after controlling for other factors, as did being under age 25 and having minor children at home.

Circumstances leading to problems paying medical bills

Among those who report problems paying medical bills, two-thirds (66 percent) say the bills were the result of a one-time or short-term medical expense such as a hospital stay or an accident, while 33 percent cite bills for treatment of chronic conditions that have built up over time. These shares are similar for people who faced medical bill problems with and without insurance coverage.

Asked which types of bills made up the largest share of what they owed, the most common responses are emergency room visits (21 percent) and hospitalization (20 percent), followed by dental care (12 percent) and diagnostic tests like X-rays and MRIs (11 percent).

Among who say their bill problems were the result of a one-time or short-term medical expense, just under one in five (18 percent) cite an accident as the main cause. Most of the others name illnesses, pain, dental issues, or surgery, suggesting that although most bill problems are caused by one-time events, these events are often acute episodes of illness or expensive surgeries, medications or tests, rather than injuries caused by accidents.

Financial status of those with bill problems

About three in ten (31 percent) of those with medical bill problems say the total amount of the bills they had problems paying was $5,000 or more, including 13 percent who report bills adding to at least $10,000.

Many of those with medical bill problems report struggling with bills of lower amounts, including 24 percent of the insured and 22 percent of the uninsured who say their bills amounted to less than $1,000. While these lower amounts may seem small, even a bill of $500 or less can present a major problem for someone who is living paycheck to paycheck. In fact, when asked to describe their financial situation, about six in ten (61 percent) of those who’ve had problems paying medical bills say they either just meet their basic expenses (43 percent) or don’t have enough to meet basic expenses (18 percent).

Even among the insured, those who have faced medical bill problems are significantly more likely than their counterparts who haven’t had such problems to say they are either just getting by or don’t have enough to make ends meet (55 percent versus 22 percent).

Compared to those without medical debt, those who’ve had medical bill problems are also less likely to say they have a credit card (53 percent versus 77 percent), a retirement savings account (43 percent versus 62 percent), or some other type of savings (17 percent versus 38 percent).

About three in ten (29 percent) say that someone in their household had to take a cut in pay or hours as a result of the illness that led to the medical bills, either because of the illness itself or in order to care for the person who was sick.

Medical bill problems among those with health insurance

While problems paying medical bills are more common among the uninsured, more than six in ten (62 percent) of those who had problems paying medical bills say the person who incurred the bills was covered by health insurance when treatment began.

Of those who were insured when the bills were incurred, three-quarters (75 percent) say that the amount they had to pay for their insurance copays, deductibles, or coinsurance was more than they could afford.

About three in 10 (32 percent) of those who had problems paying medical bills while insured say they received care from an out-of-network provider that their insurance wouldn’t pay for. For many, these bills came as a surprise.

About a quarter (26 percent) of the insured who had medical bill problems say they had a claim denied by their insurance company.

The impact of medical bills on families

Among those with medical bill problems, almost identical shares of the insured (44 percent) and uninsured (45 percent) say the bills have had a major impact on their families.

A few groups among those with medical bill problems are more likely to say the medical bills have had a major impact on their families, including people with bills amounting to $5,000 or more (66 percent), those who say the family member who generated the bills has a disability (57 percent), and those who describe their financial situation as not having enough to meet basic expenses (56 percent).

Sacrifices made to pay medical bills

Even among those with health insurance, people who’ve faced medical bill problems report making various sacrifices in order to pay these bills, including significant changes to their employment, financial situation, or lifestyle. Overall, about seven in ten report cutting back or delaying vacations or major household purchases (72 percent) as well as reducing spending on food, clothing and basic household items (70 percent). About six in ten (59 percent) say they used up all or most of their savings in order to pay medical bills. Substantial shares say that someone in their household took on an extra job or worked more hours (41 percent), borrowed money from family and friends (37 percent), or increased their credit card debt (34 percent). Roughly a quarter (26 percent) say they took money out of a retirement, college, or other long-term savings account. Smaller – but not inconsequential – shares say they changed their living situation (17 percent), took out another type of loan (15 percent), borrowed from a payday lender (13 percent), or sought the aid of a charity or non-profit (12 percent) in order to pay medical bills.

These sacrifices are reported by people in all walks of life, and not just the uninsured or those with precarious financial situations.

Effects of medical bills on ability to get needed health care

Overall, about three in ten (31 percent) of those who faced problems paying medical bills say they had problems getting other health care they needed directly as a result of these problems.

More broadly, many of those with medical bill problems report delaying or skipping health care over the past 12 months because of the cost – at rates 2 to 3 times those of their counterparts who did not have problems paying medical bills, regardless of their insurance status.

Effects of medical bills on household finances and ability to afford basic needs

Medical bills can also lead to problems meeting other financial obligations and paying for basic necessities. Among those with medical bill problems, about six in ten of both the insured (62 percent) and the uninsured (62 percent) say they’ve had difficulty paying other bills as a result of medical debt. Over a third in each group (34 percent of the insured and 39 percent of the uninsured) say they were unable to pay for basic necessities like food, heat, or housing as a result of medical bills.

