By Don McCanne
September 1, 2010
Speaker John Perez of the California State Assembly, on the very last day of the legislative session, pulled SB 810, the single payer bill, from the Assembly floor.
This highly unusual move of pulling a bill that had cleared all legislative hurdles except for the final Assembly floor vote was to protect Democrats from having to cast a health care reform vote in a difficult political environment three months before the next election.
Democrats feared a backlash from those who are opposed to the recently enacted federal health care legislation should they vote for the bill, and they feared offending their progressive base should they vote against the bill. Since a veto by Gov. Schwarzenegger was a given, it was decided that it would be safer to avoid the political risks by simply pulling the bill.
But did they really avoid that risk? Are the single payer advocates expendable? Don’t think so.
Fortunately, Senator Mark Leno is not to be deterred. He has vowed to reintroduce the bill in the next legislative session which begins in January.
The Democrats are worried about their political base, but maybe that’s not the framing we should be looking at. Perhaps the single payer advocates should be reassessing their own base instead.
Not all Democrats have been supportive of single payer, and several Republicans who are not part of the prevailing lock-step bloc do understand the benefits of the single payer model. The Patient Protection and Affordable Care Act is proof that we can’t rely on the Democrats to do the right thing. Most importantly, everyone understands the benefits of Medicare as a social insurance program (even if there is a fringe reactionary element that would emasculate it).
The Tea Party is proving that passionate voices can be heard. Maybe we can learn from them, though our message should contain more than simple platitudes. Our message needs to convey the principled substance of health care justice, and it needs to be loud, clear and highly infectious.

By Drew Armstrong
Bloomberg
August 26, 2010

Health insurers led by WellPoint Inc. are backing Republicans with campaign donations by an 8-to-1 margin, favoring the party that’s promised to repeal President Barack Obama’s health-care overhaul if it wins back Congress.

WellPoint, Humana, Aetna, Cigna and UnitedHealth Group Inc. have also been considering a $20 million-plus campaign fund to reward friends and punish enemies in Congress. That fund would target vulnerable Democrats who have spoken out against the industry, and would support candidates who are likely to argue for the industry’s positions during future debate on the health overhaul.

http://www.bloomberg.com/news/2010-08-26/health-insurer-cash-shifts-to-favor-republicans-before-november-elections.html

Comment:

By Don McCanne, MD

With private insurers supporting Republicans by an 8-to-1 margin, there is no question but that the insurers are supporting their own financial interests, regardless of the negative impact on people who need health care.

The Republicans remain opposed to all forms of social insurance that would make health care accessible and affordable for everyone (not that the Democrats did much better this time around). Instead Republicans support measures such as high-deductible health plans, health savings accounts, elimination of mandated benefits such as mental health and maternity care, and promoting interstate sale of less regulated, Spartan plans.

Insurers prefer these plans because they are the most profitable. Many individuals in the large healthy sector of our population tend to prefer these plans because the premiums are lower. Unfortunately for the sick, these plans shift a burdensome amount of the health care costs to the patients in need, not to mention the fact that the insurers have been relatively successful in avoiding these higher-cost individuals in the first place.

Republicans support these proposals because of their ideological stance, believing that each person should be responsible for their own welfare, making exceptions only for those who are the most destitute, not of their own making. They oppose the social solidarity of “collectivist” approaches such as universal insurance programs, whether public or private.

A distinction should be made between the current, lock-step, obstructionist, party-of-NO Republicans, and the nearly extinct species of progressive Republican – many of whom have become independent. It is this obstructionist Republican bloc that serves so well the interests of the private insurers.

It’s sad that the Democrats got into bed with these people. The Democrats ended up supporting the right-wing private insurance model of Mitt Romney and the Heritage Foundation to appease the Republicans and the private insurers. That resulted in the enactment of a terribly flawed program that will not adequately control costs, and will leave tens of millions uninsured and many more underinsured.

The insurers now want to send us more of these reactionary politicians. Aren’t there enough of us who care about the health of all of our people to step up and counter this? Or is it merely all words (for the pollsters), and no action (on behalf of those with health care needs)?

Where are our activists?

