PNHP

Underinsurance Remains Big Problem Under Obama Health Law

Underinsurance Remains Big Problem Under Obama Health Law

By Aaron E. Carroll, MD
The New York Times, December 1, 2014

The Affordable Care Act, like most health care reform efforts, focuses on people without insurance. That’s fine, because those people do face significant problems obtaining health care in the United States.

But underinsurance is a real concern, too, and it’s often ignored.

Before the A.C.A. was passed, underinsurance was prevalent. Of adults age 19-64 in 2010, 16 percent, or 29 million, met the Commonwealth Fund’sdefinition of being underinsured: one’s out-of-pocket health care costs exceeding 10 percent of income (5 percent when income is less than 200 percent of the federal poverty line), or one’s insurance deductible being more than 5 percent of income. The number of underinsured Americans had grown by 80 percent from 2003 to 2010.

Some of the A.C.A.’s regulations, such as removing annual or lifetime limits on reimbursements, were aimed at reducing the out-of-pocket spending that people might have to make. When the act went into effect and some people found their policies had been canceled (despite President Obama’s now-infamous assurance that “if you like your health care plan, you can keep it”), it was often because those policies left them underinsured, even if they didn’t realize it.

But the A.C.A. has not done as much as many had hoped it would to reduce underinsurance. In fact, it may be helping to spread it. And proposed modifications to the law, like those that would introduce a new tier of “copper” plans in addition to bronze, silver, gold and platinum, might make underinsurance worse.

This is important, because research shows that those who are underinsured are more likely to go without needed care.

In the most recent update of the Commonwealth Fund survey, conducted in September and October of this year, investigators found that 13 percent of all adults 19-64 spent more than 10 percent of their income on out-of-pocket health care costs. Poor adults were the most likely to spend this amount. More than 30 percent of nonelderly adults earning less than the poverty line spent more than 10 percent of their income on out-of-pocket costs, and 18 percent of those making between 100 percent and 200 percent of the poverty line did so. All of these people were insured.

Deductibles remain high for Americans as well. Over all, 13 percent of people age 19-64 had a deductible that was 5 percent of their income or more. Since Medicaid traditionally doesn’t have deductibles, pretty much all of these people had private insurance. Still, those at the lowest end of the socio-economic spectrum were hit the hardest. A full quarter of nonelderly adults below the poverty line had deductibles this large, and 20 percent of those making between 100 percent and 200 percent of the poverty line did.

This is too much for many to spend. More than 40 percent of people who were surveyed said their deductibles were unaffordable. Almost two-thirds of people making between 100 percent and 200 percent of the poverty line said they were unaffordable.

The point of having insurance is to be able to get care when you need it, without too large a financial burden. Underinsured Americans are not receiving this benefit, though. They can’t get the care they need. Twenty-seven percent of adults with a deductible large enough to render them underinsured didn’t see the doctor when they were sick; 23 percent didn’t get a preventive care test; 29 percent skipped a test, treatment or follow-up appointment; and 22 percent didn’t see a specialist to whom they were referred. Forty percent of them had at least one of these cost-related access problems.

These are people who had private health insurance for the full year. They are not the uninsured.

Last year, the average deductible for a silver-level plan offered in the exchanges was more than $2,500. Some plans had deductibles as high as $5,000. These figures are most likely at least 5 percent of income for many, if not most, Americans (half of American households earn less than $53,046 per year), even for those who qualify for cost-sharing subsidies. If people choose bronze plans, things are even worse. The average deductible for such plans was more than $5,000, with some plans hitting the out-of-pocket maximum of $6,350. Almost anyone purchasing such plans would be, by definition, underinsured.

Moreover, efforts are underway to go even further. The Expanded Consumer Choice Act, co-sponsored by six Democratic senators and one independent, seeks to add a new level of insurance coverage. “Copper” plans would have 50 percent actuarial value. Such plans would have significantly lower premium costs than bronze plans, which might increase the number of people who will buy insurance.

But this would be accomplished at the expense of higher out-of-pocket costs. Deductibles for these plans might have to be as high as $9,000, which would mean increasing the out-of-pocket maximum allowable by law. This would lead to even more people being underinsured.

As I’ve highlighted in previous Upshot articles, people who have chronic illnesses fare worse when they have more cost-sharing. They are also more likely to be underinsured. The Commonwealth Fund found that 17 percent of people who were in fair or poor health, or who had a chronic condition, spent at least 10 percent of their income on out-of-pocket costs. This was on top of the cost of their insurance premiums, because all of them were insured.

Just a month ago, Gallup asked Americans to identify the “most urgent health problem facing this country at the present time.” Eighteen percent replied that it was access to health care, or universal health coverage; but 19 percent replied that it was affordable health care or costs.

In the quest for universal coverage, it’s important that we not lose sight of “coverage” in order to achieve “universal.” The point of improving access is, after all, to make sure that people can get, and afford, care when they need it.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine. He blogs on health research and policy at The Incidental Economist, and you can follow him on Twitter at @aaronecarroll.