Most of those with medical bill problems report having other kinds of debt, including credit card debt (56 percent), car loans (46 percent), student loans (33 percent), mortgages (32 percent), payday loans (17 percent), and other outstanding loans (31 percent).

For some of those with problems paying medical bills, medical debt makes up a large share of their total debt. About one in five (22 percent, including 17 percent of the insured and 34 percent of the uninsured) say their medical bills represent all or almost all of their total non-mortgage debt.

The survey also finds that once medical bill problems start, it can be difficult to make them stop, and that for some, medical bills can start a cascade of other bill problems.

While almost half (47 percent) say they’ve also had problems paying other unrelated bills in the past year, medical bills appear to be either the sole problem or the main trigger of bill problems for the other half, including 31 percent who say they’ve only had problems with medical bills, not other types of bills, and 19 percent who say their problems paying other bills started as a result of their medical bills.

Financial consequences of struggling to make payments

Once a person has problems paying medical bills, their insurance status appears to make little difference in their ability to pay bills on time. Among those with medical bill problems, similar shares of the insured and uninsured say they’ve been late on a payment (62 percent and 63 percent, respectively) or missed a payment (55 percent and 61 percent) for a medical bill in the past year.

Likely as a result of missed or late payments, almost six in ten (58 percent) of those with medical bill problems say they’ve been contacted by a collection agency in the past year, mostly because of medical bills alone (25 percent) or a combination of medical bills and some other type of debt (20 percent).

Overall, 11 percent say they’ve declared bankruptcy at some point and that medical bills were at least a partial contributor to their bankruptcy.

From the Conclusion

Insurance features like cost-sharing, provider networks, and confusing billing practices can all lead to medical bill problems among the insured. While higher deductibles and other forms of cost-sharing have helped to keep health insurance premium growth at historically low levels in recent years, the survey highlights the consequences these changes can have for people.

The survey also shows that medical bill problems can have real and often lasting impacts on individuals and families in terms of their standard of living, their financial stability, and their ability to access needed health care. While insurance provides some protection against incurring medical bill problems in the first place, once these problems occur, the effects on individuals and families are often as serious for the insured as they are for the uninsured.

Full report (32 pages):
https://kaiserfamilyfoundation.files.wordpress.com/2016/12/8806-the-burden-of-medical-debt-results-from-the-kaiser-family-foundation-new-york-times-medical-bills-survey1.pdf

***

Comment:

By Don McCanne, M.D.

These excerpts from the Kaiser Family Foundation/New York Times Medical Bills Survey of adults 18 to 64 confirm once again that our multi-payer health insurance system falls far short in preventing financial insecurity for those with medical needs. This survey expands on our knowledge base by demonstrating the deplorable consequences of the financial hardships created by this system.

These deficiencies cannot be corrected by merely tweaking our current dysfunctional financing system. A massive infusion of funds would be required under the current system if we wish to reduce the negative financial consequences, but the political and policy communities currently oppose any increase in spending. In fact, their current approach is to control spending by increasing barriers to care through unaffordable cost sharing and narrower networks designed to reduce access. Obstructing access to care might reduce spending, but preventing beneficial health care is the opposite of what a health care financing system should be doing.

Think of that. It is bad enough that people have the misfortune to suffer medical disorders, yet we add to that grief by perpetuating a system that dumps personal financial hardship on top of their medical misfortunes.

The efficiencies of a single payer system would save enough to more assuredly enable access to appropriate health care services by removing cost-sharing barriers to care, not to mention the benefit that absolutely everyone would be included. What are we waiting for? The status quo is unequivocally unacceptable.

KFF/NYT survey demonstrating the burden of medical debt, even with insurance

The Burden of Medical Debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey

Prepared by: Liz Hamel, Mira Norton, Karen Pollitz, Larry Levitt, Gary Claxton and Mollyann Brodie
Kaiser Family Foundation, December 2015

Previous Kaiser surveys have found that about a quarter of people say they or someone in their household had problems paying medical bills in the past year, and a 2014 Kaiser report provided a qualitative look at some of the circumstances and consequences of unpaid medical bills through interviews with people who had sought credit counseling for medical debt. But to date, there has been little research providing a quantitative look at the causes of medical bill problems and the impacts they have on people’s families, their finances, and their access to health care.

To fill this gap, the Kaiser Family Foundation and The New York Times conducted an in-depth survey with 1,204 adults ages 18-64 who report that they or someone in their household had problems paying or an inability to pay medical bills in the previous 12 months.

Prevalence of problems paying medical bills among different groups

Insurance status has a strong association with medical bill difficulties, with over half (53 percent) of the uninsured saying they had problems paying household medical bills in the past year. However, as previous surveys have shown, insurance is not a panacea against these problems. Roughly one in five of those with health insurance through an employer (19 percent), Medicaid (18 percent), or purchased on their own (22 percent) also report problems paying medical bills. In fact, overall among all people with household medical bill problems, more than six in ten (62 percent) say the person who incurred the bills was covered by health insurance, while a third (34 percent) say that person was uninsured. Among those with private insurance (either through an employer or self-purchased), their plan’s deductible makes a difference in ability to afford health care bills, with those in higher deductible plans more likely to report medical bill problems than those in plans with lower deductibles (26 percent versus 15 percent).