Health Insurer Cash Shifts to Favor Republicans Before Election

By Drew Armstrong
Bloomberg
August 26, 2010
Health insurers led by WellPoint Inc. are backing Republicans with campaign donations by an 8-to-1 margin, favoring the party that’s promised to repeal President Barack Obama’s health-care overhaul if it wins back Congress.
WellPoint, Humana, Aetna, Cigna and UnitedHealth Group Inc. have also been considering a $20 million-plus campaign fund to reward friends and punish enemies in Congress. That fund would target vulnerable Democrats who have spoken out against the industry, and would support candidates who are likely to argue for the industry’s positions during future debate on the health overhaul.
http://www.bloomberg.com/news/2010-08-26/health-insurer-cash-shifts-to-favor-republicans-before-november-elections.html

With private insurers supporting Republicans by an 8-to-1 margin, there is no question but that the insurers are supporting their own financial interests, regardless of the negative impact on people who need health care.
The Republicans remain opposed to all forms of social insurance that would make health care accessible and affordable for everyone (not that the Democrats did much better this time around). Instead Republicans support measures such as high-deductible health plans, health savings accounts, elimination of mandated benefits such as mental health and maternity care, and promoting interstate sale of less regulated, Spartan plans.
Insurers prefer these plans because they are the most profitable. Many individuals in the large healthy sector of our population tend to prefer these plans because the premiums are lower. Unfortunately for the sick, these plans shift a burdensome amount of the health care costs to the patients in need, not to mention the fact that the insurers have been relatively successful in avoiding these higher-cost individuals in the first place.
Republicans support these proposals because of their ideological stance, believing that each person should be responsible for their own welfare, making exceptions only for those who are the most destitute, not of their own making. They oppose the social solidarity of “collectivist” approaches such as universal insurance programs, whether public or private.
A distinction should be made between the current, lock-step, obstructionist, party-of-NO Republicans, and the nearly extinct species of progressive Republican – many of whom have become independent. It is this obstructionist Republican bloc that serves so well the interests of the private insurers.
It’s sad that the Democrats got into bed with these people. The Democrats ended up supporting the right-wing private insurance model of Mitt Romney and the Heritage Foundation to appease the Republicans and the private insurers. That resulted in the enactment of a terribly flawed program that will not adequately control costs, and will leave tens of millions uninsured and many more underinsured.
The insurers now want to send us more of these reactionary politicians. Aren’t there enough of us who care about the health of all of our people to step up and counter this? Or is it merely all words (for the pollsters), and no action (on behalf of those with health care needs)?
Where are our activists?

By Jessica Marcy
Kaiser Health News
August 27, 2010

Under federal rules, most people with disabilities who are younger than 65 aren’t eligible for Medicare until more than two years after they qualify for Social Security disability income. A coalition of more than 65 organizations led by the Medicare Rights Center has been pushing Congress to do away with the waiting period. But the effort has stalled because of the high cost to the federal government – an estimated $113 billion over 10 years, according to the Congressional Budget Office. That takes into account a $32 billion reduction in federal spending on Medicaid, the state-federal program for the poor and the disabled. Many people with disabilities go on Medicaid while they wait to become eligible for Medicare.

When Medicare expanded in 1972 to cover the disabled, Congress created the waiting period to help control costs and ensure that only people with severe, ongoing disabilities received coverage. About 17 percent of Medicare’s total 47 million beneficiaries – just over 8 million people in 2010 – receive disability benefits, according to the Kaiser Family Foundation.

Still, the patient groups are pushing to end the Medicare waiting period because many people may still need government help. Currently, nearly 39 percent of patients are uninsured for at least some of the time during the Medicare two-year waiting period while 26 percent have no insurance for the entire time.

Discarding the Medicare waiting period “is always going to be an issue in Congress,” said Edmund Haislmaier, senior health policy research fellow at the Heritage Foundation. “Some of it is money, some of it is politics, too. For members of Congress, irrespective of party or where they stand on the issue, it’s kind of all-or-nothing because if they did it for some diseases, then they’re immediately going to be inundated with ‘Why didn’t you do it for us?'”

Joseph Antos, health care policy scholar at the American Enterprise Institute, said that a total elimination of the waiting period was not going to happen. “Across the board eliminating the two years just doesn’t seem practical,” he said. “This really is a money issue.”

http://www.kaiserhealthnews.org/Stories/2010/August/27/huntington-waiting-period.aspx

Comment: 

By Don McCanne, MD

When Congress expanded Medicare to cover individuals under 65 with long-term disabilities, they specified a two year waiting period to be certain that only those with truly permanent disabilities would be admitted to the program. Obviously this creates a hardship for precisely those for whom the eligibility was established. Will the Patient Protection and Affordable Care Act (PPACA) adequately address this injustice?