Prevalence of underinsurance unimproved and likely worse under ACA

Cost Still a Barrier Between Americans and Medical Care

By Rebecca Riffkin
Gallup, November 28, 2014

One in three Americans say they have put off getting medical treatment that they or their family members need because of cost. Although this percentage is in line with the roughly 30% figures seen in recent years, it is among the highest readings in the 14-year history of Gallup asking the question.

Last year, many hoped that the opening of the government healthcare exchanges and the resulting increase in the number of Americans with health insurance would enable more people to seek medical treatment. But, despite a drop in the uninsured rate, a slightly higher percentage of Americans than in previous years report having put off medical treatment, suggesting that the Affordable Care Act has not immediately affected this measure.

The percentage of Americans with private health insurance who report putting off medical treatment because of cost has increased from 25% in 2013 to 34% in 2014.

This year, 22% of Americans say they have put off medical treatment for a “very” or “somewhat serious” condition. 

Bottom Line

One of the goals of opening the government exchanges was to enable more Americans to get health insurance to help cover the costs of needed medical treatments. While many Americans have gained insurance, there has been no downturn in the percentage who say they have had to put off needed medical treatment because of cost.

http://www.gallup.com/poll/179774/cost-barrier-americans-medical-care.aspx

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Underinsurance Remains Big Problem Under Obama Health Law

By Aaron E. Carroll
The New York Times, December 1, 2014

The A.C.A. has not done as much as many had hoped it would to reduce underinsurance. In fact, it may be helping to spread it. And proposed modifications to the law, like those that would introduce a new tier of “copper” plans in addition to bronze, silver, gold and platinum, might make underinsurance worse.

The point of having insurance is to be able to get care when you need it, without too large a financial burden. Underinsured Americans are not receiving this benefit, though. They can’t get the care they need. Twenty-seven percent of adults with a deductible large enough to render them underinsured didn’t see the doctor when they were sick; 23 percent didn’t get a preventive care test; 29 percent skipped a test, treatment or follow-up appointment; and 22 percent didn’t see a specialist to whom they were referred. Forty percent of them had at least one of these cost-related access problems.

These are people who had private health insurance for the full year. They are not the uninsured.

In the quest for universal coverage, it’s important that we not lose sight of “coverage” in order to achieve “universal.” The point of improving access is, after all, to make sure that people can get, and afford, care when they need it.

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Comment:

By Don McCanne, MD

Health care reform should have eliminated underinsurance, not create more of it. The private insurance industry will not fix this problem but only compound it as it strives to keep its premiums competitive.

We need to replace the private insurers with our own single payer program. For some, Medicare is also underinsurance. We need to fix that and then provide it to everyone.

OECD: United States is first in private social spending

Social spending is falling in some countries, but in many others it remains at historically high levels

OECD, November 2014

In 2014, OECD countries devote more than one-fifth of their economic resources to public social support.

Countries on average spent more on cash benefits (12.3% of GDP) than on social and health services (8.6% of GDP).

Cash income support to the working age population accounts for 4.4% GDP on average across the OECD, of which 1% GDP towards unemployment benefits, 1.8% on disability/sickness benefits, 1.3% on family cash benefits and another 0.4% on other social policy cash supports.

Public expenditure on health is another important social policy area. On average across the OECD, public expenditure on health has increased from 4% in 1980 to 6% of GDP.

In terms of spending, public pension payments constitute the largest social policy area with spending at just below 8% of GDP.

In the United States public social spending is relatively low, but total social spending is the second highest in the world

Thus far, the discussion focussed on public social spending on cash benefits and social and health services, and in the United States and other non-European OECD countries such spending is lower than in most European countries. However, a focus on public budgets misses two important features that affect social spending totals and international comparisons of social expenditure: 1) private social expenditure and 2) the impact of tax systems.

Private social expenditure

Private social expenditure concerns social benefits delivered through the private sector (not transfers between individuals) which involve an element of compulsion and/or inter-personal redistribution, for example through the pooling of contributions and risk sharing in terms of health and longevity. Pensions constitute an important part of both public and private social expenditure. Private pension payments can derive from mandatory and voluntary employer-based (sometimes occupational and industry wide) programmes (e.g. in the Netherlands or the United Kingdom), or tax-supported individual pension plans (e.g., individual retirement accounts in the United States).

Individual out-of-pocket spending on health services is not regarded as social spending, but many private health insurance plans across the OECD involve pooling of contributions and risk sharing across the insured population. On average across the OECD, such private social health expenditure amounted to 0.6% of GDP in 2012. It was 1.5% of GDP in France and 2.5% of GDP in Chile, but across OECD countries private health insurance is most important in the United States where it amounted to 5.7% of GDP. Taken together with public spending on health amounting to 8% of GDP in the same year, and the value of revenue foregone on tax breaks on health premiums (just over 0.5% of GDP), total social health spending in the United States amounted to over 14% of GDP – 4 percentage points higher than in France which is the second biggest “health spender” among OECD countries.

Private social spending plays the most important role in the United States where it amounted to almost 11% of GDP.