To explore these relationships further, we used a statistical technique called logistic regression analysis to isolate which demographic characteristics are the strongest predictors of problems paying medical bills when holding other factors constant. In that analysis, income, insurance status, and all 3 measures of health status (being in fair or poor health and having a disability or chronic condition) had a significant and strong association with problems paying medical bills, even after accounting for the influence of the other demographic factors. Having a private insurance plan with a high deductible also remained a significant predictor, even after controlling for other factors, as did being under age 25 and having minor children at home.

Circumstances leading to problems paying medical bills

Among those who report problems paying medical bills, two-thirds (66 percent) say the bills were the result of a one-time or short-term medical expense such as a hospital stay or an accident, while 33 percent cite bills for treatment of chronic conditions that have built up over time. These shares are similar for people who faced medical bill problems with and without insurance coverage.

Asked which types of bills made up the largest share of what they owed, the most common responses are emergency room visits (21 percent) and hospitalization (20 percent), followed by dental care (12 percent) and diagnostic tests like X-rays and MRIs (11 percent).

Among who say their bill problems were the result of a one-time or short-term medical expense, just under one in five (18 percent) cite an accident as the main cause. Most of the others name illnesses, pain, dental issues, or surgery, suggesting that although most bill problems are caused by one-time events, these events are often acute episodes of illness or expensive surgeries, medications or tests, rather than injuries caused by accidents.

Financial status of those with bill problems

About three in ten (31 percent) of those with medical bill problems say the total amount of the bills they had problems paying was $5,000 or more, including 13 percent who report bills adding to at least $10,000.

Many of those with medical bill problems report struggling with bills of lower amounts, including 24 percent of the insured and 22 percent of the uninsured who say their bills amounted to less than $1,000. While these lower amounts may seem small, even a bill of $500 or less can present a major problem for someone who is living paycheck to paycheck. In fact, when asked to describe their financial situation, about six in ten (61 percent) of those who’ve had problems paying medical bills say they either just meet their basic expenses (43 percent) or don’t have enough to meet basic expenses (18 percent).

Even among the insured, those who have faced medical bill problems are significantly more likely than their counterparts who haven’t had such problems to say they are either just getting by or don’t have enough to make ends meet (55 percent versus 22 percent).

Compared to those without medical debt, those who’ve had medical bill problems are also less likely to say they have a credit card (53 percent versus 77 percent), a retirement savings account (43 percent versus 62 percent), or some other type of savings (17 percent versus 38 percent).

About three in ten (29 percent) say that someone in their household had to take a cut in pay or hours as a result of the illness that led to the medical bills, either because of the illness itself or in order to care for the person who was sick.

Medical bill problems among those with health insurance

While problems paying medical bills are more common among the uninsured, more than six in ten (62 percent) of those who had problems paying medical bills say the person who incurred the bills was covered by health insurance when treatment began.

Of those who were insured when the bills were incurred, three-quarters (75 percent) say that the amount they had to pay for their insurance copays, deductibles, or coinsurance was more than they could afford.

About three in 10 (32 percent) of those who had problems paying medical bills while insured say they received care from an out-of-network provider that their insurance wouldn’t pay for. For many, these bills came as a surprise.

About a quarter (26 percent) of the insured who had medical bill problems say they had a claim denied by their insurance company.

The impact of medical bills on families

Among those with medical bill problems, almost identical shares of the insured (44 percent) and uninsured (45 percent) say the bills have had a major impact on their families.

A few groups among those with medical bill problems are more likely to say the medical bills have had a major impact on their families, including people with bills amounting to $5,000 or more (66 percent), those who say the family member who generated the bills has a disability (57 percent), and those who describe their financial situation as not having enough to meet basic expenses (56 percent).

Sacrifices made to pay medical bills

Even among those with health insurance, people who’ve faced medical bill problems report making various sacrifices in order to pay these bills, including significant changes to their employment, financial situation, or lifestyle. Overall, about seven in ten report cutting back or delaying vacations or major household purchases (72 percent) as well as reducing spending on food, clothing and basic household items (70 percent). About six in ten (59 percent) say they used up all or most of their savings in order to pay medical bills. Substantial shares say that someone in their household took on an extra job or worked more hours (41 percent), borrowed money from family and friends (37 percent), or increased their credit card debt (34 percent). Roughly a quarter (26 percent) say they took money out of a retirement, college, or other long-term savings account. Smaller – but not inconsequential – shares say they changed their living situation (17 percent), took out another type of loan (15 percent), borrowed from a payday lender (13 percent), or sought the aid of a charity or non-profit (12 percent) in order to pay medical bills.

These sacrifices are reported by people in all walks of life, and not just the uninsured or those with precarious financial situations.