PPACA did not include any adjustments in the two year waiting period. Consequently different groups representing specific chronic disorders are lobbying for exceptions to the two year wait. Even if some of these groups achieve legislative success, it will not help the others who must wait the two years.

Since many lose their insurance and their income during that two year wait, some may become eligible for the expanded Medicaid program. Yesterday’s message explained how Medicaid may leave those with chronic disorders underinsured with impaired outcomes, so this is certainly not a satisfactory solution. Besides, many with inadequate incomes may still fall above the threshold for Medicaid eligibility.

For those who lose their insurance during the two year wait, the individual mandate would require that they purchase private plans. Even with premium subsidies, these plans may still not be affordable. Besides, their low actuarial values will not provide adequate protection for these individuals with high health care costs, even with out-of-pocket spending subsidies.

PPACA included the CLASS Act (Community Living Assistance Services and Supports Act) designed to provide long-term care insurance. Though you might think that this provides an out, there are significant problems with CLASS. The program is voluntary and the individual must pay premiums for five years before benefits are available. That alone will exclude those with modest incomes who might consider the premiums to be unaffordable, especially for a program they can’t use for five years and may never need. Furthermore, the benefits are anticipated to be quite meager and likely will provide only a modest daily cash benefit. The CLASS Act will not fulfill the insurance need for the two year gap.

The comments from the representatives of the Heritage Foundation and the American Enterprise Institute describe the real hurdles: politics and money. It’s not that we can’t find the money, but the anti-government politics of today is driven by the philosophy that the government has been drained dry so that no funds are available. That is ridiculous. Our national health expenditures are already adequate, but the funds are inequitably and inefficiently distributed. We need more government involvement, not less, in providing stewardship over our health care funds.

The two year waiting period is yet one more example of the profound injustices inherent in our fragmented, dysfunctional health care financing system – a unsound and iniquitous system perpetuated by Congress through the enactment of PPACA. All of this evil nonsense would go away if they instead would enact a single payer, improved Medicare for all.

Groups Press Congress To End Patients’ Wait For Medicare

By Jessica Marcy
Kaiser Health News
August 27, 2010
Under federal rules, most people with disabilities who are younger than 65 aren’t eligible for Medicare until more than two years after they qualify for Social Security disability income. A coalition of more than 65 organizations led by the Medicare Rights Center has been pushing Congress to do away with the waiting period. But the effort has stalled because of the high cost to the federal government – an estimated $113 billion over 10 years, according to the Congressional Budget Office. That takes into account a $32 billion reduction in federal spending on Medicaid, the state-federal program for the poor and the disabled. Many people with disabilities go on Medicaid while they wait to become eligible for Medicare.
When Medicare expanded in 1972 to cover the disabled, Congress created the waiting period to help control costs and ensure that only people with severe, ongoing disabilities received coverage. About 17 percent of Medicare’s total 47 million beneficiaries – just over 8 million people in 2010 – receive disability benefits, according to the Kaiser Family Foundation.
Still, the patient groups are pushing to end the Medicare waiting period because many people may still need government help. Currently, nearly 39 percent of patients are uninsured for at least some of the time during the Medicare two-year waiting period while 26 percent have no insurance for the entire time.
Discarding the Medicare waiting period “is always going to be an issue in Congress,” said Edmund Haislmaier, senior health policy research fellow at the Heritage Foundation. “Some of it is money, some of it is politics, too. For members of Congress, irrespective of party or where they stand on the issue, it’s kind of all-or-nothing because if they did it for some diseases, then they’re immediately going to be inundated with ‘Why didn’t you do it for us?'”
Joseph Antos, health care policy scholar at the American Enterprise Institute, said that a total elimination of the waiting period was not going to happen. “Across the board eliminating the two years just doesn’t seem practical,” he said. “This really is a money issue.”
http://www.kaiserhealthnews.org/Stories/2010/August/27/huntington-waiting-period.aspx