Cross-country rankings

The combination of small “net tax effects” and considerable private social spending ensures that Australia, Canada, Japan and in particular the United States move up the international social spending ladder. As private social spending (including health) is so much larger in the United States compared with other countries, its inclusion moves the United States from 23rd in the ranking of the gross public social spending to 2nd place when comparing net total social spending across countries.

http://www.oecd.org/els/soc/OECD2014-Social-Expenditure-Update-Nov2014-8pages.pdf

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Comment:

By Don McCanne, MD

The character of a nation is determined by support of its social programs. Medicare and Social Security are two social insurance programs that are revered by U.S. citizens. Yet those programs, combined with other public social programs, leave us ranked only 23rd amongst OCED nations. It is our unique private social spending programs that move us from 23rd to 2nd place.

At almost 11% of our GDP, private social spending was by far the highest in the United States, as compared to other nations. Contributing to this are our private pension plans (5% of GDP) and especially spending on private health insurance (5.7% of GDP). In fact, our total public and private social spending on health care (private insurance @ 5.7%, public spending @ 8%, and tax breaks on health premiums @ 0.5%) amount to 14% of GDP, making us by far the biggest health spender of all nations.

Is it wise for us to rely so heavily on private social spending? First of all, administration of private retirement accounts is much more expensive and complex than administration of our Social Security system, and administration of private health insurance plans is also much more expensive and complex than is administration of Medicare. We are wasting private social funds on these inefficient intermediaries.

But more than that, as a percentage of income, contributions to private retirement accounts and private health insurance are regressive. For comparable benefits, lower-income individuals pay a higher percentage of their incomes for private pensions and private health insurance than do higher-income individuals. The fact that we rely much more heavily on private social spending demonstrates how inegalitarian the United States has become, in contrast to other nations.

Imagine folding the benefits of individual retirement accounts into Social Security and folding the benefits of private health insurance plans into Medicare, and then fund both programs with equitable progressive taxes. We would have the finest retirement and health programs in the world.

Tomorrow – Thanksgiving – we can give thanks for having the wisdom to do that as a nation (or did I get something wrong here?).

Grady and WellPoint fight, patients lose

Grady, Blue Cross at impasse as contract expires

By Andy Miller
Georgia Health News, November 24, 2014

Contract standoffs between hospital systems and health insurers typically have a way of being resolved — often right before a deadline.

But high-stakes negotiations between Grady Health System and Georgia’s biggest insurer failed to produce a new contract before the midnight deadline Sunday.

That means Grady Memorial Hospital is now “out of network” for Blue Cross and Blue Shield of Georgia members. Patients with Blue Cross insurance will face higher out-of-pocket costs at the Atlanta hospital and its clinics.

Lindsay Caulfield, senior vice president of public affairs at Grady, said in a statement Monday that Blue Cross “pays our health system up to 70 percent less than it pays other Georgia hospitals. By paying us unfairly low rates, Blue Cross Blue Shield has long put Grady at a disadvantage and threatens our long-term sustainability.”

Grady proposed several compromise plans, Caulfield said, “but Blue Cross continually refused to move in their position in any meaningful way.”

The lack of an agreement will affect Blue Cross in trauma services, where Grady has a strong profile, Smith said. But he added that he believes the two sides will eventually reach a new deal. “It’s going to be very difficult for any hospital not to have the largest payer in the state,’’ he said.

http://www.georgiahealthnews.com/2014/11/grady-blue-cross-impasse-contract-expires/

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Comment:

By Don McCanne, MD

We’ve heard similar stories many times before. The largest insurer in Georgia, WellPoint’s Blue Cross and Blue Shield of Georgia, has been unable or unwilling to negotiate a contract renewal with Grady Memorial Hospital, the home of one of the most prominent trauma centers in the nation.

Although Grady will continue to provide emergency services, it is the patients who will be exposed to excessive costs, only because we have a system in which we insist that private, for-profit, autonomous corporations be allowed to take charge of our health care dollars.

The solution is obvious – fire WellPoint and the other private insurers and replace them with our own single payer national health program – an improved Medicare that covers everyone.

Ebola Preparedness Without a Single-Payer System

By Michael Lighty
Healthcare-Now, Nov. 24, 2014

Below is testimony from Michael Lighty, director of public policy for National Nurses United, to the California Assembly Health Committee regarding Ebola preparedness in a fragmented health care system with cost-barriers to care and declining investment in public health.

This is a proud moment for California Nurses Association/National Nurses United, whose members have taken the lead in blowing the whistle for Ebola preparedness. From a die-in on the Las Vegas Strip in September to the 50,000 strong national day of action on Nov. 12, the nurses of CNA/NNU have made history.

Contrary to what their hospital administrators have said about their adherence to the CDC guidelines — nurses reported quite the opposite in a survey of over 3,500 nurses from every state in the U.S. So this new guidance in California creates a real level of security for nurses, and we thank Governor Brown and Director Baker, and the staff who worked so diligently to set this new national standard.