Effects of medical bills on ability to get needed health care

Overall, about three in ten (31 percent) of those who faced problems paying medical bills say they had problems getting other health care they needed directly as a result of these problems.

More broadly, many of those with medical bill problems report delaying or skipping health care over the past 12 months because of the cost – at rates 2 to 3 times those of their counterparts who did not have problems paying medical bills, regardless of their insurance status.

Effects of medical bills on household finances and ability to afford basic needs

Medical bills can also lead to problems meeting other financial obligations and paying for basic necessities. Among those with medical bill problems, about six in ten of both the insured (62 percent) and the uninsured (62 percent) say they’ve had difficulty paying other bills as a result of medical debt. Over a third in each group (34 percent of the insured and 39 percent of the uninsured) say they were unable to pay for basic necessities like food, heat, or housing as a result of medical bills.

Most of those with medical bill problems report having other kinds of debt, including credit card debt (56 percent), car loans (46 percent), student loans (33 percent), mortgages (32 percent), payday loans (17 percent), and other outstanding loans (31 percent).

For some of those with problems paying medical bills, medical debt makes up a large share of their total debt. About one in five (22 percent, including 17 percent of the insured and 34 percent of the uninsured) say their medical bills represent all or almost all of their total non-mortgage debt.

The survey also finds that once medical bill problems start, it can be difficult to make them stop, and that for some, medical bills can start a cascade of other bill problems.

While almost half (47 percent) say they’ve also had problems paying other unrelated bills in the past year, medical bills appear to be either the sole problem or the main trigger of bill problems for the other half, including 31 percent who say they’ve only had problems with medical bills, not other types of bills, and 19 percent who say their problems paying other bills started as a result of their medical bills.

Financial consequences of struggling to make payments

Once a person has problems paying medical bills, their insurance status appears to make little difference in their ability to pay bills on time. Among those with medical bill problems, similar shares of the insured and uninsured say they’ve been late on a payment (62 percent and 63 percent, respectively) or missed a payment (55 percent and 61 percent) for a medical bill in the past year.

Likely as a result of missed or late payments, almost six in ten (58 percent) of those with medical bill problems say they’ve been contacted by a collection agency in the past year, mostly because of medical bills alone (25 percent) or a combination of medical bills and some other type of debt (20 percent).

Overall, 11 percent say they’ve declared bankruptcy at some point and that medical bills were at least a partial contributor to their bankruptcy.

From the Conclusion

Insurance features like cost-sharing, provider networks, and confusing billing practices can all lead to medical bill problems among the insured. While higher deductibles and other forms of cost-sharing have helped to keep health insurance premium growth at historically low levels in recent years, the survey highlights the consequences these changes can have for people.

The survey also shows that medical bill problems can have real and often lasting impacts on individuals and families in terms of their standard of living, their financial stability, and their ability to access needed health care. While insurance provides some protection against incurring medical bill problems in the first place, once these problems occur, the effects on individuals and families are often as serious for the insured as they are for the uninsured.

Full report (32 pages):
https://kaiserfamilyfoundation.files.wordpress.com/2016/12/8806-the-burden-of-medical-debt-results-from-the-kaiser-family-foundation-new-york-times-medical-bills-survey1.pdf

These excerpts from the Kaiser Family Foundation/New York Times Medical Bills Survey of adults 18 to 64 confirm once again that our multi-payer health insurance system falls far short in preventing financial insecurity for those with medical needs. This survey expands on our knowledge base by demonstrating the deplorable consequences of the financial hardships created by this system.These deficiencies cannot be corrected by merely tweaking our current dysfunctional financing system. A massive infusion of funds would be required under the current system if we wish to reduce the negative financial consequences, but the political and policy communities currently oppose any increase in spending. In fact, their current approach is to control spending by increasing barriers to care through unaffordable cost sharing and narrower networks designed to reduce access. Obstructing access to care might reduce spending, but preventing beneficial health care is the opposite of what a health care financing system should be doing.

Think of that. It is bad enough that people have the misfortune to suffer medical disorders, yet we add to that grief by perpetuating a system that dumps personal financial hardship on top of their medical misfortunes.

The efficiencies of a single payer system would save enough to more assuredly enable access to appropriate health care services by removing cost-sharing barriers to care, not to mention the benefit that absolutely everyone would be included. What are we waiting for? The status quo is unequivocally unacceptable.

Even Insured Can Face Crushing Medical Debt, Study Finds

By Margot Sanger-Katz
The New York Times, Jan. 5, 2016
(excerpt)

Here is the surest way to enjoy the peace of mind that comes with having health insurance: Don’t get sick.

The number of uninsured Americans has fallen by an estimated 15 million since 2013, thanks largely to the Affordable Care Act. But a new survey, the first detailed study of Americans struggling with medical bills, shows that insurance often fails as a safety net. Health plans often require hundreds or thousands of dollars in out-of-pocket payments — sums that can create a cascade of financial troubles for the many households living paycheck to paycheck.

Carrie Cota learned the hard way that health insurance does not guarantee financial security. Ms. Cota, a 56-year-old travel agent from Rosamond, Calif., learned she had the autoimmune disease lupus in 2007. She ran up thousands of dollars in medical and dental bills and ended up losing her job, and eventually her house.