When Congress expanded Medicare to cover individuals under 65 with long-term disabilities, they specified a two year waiting period to be certain that only those with truly permanent disabilities would be admitted to the program. Obviously this creates a hardship for precisely those for whom the eligibility was established. Will the Patient Protection and Affordable Care Act (PPACA) adequately address this injustice?
PPACA did not include any adjustments in the two year waiting period. Consequently different groups representing specific chronic disorders are lobbying for exceptions to the two year wait. Even if some of these groups achieve legislative success, it will not help the others who must wait the two years.
Since many lose their insurance and their income during that two year wait, some may become eligible for the expanded Medicaid program. Yesterday’s message explained how Medicaid may leave those with chronic disorders underinsured with impaired outcomes, so this is certainly not a satisfactory solution. Besides, many with inadequate incomes may still fall above the threshold for Medicaid eligibility.
For those who lose their insurance during the two year wait, the individual mandate would require that they purchase private plans. Even with premium subsidies, these plans may still not be affordable. Besides, their low actuarial values will not provide adequate protection for these individuals with high health care costs, even with out-of-pocket spending subsidies.
PPACA included the CLASS Act (Community Living Assistance Services and Supports Act) designed to provide long-term care insurance. Though you might think that this provides an out, there are significant problems with CLASS. The program is voluntary and the individual must pay premiums for five years before benefits are available. That alone will exclude those with modest incomes who might consider the premiums to be unaffordable, especially for a program they can’t use for five years and may never need. Furthermore, the benefits are anticipated to be quite meager and likely will provide only a modest daily cash benefit. The CLASS Act will not fulfill the insurance need for the two year gap.
The comments from the representatives of the Heritage Foundation and the American Enterprise Institute describe the real hurdles: politics and money. It’s not that we can’t find the money, but the anti-government politics of today is driven by the philosophy that the government has been drained dry so that no funds are available. That is ridiculous. Our national health expenditures are already adequate, but the funds are inequitably and inefficiently distributed. We need more government involvement, not less, in providing stewardship over our health care funds.
The two year waiting period is yet one more example of the profound injustices inherent in our fragmented, dysfunctional health care financing system – a unsound and iniquitous system perpetuated by Congress through the enactment of PPACA. All of this evil nonsense would go away if they instead would enact a single payer, improved Medicare for all.

By Michael D. Kogan, Ph.D., Paul W. Newacheck, Dr.P.H., Stephen J. Blumberg, Ph.D., Reem M. Ghandour, Dr.P.H., Gopal K. Singh, Ph.D., Bonnie B. Strickland, Ph.D., and Peter C. van Dyck, M.D., M.P.H.
The New England Journal of Medicine
August 25, 2010

ABSTRACT

Background

Recent interest in policy regarding children’s health insurance has focused on expanding coverage. Less attention has been devoted to the question of whether insurance sufficiently meets children’s needs.

Methods

We estimated underinsurance among U.S. children on the basis of data from the 2007 National Survey of Children’s Health (sample size, 91,642 children) regarding parents’ or guardians’ judgments of whether their children’s insurance covered needed services and providers and reasonably covered costs. Data on adequacy were combined with data on continuity of insurance coverage to classify children as never insured during the past year, sometimes insured during the past year, continuously insured but inadequately covered (i.e., underinsured), and continuously insured and adequately covered. We examined the association between this classification and five overall indicators of health care access and quality: delayed or forgone care, difficulty obtaining needed care from a specialist, no preventive care, no developmental screening at a preventive visit, and care not meeting the criteria of a medical home.

Results

We estimated that in 2007, 11 million children were without health insurance for all or part of the year, and 22.7% of children with continuous insurance coverage — 14.1 million children — were underinsured. Older children, Hispanic children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. As compared with children who were continuously and adequately insured, uninsured and underinsured children were more likely to have problems with health care access and quality.

Conclusions

The number of underinsured children exceeded the number of children without insurance for all or part of the year studied. Access to health care and the quality of health care are suboptimal for uninsured and underinsured children. (Funded by the Health Resources and Services Administration.)

From the Discussion

We found that inadequate coverage of charges was far and away the most common source of underinsurance. We also found that children enrolled in private plans were more than three times as likely as their counterparts in public plans to have inadequate coverage of charges. This dramatic difference is probably the result of federal rules that permit only very limited cost sharing under Medicaid and modest cost sharing under the Children’s Health Insurance Program.

http://healthpolicyandreform.nejm.org/?p=12176&query=TOC

And…

Treating Underinsurance

By James M. Perrin, M.D.
Editorial, The New England Journal of Medicine
August 25, 2010

Health care reform, through the Patient Protection and Affordable Care Act of 2010, may improve access to needed health care services for people with chronic health conditions, including children. Key private insurance reforms, including the removal of provisions imposing lifetime limits or unreasonable limits on annual benefit, the removal of discriminatory premium rates, guaranteed availability of coverage, and dependent coverage for young people up the age of 26 years, may go a long way toward improving coverage for Americans and lowering out-of-pocket costs.