But what about the patients in a fragmented, under resourced “non-system” who are at the mercy of their insurance company’s high-deductible, minimal benefit, narrow network, sparse drug formulary health plan? And those on Medi-Cal who can’t find a doctor to accept them, or those undocumented workers and others who must rely solely on ER visits and a decimated public health system?

Funding for public health preparedness and response activities in the U.S. was $1billion less in 2013, than in 2002, according to a CDC report from earlier this year.

According to CMS data collected in 2013, patients in California Emergency Departments faced waits that are 23 minutes longer than the national average. Specifically, California patients waited on average more than two-and-a-half hours in the ED.

Further, if a patient is admitted to the hospital, the average wait increased to:

  • About five hours and 18 minutes from arrival to the time a patient is admitted; and
  • Nearly an additional two hours before a patient is moved to a bed.

At least 5 percent of patients at 20 of the state’s EDs left before being treated because of the long waits, according to Center for Health Reporting/Daily News.

Let’s make a distinction between an integrated, well-resourced system that guarantees a single standard of care for all with a dedicated funding source and real public accountability – known as single payer – verses the existing fragmented approach that seeks to regulate behavior sometimes with the force of law as in the case of this new guidance, and mostly as monetary incentives and voluntary guidance. Now, the treatment response to Ebola, for example, as other in other pandemics is largely governed by private health care corporations who are only accountable to their shareholders or board of directors, not the public.

Understaffing, access to treatment based on ability to pay, technology replacing hands-on care, difficulty gaining admission: it could and does happen everyday in our fragmented corporate health care system. All this happened to Ebola patient Thomas Eric Duncan in a Dallas hospital, and in his case, it was fatal and two nurses were infected.

We know what works, Canada has done it: A province-based single-payer system and federal agency that has the responsibility and authority to ensure local, state and national coordination to detect, respond and treat outbreaks.

The Ebola epidemic reveals the fissures and fatal inadequacies of our health care “non-system.” Only greater integration, planned and directed resources, and authority to a public health system can protect people in California from the dangers of pandemics like Ebola.

This new guidance issued by Cal/OSHA stands out as a clear mandate for precaution and protection establishing a national standard. Let us a create system where that is the rule, rather than the exception.

http://www.healthcare-now.org/ebola-preparedness-without-a-single-payer-system

Single payer: a powerful tool for better care, better health and reduced costs

By Donald M. Berwick, M.D.

The following is an unofficial transcript of the remarks delivered by Dr. Donald Berwick to the Annual Meeting of Physicians for a National Health Program on Nov. 15, 2014, in New Orleans. Dr. Berwick spoke to the assembly via live video.

Greetings, everyone,

I wish I were there in person, but I’m very grateful you’re letting me join you in this way. Obviously I’m talking to people who have had the vision and leadership and energy on this crucial issue for longer than I have, and I feel flattered you’ve asked me to share my thoughts.

As Gordy [Dr. Gordon Schiff] said, I just ran for the Democratic nomination for governor in Massachusetts. Unfortunately, I did not win the primary election. But in that experience I got much closer, face-to-face, with public policy and social justice issues – not just health care, but more than a dozen other issues – housing, homelessness, education, transportation, environment, energy, support for the arts, criminal justice, and frankly everywhere, poverty and immense debt, disparity, and inequality in our society, including in the state of Massachusetts.

And in the course of that campaign, and partly as a result of speaking to that very wide range of issues, I did take a clear stand – for the first time in my career – in favor of single-payer health care, Medicare for All, in Massachusetts.

I did it openly, I did it as forcefully as I possibly could, and I said it to no matter who I was talking to. And I want to explain in a few minutes why I did that, what I’ve learned from that campaign, and then a few thoughts about what I think is next, although I have to defer to you and your colleagues gathered at your meeting today on the latter.

First: Why did I do this?

I want to frame something first: single-payer health care is important in terms of policy, but it is not, in and of itself, a moral commitment. Social justice and equality, ending poverty and hunger: those would be moral aims. But how we pay for the care we want, and how we get that care, isn’t a matter of morality; it’s just a mechanism.

The test of the value of single payer as a policy isn’t whether or not it is self-evidently or ethically right, but only whether it’s a smart way to achieve quality of care, and I think it is. And I want to tell you why that is.

Drawing on my experience at the Institute for Healthcare Improvement, I’ve seen how powerful the concept of the Triple Aim is: an attempt to designate or help advance health care as an enterprise by starting with what specifically needs to be accomplished on behalf of the communities and the people that we serve. There’s a constellation of such aims in each and every system, and you cannot take them apart.

The Triple Aim includes, first, the aim of better care if you need care, from a check-up to treatment for a heart attack. There is a social need for better care for individuals; that means care that is safe, effective, patient-centered, timely, efficient, and equitable. That’s the first aim: better care for individuals.

The second aim is to help people not get sick in the first place, i.e. better health for populations.

And the third aim is to reduce the per capita cost of health care, so that resources are freed up for worthy alternative public and private endeavors.

So what I began to believe, more and more fully, is that if we consolidate payment into a single pool, a single stream, under public accountability, we’ll be better able to attain the Triple Aim. And that is the key argument for single-payer care.