“I had to move in temporarily with my ex-husband,” she said in a recent interview. “I’m staying with him until I can figure out what to do.”

In the new poll, conducted by The New York Times and the Kaiser Family Foundation, roughly 20 percent of people under age 65 with health insurance nonetheless reported having problems paying their medical bills over the last year. By comparison, 53 percent of people without insurance said the same.

These financial vulnerabilities reflect the high costs of health care in the United States, the most expensive place in the world to get sick. They also highlight a substantial shift in the nature of health insurance. Since the late 1990s, insurance plans have begun asking their customers to pay an increasingly greater share of their bills out of pocket though rising deductibles and co-payments. The Affordable Care Act, signed by President Obama in 2010, protected many Americans from very high health costs by requiring insurance plans to be more comprehensive, but at the same time it allowed or even encouraged increases in deductibles.

“We’re at a point where there’s been slow growth in health care costs and huge improvements in the numbers of people who have health insurance,” said Sara Collins, a vice president at the Commonwealth Fund, a health research group. “But there is this underlying trend towards higher cost sharing that could put increasing numbers of people at risk for being underinsured.”

Full article, with many hyperlinks, quotes:
http://www.nytimes.com/2016/01/06/upshot/lost-jobs-houses-savings-even-insured-often-face-crushing-medical-debt.html?_r=0

More in Congress sign on as cosponsors of HR 676, single-payer healthcare bill

News release
Single Payer News, Jan. 4, 2016

In December six representatives, Danny Davis (IL), Grace Napolitano (CA), Emanuel Cleaver (MO), Jerry McNerney (CA), Robin Kelly (IL), and Alan Lowenthal (CA), added their names as cosponsors on HR 676, Congressman John Conyers’ Expanded and Improved Medicare for All, the national single-payer legislation.

The total number of cosponsors is now 59, not including chief sponsor Conyers.

The more cosponsors that are added, the more quickly this real solution becomes politically viable. The more representatives who speak boldly for HR 676, the higher single payer advances on the nation’s agenda. 

Call your representative and ask her or him to sign on to HR 676. The Capitol switchboard number is (202) 224-3121.  Ask to speak to your representative by name. If you need to look up a representative, you can do so here.

When talking with representatives who have already signed on, encourage them to speak up for HR 676 on the House floor, to the press, in town hall meetings, and to put their support for HR 676 on their website. If they need further information, spend the time to bring the facts about HR 676 to their attention. This clear and simple statement of Dr. Marcia Angell may help.

The list of representatives who have already signed on to HR 676 is here.

The list of representatives who were cosponsors of HR 676 in earlier Congresses but have not yet signed on in the 114th is below. This is a good place to start.

Rep. Xavier Becerra, California 34th
Rep. Sanford D. Bishop, Jr., Georgia 2nd
Rep. Corrine Brown, Florida 5th
Rep. G. K. Butterfield, North Carolina 1st
Rep. Andre Carson, Indiana 7th,
Rep. Marcia Fudge, Ohio 11th,
Rep. Eddie Bernice Johnson, Texas 30th,
Rep. David Loebsack, Iowa 2d
Rep. Nita M. Lowey, New York 17th
Rep. Ben Ray Luján, New Mexico 3d
Rep. Stephen F. Lynch, Massachusetts 8th
Rep. Gregory W. Meeks, New York 5th
Rep. Donald M. Payne, Jr., New Jersey 10th
Rep. Jared Polis, Colorado 2nd
Rep. David Scott, Georgia 13th
Rep. Bennie G. Thompson, Mississippi 2nd
Rep. Nydia M. Velázquez, New York 7th
Rep. Peter J. Visclosky, Indiana 1st 
Rep. Maxine Waters, California 43rd  

“According to myth…a single-payer system is a good idea, but unrealistic…. What is truly unrealistic is anything else.”

–Marcia Angell, MD, former editor-in-chief, New England Journal of Medicine, June 10, 2009

****

HR 676 would institute a single payer health care system by expanding a greatly improved Medicare to everyone residing in the U.S. Patients will choose their own physicians and hospitals.

HR 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long term care.

HR 676 ends deductibles and co-payments. HR 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

In the current Congress, HR 676 has 59 co-sponsors in addition to Congressman Conyers.

HR 676 has been endorsed by 622 union organizations including 151 Central Labor Councils/Area Labor Federations and 44 state AFL-CIO’s (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA, RI, NH, ID.

For a list of union endorsers, or a sample endorsement resolution, contact:

Kay Tillow
All Unions Committee for Single Payer Health Care–HR 676
c/o Nurses Professional Organization (NPO)
1169 Eastern Parkway, Suite 2218
Louisville, KY 40217

(502) 636 1551

Email: nursenpo@aol.com
http://unionsforsinglepayer.org
https://www.facebook.com/unionsforsinglepayer

Health care should be top priority for voters

By Thomas Clairmont, M.D.
Foster’s Daily Democrat (Dover, N.H.), Dec. 27, 2015

Health care now represents almost 20 percent of the economy. It is surprising that there is so little discussion about an issue that affects everyone and costs so much. Repeal of Obamacare is on every Republican’s list, but the replace part is elusive. I have tried to elucidate the candidate’s positions and provide some analysis. At this stage everyone should state their plan.