However, the growth in child and adolescent disability, combined with the problem of underinsurance and its effects on the quality of care and access to care, also highlights gaps that will remain in public insurance coverage even after the institution of safeguards affecting private coverage. The basic Medicaid program, unlike Medicare, includes long-term care benefits, such as care at home or in nursing homes and specialized therapies, and it serves as a vital source of financing for nursing home care (about 41% of current total nursing home support). The assumption that most children are healthy, however, has led policymakers to limit long-term care and coverage of a number of other benefits for chronic conditions in other programs for children. SCHIP provided a less generous benefit package — and excluded coverage of services for many chronic conditions (e.g., respiratory therapy, speech and language services, and home-based services) on the basis of the belief that the SCHIP population would not need such benefits. Research conducted since the enactment of SCHIP has indicated that substantial numbers of enrolled children have chronic conditions and could benefit from these services.

The Affordable Care Act calls for a major expansion in Medicaid, especially to provide insurance for a large number of currently uninsured and ineligible adults — that is, those under 65 years of age who have incomes below 133% of the federal poverty line (an estimated 12 million to 17 million people). Here, too, the benefit package will resemble the SCHIP (now CHIP) benefit, with an emphasis on coverage of care for acute conditions and less generous coverage of long-term care. Yet the members of the low-income adult population who will become eligible under this Medicaid expansion include substantial numbers of people with chronic conditions, especially mental health conditions. Here, too, for cases in which long-term care is needed, the Medicaid expansion may leave many newly insured people underinsured. For those instances in which the major epidemics of chronic conditions among adolescents have already begun to affect the young adult population, it is unlikely that many of these young people, even with their new Medicaid coverage, will receive the coverage they need for long-term care.

http://healthpolicyandreform.nejm.org/?p=12178&query=TOC

Comment: 

By Don McCanne, MD

Being underinsured often results in the same or similar adverse outcomes as not being insured at all. This study demonstrates that the problem of underinsurance amongst children is even more widespread than being uninsured. Does the Patient Protection and Affordable Care Act (PPACA) adequately address this shameful injustice?

PPACA does expand coverage for children through the individual mandate to purchase private insurance, though this study demonstrates that private insurance plans were three times as likely as public insurance plans to have inadequate coverage of charges. Thus PPACA, while reducing the numbers who are uninsured, actually increases the incidence of underinsurance. Most will still be insured through private employer-sponsored plans. For those purchasing their plans through the exchanges, the subsidies will provide some relief but still will not be not adequate to eliminate underinsurance.

PPACA also expands Medicaid, though primarily for adults. Although Medicaid and CHIP cover out-of-pocket expenses better than do the private plans, the editorial by James Perrin explains how lower-income individuals in these programs may still be underinsured. This is particularly true of those with chronic conditions who may need long-term care.

An appropriately designed single payer system eliminates the problem of underinsurance by eliminating significant cost sharing for all appropriate health care services. The efficiencies and policies of the single payer model create enough savings to pay these costs equitably without increasing our national health expenditures.

As long as we remain content with merely tweaking PPACA, we will continue to live in a society that tolerates exposing individuals and families to the hardships created by underinsurance or by having no insurance at all. Certainly we must be a better nation than that.

Underinsurance among Children in the United States

By Michael D. Kogan, Ph.D., Paul W. Newacheck, Dr.P.H., Stephen J. Blumberg, Ph.D., Reem M. Ghandour, Dr.P.H., Gopal K. Singh, Ph.D., Bonnie B. Strickland, Ph.D., and Peter C. van Dyck, M.D., M.P.H.
The New England Journal of Medicine
August 25, 2010
ABSTRACT
Background
Recent interest in policy regarding children’s health insurance has focused on expanding coverage. Less attention has been devoted to the question of whether insurance sufficiently meets children’s needs.
Methods
We estimated underinsurance among U.S. children on the basis of data from the 2007 National Survey of Children’s Health (sample size, 91,642 children) regarding parents’ or guardians’ judgments of whether their children’s insurance covered needed services and providers and reasonably covered costs. Data on adequacy were combined with data on continuity of insurance coverage to classify children as never insured during the past year, sometimes insured during the past year, continuously insured but inadequately covered (i.e., underinsured), and continuously insured and adequately covered. We examined the association between this classification and five overall indicators of health care access and quality: delayed or forgone care, difficulty obtaining needed care from a specialist, no preventive care, no developmental screening at a preventive visit, and care not meeting the criteria of a medical home.
Results
We estimated that in 2007, 11 million children were without health insurance for all or part of the year, and 22.7% of children with continuous insurance coverage — 14.1 million children — were underinsured. Older children, Hispanic children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. As compared with children who were continuously and adequately insured, uninsured and underinsured children were more likely to have problems with health care access and quality.
Conclusions
The number of underinsured children exceeded the number of children without insurance for all or part of the year studied. Access to health care and the quality of health care are suboptimal for uninsured and underinsured children. (Funded by the Health Resources and Services Administration.)
From the Discussion
We found that inadequate coverage of charges was far and away the most common source of underinsurance. We also found that children enrolled in private plans were more than three times as likely as their counterparts in public plans to have inadequate coverage of charges. This dramatic difference is probably the result of federal rules that permit only very limited cost sharing under Medicaid and modest cost sharing under the Children’s Health Insurance Program.
http://healthpolicyandreform.nejm.org/?p=12176&query=TOC