That would help us achieve the first aim, better care. We have problems in our care. We have care that doesn’t match need, and care that is not safe. The progress toward patient safety in America is nowhere near where it really needs to be in this country, and not, very frankly, in other countries as well. Our care could be far, far more effective. People too often get care they don’t need, and care that is not aligned with science. Nor is care truly patient-centered. There has been some progress, but it’s limited.

I think single-payer care is a strong lever on better care. With it, we could decide to make care safer as a nation, and we could decide to align it with science. We have a lot of trouble doing this with a multi-payer system.

In my Medicaid work at the CMS, I got a report from the Inspector General about overuse of anti-psychotic drugs on Medicaid patients in nursing homes. The report came to my desk, and it showed 300,000 patients in nursing homes getting over-sedated.

So I picked up the phone and called in the head of the nursing home associations, the for-profits, the nonprofits, a dozen people, asking that they meet with me. And they all showed up. I said overmedication in our nursing homes was not OK. “Either you fix it,” I said, “or we will.” Within a few weeks I had reports on my desk, replies from those associations, none perfect, but all showing strong plans to decrease the use of such medications, and those projects are still underway today with good success.

With a single-payer system you have leverage, a voice for improvement. The leverage that you have in the form of payment is powerful.

A single-payer system would also help us achieve more meaningful transparency about the quality of care. Uncoordinated and multiple metrics are driving people in health care crazy right now. We need transparency, we need consolidated metrics that really work.

It would be much easier to achieve meaningful and parsimonious measurement under a single-payer system. It allows us to see how we’re doing. Where did the money go? How is our quality? It’s very hard to get that information, across time and space, in a fragmented, multi-payer system. A single-payer system provides much clearer eyes on the care, to the advantage of patients and the community, like it should be.

Under a single-payer system we can shift resources toward need. A single payer can get a better handle on fee-for-service. We can invest in behavioral health care, as some of you are talking about today, I know. And we would have the kind of community risk pool that we need in order to achieve justice and equality in health care.

And finally, a single payer would be even more effective than Medicare is today. We could do much more under the aegis of a consolidated payment system. It would be a powerful lever for better care.

As for Aim Two, better health, a single-payer system would let us invest upstream, for population health, to address population-based causes of poor health, over space and over time. It would be a powerful force for cross-sectional justice.

I have an illustrative story from New Zealand: I was talking with their Chief Medical Officer several years ago who was proudly telling me that they have an annual budget for health care, and that one year he asked that some of the money originally intended for the Ministry of Health be turned over to the Ministry of Housing. He understood that a lot of the burden of illnesses among children, particularly Maori children, is the result of poor housing conditions. So he actually proposed that money be taken from the health care pot and moved to the housing pot. You can’t do that under a multi-payer system. That won’t work.

So a single-payer system can offer new and powerful levers for prevention.

A single-payer system allows us to track a patient, which is very difficult under a multi-payer system.

Finally, the third leg of the Triple Aim triangle, beyond better care and better health, is lower cost. And here is where single payer stands out.

You know from the studies of David [Himmelstein] and Steffie [Woohandler] about administrative costs. I don’t know the total, I don’t know exactly what it is – something like 12 percent or 15 percent of health care spending is spent on supporting the complexity of our system, not better care. As I pointed out as a candidate for governor, some of that money should be used for building housing, schools, roads. It’s not right for health care to take more than it needs.

A single payer would also give us stronger bargaining power in payment for hospital supplies and more. I oversaw several procurements for durable medical equipment under Medicare, which we put out to bid, and which achieved a 42 percent decline in costs, with higher quality and service, over a several-year period.

Consolidated payment means better metrics and better quality on behalf of the people we serve.

An overarching consideration in this picture is justice. Until health care is less costly per capita, we will be unable to properly address the problems of our schools, poverty, and hunger.

So what I learned, very briefly, is that our current approach – a complex multi-payer system – makes it harder for us to get where we should get: to the Triple Aim.

With respect to health care, I think I discovered a sense of helplessness, a latent anger in the public that was sobering. As I campaigned in working-class communities, many of which may have voted Republican, people are weary. They’re worn down by forces they do not understand.

I remember meeting a carpenter, a soft-spoken guy. He told me about his health insurance problems and debts that have been weighing on him for more than a year and that were driving him over the edge.

That said, I want to stress, people don’t really understand the term single payer. They often lack a clear idea of what the term means or intends.

I would say that maybe a majority of the people I spoke with thought that single payer, Medicare for All, means both a government payer and a government provider or governmentally run delivery system. They thought I was speaking of the English or Scottish health systems or the VA.

That is not actually correct. You can have a single payer as a form of payment, and you can have a unified health care delivery system, but they’re not the same idea. Both can be discussed, but they’re not the same idea. It is quite possible to have a single payer and the same time have a pluralistic, partly public and partly private health care delivery system such as we have today in the U.S.