Jeb Bush – will give you a tax credit to buy an “affordable” portable plan. No definition of what affordable is – less than 10 percent of income going to health care is an accepted definition. He keeps all the unnecessary insurance companies in business.

Ben Carson – supports Health Savings Accounts. A poor idea because they attract healthy and wealthy individuals, leaving sicker patients in increasingly expensive plans. They also discriminate against women whose annual care costs $1,000 more then men’s.

Chris Christie – says nothing about health premiums for the 26-64 groups. For Medicare “if you can afford to pay more you will.” This does zero for you and does nothing to reduce your health care costs.

Ted Cruz – “Repeal every blasted word of Obamacare.” This brings back pre-existing conditions, annual and lifetime caps, kicks your kids off your insurance the minute they graduate, and sends millions of people off Medicaid to fend for themselves. Why does this nonsense get applause?

Donald Trump – “I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now.” This is a nod towards single-payer that does indeed take care of everyone, provides better coverage and saves money.

Marco Rubio – will give you a refundable tax credit to purchase insurance. We don’t need insurance companies going forward, so having individuals trying to decide what expensive plan to buy does nothing for improving access or controlling costs.

Hillary Clinton – retains the Affordable Care Act, says she will lower out of pocket and prescription costs but doesn’t say how. The Affordable Care Act is not universal, has not lowered costs and has way too many expensive options.

Bernie Sanders – the only candidate with a concrete plan you can actually read. Endorses HR 676 – the Expanded and Improved Medicare for All Act – “Access to health care is a human right.” Don’t be fooled by Clinton’s ruse that this plan increases taxes. Your new tax bill includes full coverage and you pay no premium. Many of us believe we need someone in charge of health care, negotiating for us all because we have no bargaining power as individuals. Every other country in the world provides full coverage to their citizens at less than half of the costs in the United States.

It is time the candidates start talking about helping you. You are already paying 2.9 percent of your income for Medicare, — 10 percent of your property tax pays for our Portsmouth employees’ health care, and your income tax covers over 4 million federal employees, the military, and 70 million people on Medicaid and the Children’s Health Insurance Program, including refugees. Then you pay part/all of your premium and then your insurer adds deductibles, co-payments, co-insurance and inconvenience.

A powerful new movie, “FIX IT,” makes a compelling case for scrapping this current dysfunctional multi-payer system and expanding Medicare to cover everyone with one plan — comprehensive, affordable, permanent and secure. Watch the trailer at fixithealthcare.com

We will show this movie on Jan. 9 at 10 a.m. at the Portsmouth Public Library. Your attendance and comments are welcome.

Dr. Thomas Clairmont is a board-certified primary care physician practicing in Portsmouth, specializing in internal medicine.

http://www.fosters.com/article/20151227/NEWS/151229651

John Geyman: ‘The Human Face of ObamaCare’ and what comes next

The Human Face of ObamaCare: Promises vs. Reality and What Comes Next

By John Geyman, M.D.
Copernicus Healthcare, January 1, 2016

Preface

Now that the Affordable Care Act (ACA) has been upheld by the U.S. Supreme Court as the law of the land, it is the target of an intense partisan debate during this 2016 election cycle. Confusion, disinformation, and misleading rhetoric dominate the airwaves as politicians and their corporate backers offer up wildly different approaches to our health care problems and solutions.

After six years with the ACA, there is a large base of experience to draw upon to assess, on the basis of evidence, what has worked and not worked. So it is time to reassess its impacts on the problems it was intended to address–reduced access to health care, uncontrolled costs, increasing unaffordability, and unacceptable quality of care for our population.

Despite promises of the Obama administration before the law was passed that we can keep our insurance if we like it, stay with our same doctors, and save money at the same time, many millions of Americans have too often found these assurances to be empty. Having insurance “coverage” for many does not translate into having access to affordable necessary care. Instead, the largely for-profit “system” continues on, profiting and sometimes profiteering from expanded markets subsidized by us, the taxpayers. The original title of the ACA as the Patient Protection and Affordable Care Act (PPACA) has become a misnomer, not surprisingly little used today.

Too we are often bombarded by abstract numbers and statistics that neglect what they mean to ordinary Americans. This book takes a different approach, starting with stories of patients and their families, thereby putting a human face on the large body of experience and evidence about the effects of the ACA since its passage in 2010.  Far from isolated anecdotes, these are common stories that best illustrate national trends and problems in our increasingly dysfunctional market-based system.