And…

Treating Underinsurance

By James M. Perrin, M.D.
Editorial, The New England Journal of Medicine
August 25, 2010
Health care reform, through the Patient Protection and Affordable Care Act of 2010, may improve access to needed health care services for people with chronic health conditions, including children. Key private insurance reforms, including the removal of provisions imposing lifetime limits or unreasonable limits on annual benefit, the removal of discriminatory premium rates, guaranteed availability of coverage, and dependent coverage for young people up the age of 26 years, may go a long way toward improving coverage for Americans and lowering out-of-pocket costs.
However, the growth in child and adolescent disability, combined with the problem of underinsurance and its effects on the quality of care and access to care, also highlights gaps that will remain in public insurance coverage even after the institution of safeguards affecting private coverage. The basic Medicaid program, unlike Medicare, includes long-term care benefits, such as care at home or in nursing homes and specialized therapies, and it serves as a vital source of financing for nursing home care (about 41% of current total nursing home support). The assumption that most children are healthy, however, has led policymakers to limit long-term care and coverage of a number of other benefits for chronic conditions in other programs for children. SCHIP provided a less generous benefit package — and excluded coverage of services for many chronic conditions (e.g., respiratory therapy, speech and language services, and home-based services) on the basis of the belief that the SCHIP population would not need such benefits. Research conducted since the enactment of SCHIP has indicated that substantial numbers of enrolled children have chronic conditions and could benefit from these services.
The Affordable Care Act calls for a major expansion in Medicaid, especially to provide insurance for a large number of currently uninsured and ineligible adults — that is, those under 65 years of age who have incomes below 133% of the federal poverty line (an estimated 12 million to 17 million people). Here, too, the benefit package will resemble the SCHIP (now CHIP) benefit, with an emphasis on coverage of care for acute conditions and less generous coverage of long-term care. Yet the members of the low-income adult population who will become eligible under this Medicaid expansion include substantial numbers of people with chronic conditions, especially mental health conditions. Here, too, for cases in which long-term care is needed, the Medicaid expansion may leave many newly insured people underinsured. For those instances in which the major epidemics of chronic conditions among adolescents have already begun to affect the young adult population, it is unlikely that many of these young people, even with their new Medicaid coverage, will receive the coverage they need for long-term care.
http://healthpolicyandreform.nejm.org/?p=12178&query=TOC

Being underinsured often results in the same or similar adverse outcomes as not being insured at all. This study demonstrates that the problem of underinsurance amongst children is even more widespread than being uninsured. Does the Patient Protection and Affordable Care Act (PPACA) adequately address this shameful injustice?
PPACA does expand coverage for children through the individual mandate to purchase private insurance, though this study demonstrates that private insurance plans were three times as likely as public insurance plans to have inadequate coverage of charges. Thus PPACA, while reducing the numbers who are uninsured, actually increases the incidence of underinsurance. Most will still be insured through private employer-sponsored plans. For those purchasing their plans through the exchanges, the subsidies will provide some relief but still will not be not adequate to eliminate underinsurance.
PPACA also expands Medicaid, though primarily for adults. Although Medicaid and CHIP cover out-of-pocket expenses better than do the private plans, the editorial by James Perrin explains how lower-income individuals in these programs may still be underinsured. This is particularly true of those with chronic conditions who may need long-term care.
An appropriately designed single payer system eliminates the problem of underinsurance by eliminating significant cost sharing for all appropriate health care services. The efficiencies and policies of the single payer model create enough savings to pay these costs equitably without increasing our national health expenditures.
As long as we remain content with merely tweaking PPACA, we will continue to live in a society that tolerates exposing individuals and families to the hardships created by underinsurance or by having no insurance at all. Certainly we must be a better nation than that.