I believe that I saw that much of the business community, which actually may stand to gain the most, doesn’t understand benefits of single payer. They don’t understand what improvements and cost reductions they could get under a system of consolidated payment.

That said, the number of people was large who pulled me aside at a town meeting, a coffee, or a forum, and said quietly, “I’m almost embarrassed to say it, but I think you’re right.”

Some of the largest resistance, it seems to me, comes from some of the largest corporations. The key pushback from the public was job loss, concern about the loss of jobs at insurance companies. Of course, such losses would be largely offset by the number of jobs created in public sector, but we should not be glib or unfeeling about the dislocation that a single-payer system would cause in the existing funding organizations.

Overall, I’ll tell you this: My takeaway is that given my experience in living rooms, libraries, and town meetings, this [single payer] is possible. This can be done.

What is next? You’re in the best position, perhaps, to judge. I have only a couple of ideas.

First, I like the idea of action at the state level.

Second, I like the idea of trying to forge an alliance of groups, including business, in support of this proposal.

Third, a very big obstacle to progressing this policy is the widespread perception that government is unable to solve problems – that government cannot manage itself well. Indeed, some of the problems we have seen at the federal and state level contribute to this belief. I think there’s a natural need here for single-payer advocates to talk about government and responsible management, to make the case that government can solve problems and manage its business well.

Finally, I think we need to continue making the economic analysis for our case. It can be strong, but it has to be disciplined and intellectually honest.

I think I’ll stop there and be happy to take a few questions. Thank you.

Dr. Donald Berwick, an internationally recognized leader in the field of quality, is president emeritus and senior fellow at the Institute for Healthcare Improvement and former chief administrator of the Centers for Medicare and Medicaid Services.

Why we don’t need long-term care insurance

Maybe You Don’t Need Long-Term Care Insurance After All

By Ben Steverman
Bloomberg, November 12, 2014

The biggest threat to a retiree’s nest egg isn’t a stock market crash. It’s a long illness requiring round-the-clock care.

The statistics behind that scenario — $81,000 a year for a nursing home, $184,000 for 24-hour home care — are what sells long-term care insurance policies. But while past research suggested that many more people needed the coverage than bought it, a new study suggests that most people should just skip it.

The study, by Boston College’s Center for Retirement Research, focused on singles, who now make up the majority of Americans. Long-term care insurance makes financial sense only for the richest 20 to 30 percent of unmarried people, it finds. For the rest, it makes more sense to go without. If they need care, spending down their assets and then letting Medicaid pick up the tab is the most practical solution.

Long-term insurance can pay off for wealthier singles, even under the Center’s new math. It takes $260,405 in assets, or about $90,000 in annual income, to put a household in the top 25 percent, the Russell Sage Foundation and the Congressional Research Service estimate. These affluent customers can afford the premiums, and insurance can protect their heirs’ inheritance if that’s a goal. The same logic works for couples, but only if they’re even wealthier. Webb warns that forthcoming research will show long-term care insurance makes even less sense for married couples than it does for singles.

http://www.bloomberg.com/news/2014-11-12/maybe-you-don-t-need-long-term-care-insurance-after-all.html

Report from Center for Retirement Research at Boston College: http://crr.bc.edu/briefs/long-term-care-how-big-a-risk/

Mediciad.gov – Community-Based Long-Term Services & Supports: http://www.medicaid.gov/affordablecareact/provisions/community-based-long-term-services-and-supports.html

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Comment:

By Don McCanne, MD

The Affordable Care Act included Senator Ted Kennedy’s Community Living Assistance Services and Supports Act (CLASS Act) which would have provided long-term care. Unfortunately the specifics of the CLASS Act proved to be unworkable and thus it has been suspended. But according to this new study, unless you are wealthy, you do not need long-term care insurance anyway. Most of us can simply spend down our assets and then Medicaid will take care of us.

Think about how that could apply to the increasing use of patient cost-sharing, especially the ever-higher deductibles. We could eliminate individual health insurance coverage. When individuals are faced with expensive acute or chronic conditions, they could simply spend down their assets and then go on Medicaid to cover their future health care costs.

The obvious flaw in all of this is that it would require near destitution for us to have our heath care expenses covered. Other nations automatically cover these expenses for everyone without forcing them to relinquish their assets. It is a sad commentary that we accept the policy that a person must go broke before we will provide them with long-term care. This should not happen in a caring society.

But what are we doing with moderate-income individuals and families right now? We are requiring cost-sharing, especially deductibles, at a level that wipes out liquid assets for many of them, if they even have such assets. Financial hardship has become an expected consequence for far too many people who have significant medical needs. It is primarily wealthier individuals and families who have the assurance of being able to obtain health care without losing their assets.

Long-term care should be covered by our health care financing system, and significant cost-sharing should be eliminated. A single payer system would ensure that all of us could get the care we need, including long-term care, without adverse financial consequences.

If we really do expect that people should use their personal assets to contribute to the financing of health care, do it through estate taxes, but make the taxes equitable, that is, progressive. Do not take away from our seniors what little they have in the final years of their lives.