The book is organized in three parts: Part One presents some 50 patient and family stories that represent problems confronted by implementation of the ACA since 2010. These are real people and their families drawn from press reports. Part Two looks at five major problems of the entire system, as we consider to what extent the ACA has addressed them, and find that we are far from the health care reform that we need. Part Three deals with where we are now, in the middle of an election year, faced with three main alternatives about where to go next: (1) stick with the ACA or try to improve it; (2) repeal and replace it with a Republican “plan”; or (3) move to single-payer system of national health insurance. You will notice that many of the chapters start with a heading, “The Promise”, “The Premise,” or “The Myth.” These denote either the promises made by the Obama administration about the ACA or the premises underlying it, which typically and ironically are based on earlier conservative ideas put forward by conservative organizations, such as the Heritage Foundation.

The stakes are too high to get health care wrong in this country. Our incremental reform attempts over many years have been compromised by the money and political power of corporate stakeholders that perpetuate many of our problems. We need objective evidence to combat the rhetoric and claims of the medical-industrial complex and direct our attention to the  real needs of patients and their families. It is my hope that this book will help in this process.

–John Geyman, M.D. 
Friday Harbor, WA
January 2016

http://www.johngeymanmd.org

Amazon:
http://www.amazon.com/gp/product/1938218027

***

Comment:

By Don McCanne, M.D.

Although many had high hopes for ObamaCare, as John Geyman shows us the human faces, we realize that reform fell too short for too many. He shows us not only those human faces but also the pained face of health care justice. He provides us with an understanding of what is wrong with our system, and then describes options for the future. He encourages us all to participate in the reform dialogue so that we can finally get this right. “The Human Face of ObamaCare” is a great place to start.

Physicians are burning out, and patients must rally around them

It is only a slight oversimplification to compare the treatment of doctors to the treatment of teachers

By Kip Sullivan, J.D.
Star Tribune (Minneapolis), Dec. 29, 2015

A silent epidemic is ravaging our health care system — an epidemic of burnout among doctors. A paper published in the December issue of Mayo Clinic Proceedings reports that the percent of physicians admitting to at least one symptom of burnout rose from 46 percent in 2011 to 54 percent in 2014. By contrast, burnout in the general population over that period stayed at about 25 percent, way below the rate among doctors.

Other research has confirmed this problem. The Star Tribune reported in May that a national survey showed a 21 percent increase in burnout among doctors between 2011 and 2014.

The media, including the Star Tribune, is doing a good job of reporting on the problem and its immediate causes — more paperwork and less autonomy. But the media is not explaining why paperwork is going up and autonomy is going down. Why are doctors spending more time at their computers? Why are so many people who don’t belong in the examining room looking over the shoulders of doctors to second-guess them, grade them and subject them to financial incentives based on their grades?

It is only a slight oversimplification to compare the treatment of doctors to the treatment of teachers. Just as teachers have been subjected to deprofessionalization — and to some extent demonization — in the name of improving education, so doctors have been deprofessionalized and subjected to grossly unfair and inaccurate criticism in the name of improving medicine.

The main difference between the campaigns to rob teachers and doctors of their autonomy is that parents and students have rallied to defend their teachers. The No Child Left Behind (NCLB) law, and the obsession with measurement that it reflected, provoked a backlash among parents. No similar movement has arisen among patients to defend doctors.

That’s because the methods used to rob doctors of their autonomy are much less visible than the methods used to deprofessionalize teachers. The NCLB forced students to spend more time taking tests and teachers to spend more time “teaching to the test.” These consequences were quite visible to anyone who wasn’t living in a cave.

But the consequences of the physician deprofessionalization movement — let’s call it the No Patient Left Behind movement — are harder to see. Although patients are the ultimate victims of the obsession with micromanaging doctors that has constipated the minds of the health policy elite, we do not see the injury being inflicted on our doctors. For that reason, and because the injuries we as patients suffer as a result of physician burnout are also hard to perceive, we are not outraged by the No Patient Left Behind movement as parents and students were by the NCLB.

We should be.

The micromanagement of doctors, directly through “utilization review” by bureaucrats and indirectly via financial incentives tied to report cards, has taken a dreadful toll. By turning medicine into “factory work,” as the Star Tribune put it in its May article, proponents of micromanagement are driving doctors into early retirement and degrading the quality of services delivered by the physicians who remain in practice. Micromanagement buffs are also driving up costs (all of those computers, all of that data entry, all of that number-crunching and all of that third-party supervision have to be paid for somehow).

So what can we as ordinary patients do? We must stick our noses into a debate that has for too long gone on over our heads. Over the last half century, an unholy coalition of large employers and insurance companies has persuaded leaders of both political parties that U.S. health care costs are double those of other industrialized nations because U.S. doctors order too many services for their patients.

Never mind that underuse of medical care is far more common than overuse, even among those of us with insurance. Never mind that people in other industrialized nations use just as much health care as we do. Never mind that insurance company bureaucrats don’t know how to reduce overuse without aggravating underuse and driving up administrative costs.

The unholy alliance made up its mind that overuse — not excessive administrative costs, not excessive profits and prices — was the reason why U.S. health care costs are high, and that someone had to force doctors to stop ordering all those unnecessary services.

The solution the unholy alliance adopted came to be called “managed care” by the late 1980s. The terminology that managed-care advocates use has changed over the intervening decades, but the basic tactics remain the same: Micromanage doctors directly by vetoing their decisions or making them get approval for a treatment from insurance industry bureaucrats, and micromanage them indirectly by exposing them to the risk of financial penalties if their patients cost “too much” or if patients with one of a dozen diseases don’t get “quality” care as the bureaucrats define it.

These counterproductive efforts to control physician behavior are what are burning doctors out. They are also driving doctors into the arms of large hospital-clinic chains called “accountable care organizations” (ACOs), where their autonomy is even further reduced. (ACOs are HMOs on training wheels). Both problems — the rising physician burnout rate and the takeover of our health care system by a few enormous corporations — have occurred with no public debate.

The deliberations of the Minnesota Health Care Reform Task Force are typical of the problem. The task force is supposed to issue a report to the Legislature in January on how to improve our health care system. But it has devoted no time to the physician burnout problem. It has, however, spent many hours discussing more measurement of doctors and pushing more doctors into ACOs.

If Minnesota patients remain oblivious to the physician burnout problem, we will soon regret it. We should let our legislators know that we want the problem addressed. And we don’t mean massages and therapy for our doctors. We mean a restoration of physician authority to make decisions based on evidence and patient values, and an end to the managed-care tactics that are burning out our doctors.

Kip Sullivan is a nonphysician member of the board of the Minnesota chapter of Physicians for a National Health Program.

http://www.startribune.com/physicians-are-burning-out-and-patients-must-rally-around-them/363775071/

A final word from David L. Adams, M.D.

Maine Voices: ‘Medicare for all’ system makes so much sense on so many levels

With lowered costs and universal coverage, single-payer American health care would cure many ills

By David L. Adams, Special to the Press Herald
Portland Press Herald, December 26, 2015

COUSINS ISLAND, Maine — It is open enrollment time for Medicare. Many people are finding themselves totally perplexed by the need to evaluate the competing offerings of the different Medicare supplement plans and Part D drug plans they have to choose from before the Dec. 7 deadline for enrollment.

The problem is the choices are so complicated that comparisons of apples to oranges don’t begin to describe the difficulties.

So why not simplify things by going to a single-payer, Medicare-for-all system, as many industrialized countries around the world have done with striking success? That success can be measured by their administrative costs, which are less than half the costs of our system of private health insurance.

Another measure of success is that there are better outcomes of care in countries with universal coverage, such as those with single-payer health care. There were 15 countries around the world with single-payer systems as of 2009, and all but four had higher-rated health care systems (by the World Health Organization) than the United States.

We pay considerably more for our health care, per person, than do people in any other country. Thanks to Congress, our current system prohibits negotiating about drug pricing, which is another source of cost savings in many countries. But our system does allow inflated salaries to the CEOs and administrators whose main function seems to be to refuse care whenever it will enhance their profit margin.

So, what are the drawbacks to single-payer Medicare for all, which have been cited by conservative Congresses since the 1960s?

• It’s socialized medicine: “Socialized medicine” refers to government-controlled medicine. Medicare for all is certainly not socialized medicine. The people providing your health care would not all work for the government. The decisions you and your health care provider make would continue to be private, without “death panels” or other suggested forms of government interference;

• It would lead to higher taxes: Because of potential savings on administrative costs and on negotiated drug prices, a recent study by economist Gerald Friedman showed that Medicare for all could save $592 billion per year in health care costs. These savings come from $476 billion saved if administrative costs were limited to the percentage spent on administration by Medicare, along with the $116 billion saved by negotiating pharmaceutical prices down to the levels charged in Europe.

This would be enough to offset cost increases for universal coverage. Gerald Friedman’s research shows that 95 percent of U.S. households would save money overall with Medicare for all.

Most importantly, by providing access to care for everyone, our health outcomes such as infant and maternal mortality, life expectancy and care for chronic illnesses, which now lag behind many developed countries, would improve.

Universal coverage and better outcomes at lower cost! So why not Medicare for all?

http://www.pressherald.com/2015/12/26/maine-voices-medicare-for-all-system-makes-so-much-sense-on-so-many-levels/

***

Comment:

By Don McCanne, M.D.

As we struggle to bring to America a better health care system for all, it seems appropriate to cap the year with the final words from David L. Adams, M.D. of Cousins Island, Maine.

Following is a note from the editor of the Portland Press Herald:

“EDITOR’S NOTE: David L. Adams, M.D., lived with his wife and family on Cousins Island in Yarmouth for almost 40 years.

“He retired in 1998 after 30 years in active practice with Maine Cardiology in Portland. He was a dedicated volunteer after retirement, winning several awards for his activities.

“A passionate advocate for single-payer health care, Adams was one of the organizers of a celebration of Medicare’s 50th birthday in Monument Square in Portland on July 30.

“As he became cognizant of his approaching death from cancer this fall, he wrote the following column as an act of devotion to his patients and his belief in the importance of affordable health care for all.

“Adams died Dec. 6, the day before the end of open enrollment for Medicare in 2015.”