And do not charge the estate specifically for the amount of health care that was given. We shouldn’t deprive families of their modest inheritances just because medical bills were high late in life. Estate tax rates should not apply to smaller estates, but then the rates should increase with the size of the estate, unrelated to whatever health care costs the family faced. Yes, the rich would pay more, but that’s the way it should work in a caring society.

Medicare for everyone

By Harriette Nye Seiler
The Courier-Journal (Louisville, Ky.), Letters, Nov. 20, 2014

Most Kentuckians are pleased that health care coverage has been expanded in our state, but there are questions to be considered.

Are the managed care organizations (MCOs) that oversee Medicaid providing quality treatment and follow-up — including prescribed medications for the mentally ill? MCOs profit by reducing costs and, bluntly stated, cost-cutting strategies often involve cutting care.

Persons who bought private plans (gold, silver, etc.) on the Kynect exchange last year must now re-enroll for 2015. Before buying, enrollees should read the policy carefully: Can you see your preferred doctor? How narrow is the hospital network? How high is the deductible? If you had to pay out of your own pocket for treatment, would that keep you from going for help when you have worrisome symptoms? If you have a chronic disease, check the drug formularies: Is your medication listed? Has the co-pay gone up?

As we ponder all these critical issues, the people in other advanced nations are happily going about their day because their leaders had sense enough to implement a single-payer system —- saving money for their country and for each individual. Instead of all the political and judicial machinations now going on across the U.S., let’s just tell Congress to pass HR 676. Simply improve traditional Medicare and give it to everybody!

Harriette Nye Seiler resides in Louisville.

http://www.courier-journal.com/story/opinion/readers/2014/11/20/letters-affordable-care-act/19324019/

Medicaid improving access for the homeless, but…

Early Impacts of the Medicaid Expansion for the Homeless Population

By Barbara DiPietro, Samantha Artiga and Alexandra Gates
Kaiser Family Foundation, November 13, 2014

The Affordable Care Act (ACA) Medicaid expansion offers a significant opportunity to increase coverage and improve access to care for individuals experiencing homelessness, who historically have had high uninsured rates and often have multiple, complex physical and mental health needs.

*  The Medicaid expansion has led to significant increases in coverage that are contributing to improved access to care and broader benefits for homeless individuals. Providers reported that these coverage gains have enabled patients to access many services that they could not obtain while uninsured, including some life-saving or life-changing surgeries or treatments. Participants also identified other broader benefits for homeless individuals stemming from Medicaid coverage gains. For example, providers noted improvements in individuals’ ability to work and maintain stable housing due to better management of health conditions. In addition, participants said individuals have reduced financial stress and improved access to other services and programs, including disability benefits.

*  Providers reported having access to a broader array of treatment options as a result of Medicaid coverage gains among their patients. With these increased options, providers said they are better able to provide care based on the best courses of treatment rather than based on the availability of charity or discounted resources.

*  Gains in Medicaid revenue are facilitating strategic and operational improvements focused on quality, care coordination, and information technology. In addition, administrators indicated that Medicaid revenue gains supported staff increases and led to changing staff roles to meet increased administrative and billing needs. However, participants emphasized that, even with Medicaid revenue gains, other funding sources remain vital for supporting the full range of services needed by the homeless population.

*  Participants from the non-expansion site (Florida – did not expand Medicaid) indicated that their patients remain uninsured and are continuing to face significant gaps in care that contribute to poor health outcomes. Participants also said they are facing an increasingly challenging financial situation because they are missing out on Medicaid expansion revenue gains and other funding sources are declining.

*  As homeless patients gain Medicaid coverage and are enrolled in managed care, some challenges are emerging. Participants commented that some patients are being auto-assigned to providers with whom they do not have an existing relationship and/or they may have difficulty accessing due to lack of transportation. Additionally, working within provider networks can be difficult given the complex needs of individuals, lack of transportation, and the limited experience among other providers in serving this population. Lastly, participants emphasized that prior authorization requirements and limited and/or changing drug formularies are leading to delays in care for individuals and creating substantial administrative burdens for providers.

Early Impacts of the Medicaid Expansion for the Homeless Population

****

Comment:

By Don McCanne, MD

The experience of the homeless population under the Affordable Care Act (ACA) demonstrates both the benefits of reform under ACA and the flaws of ACA that call for replacement with a single payer system. ACA was better than nothing, but we can have so much more through enactment of a single payer system.

The primary ACA benefit for the homeless is that most of them in expansion states qualify for Medicaid and thus have improved access to health care without financial barriers. Some of the homeless who access health care have been noted to have an increased ability to work and to maintain stable housing. Financial stress is reduced and some have gained access to appropriate disability benefits. These benefits to the homeless are more reasons why calls for simple repeal of ACA are bad policy, devoid of compassion.

Yet the last paragraph from the excerpts above explains why Medicaid managed care is often a poor choice for the homeless (and many other lower-income individuals as well). Homeless patients often are unable to see the health care professionals who would be most accessible and appropriate for them. Transportation concerns are more likely. Essential specialized services may not be available. Managed care intrusions such as prior authorization requirements, limitations and changes in formularies, or other perverse managed care innovations may impair access to important health care services or products. Further, those states that refuse to expand Medicaid are leaving most of the homeless without any coverage and therefore reliant on often inadequately funded safety-net institutions.

There are those who believe that we should merely proceed with implementation of ACA and try to obtain legislative and administrative patches along the way. Compared to the deficiencies in our dysfunctional system, patches have only minimal beneficial impact while increasing the administrative complexity that already overburdens our system. Patches fall way too short of what we need.

We should not repeal ACA since it does provide some temporary benefit until we can implement a single payer system. But we should not let ACA implementation divert us from instituting what we really need – a single payer national health program. Not only would that benefit the homeless, it would benefit all of the rest of us as well.

Actually, health insurance premiums are rising more slowly

Health care and insurance costs are, however, still rising and need work. Let’s just make sure we consider all the facts.

By Dimitri Drekonja, M.D.
Star Tribune (Minneapolis), Nov. 20, 2014

In “Gruber’s gaffes show why MNsure was sure to fail” (Nov. 20), Sen. David Hann, R-Eden Prairie, asked for “every well-intentioned voice to be heard” and urged that we “take a hard look at the facts.” Good advice, which I’ll try to follow.

Hann cites the Kaiser Family Foundation as his source that health insurance premiums are increasing by 20 percent in the last year. On the face of it, this seems noncontroversial. Kaiser is a well-respected nonpartisan organization that many rely on as a source of high-quality analysis of health policy, and an annual increase of 20 percent seems high.

However, I happened to be catching up on my journal reading last night, and a recent issue of the Journal of the American Medical Association (JAMA) had an update on health insurance costs, provided by Kaiser. For those wanting to see it, it is freely available at the JAMA website (http://jama.jamanetwork.com/article.aspx?articleid=1930824).

The report tracked increases in health insurance premiums over three five-year periods (1999-2004, 2004-2009 and 2009-2014). For the last five years, the increase in premiums agrees with Hann’s number: 26 percent. However, what Hann chose to leave out is that from 1999-2004, premiums rose 72 percent, and from 2004-2009, the increase was 34 percent.

So over the last 15 years, the lowest increases in health insurance costs came during the period in which the Affordable Care Act (ACA) began to be implemented.

This is one of the good things about the ACA — costs have not risen as fast as during the pre-ACA period. The other good thing is that more people have health insurance.

However, there are indeed problems with the ACA. An improvement from the pre-ACA days was easy — costs were rising rapidly and the number of uninsured was far too high. The downsides are that we still have millions of people uninsured and that the cost of insurance still is rising faster than both overall inflation and workers’ earnings (from 2009-2014, when premiums rose by 26 percent, overall inflation and workers earnings both rose 11 percent). This pattern is ultimately unsustainable.

Responding to Hann’s call for facts, here is another: the United States spends close to 20 percent of its gross domestic national product on health care; the next closest countries are France, Germany, Switzerland and Canada — all hovering just below 12 percent and all of which are able to provide universal health care coverage for their citizens.

If Hann is indeed interested in these facts and wanting “every idea to be considered,” here is a suggestion: Just down the road is the University of Minnesota, an institution with the resources and expertise to study different ways of providing health care for all Minnesotans. Give researchers the task of assessing the pros and cons of various ways to pay for health care. They could consider a single-payer system like Canada’s; a system that includes private insurers, like Germany’s; the current status quo with the ACA, or some proposal put forward by Hann and his colleagues (if he has such a plan, I am unaware of it).

Let each proposal undergo rigorous analysis by experts in the field, and share the results publicly.

Studying what someone (like Prof. Jonathan Gruber) said three years ago about how a piece of legislation passed is not terribly high on my priority list; studying how to achieve a cost-effective way to provide health care to all Minnesotans is.

Hopefully, this is a goal shared by Hann, and he will indeed look at all the facts.

Dimitri Drekonja is a staff physician, infectious diseases, with the Minneapolis VA Health Care System, an assistant professor of medicine at the University of Minnesota Medical School and a board member of the Minnesota chapter of Physicians for a National Health Program. The views expressed here are solely his own.

http://www.startribune.com/opinion/commentaries/283424521.html

Medicare for all would be affordable

By Stan Gutelius, M.D.
Auburn (N.Y.) Citizen, Letters, Nov. 20, 2014

Good news! Now that we are in that time of year when you should be comparing your medical insurance policy with other possible policies, I can offer you the one you have been looking for.

It is offered by a company that has been in business for 49 years. Once you have it, it is yours forever. It is not related to your employment or the state of your health. It pays for 80 percent of the covered services. (That’s the GOLD level). You can’t go “out of network” because there are no networks. You can see any physician or go to any hospital you desire.

The premium is $104.90 per month. The deductible for physician’s visits is $147 per year. The hospital deductible is $1,260 for the first 60 days.

Signup is simple. You don’t need to go to an Exchange. Just present your birth certificate dated prior to November 17, 1949 and you’re in. What’s that? You don’t have such a birth certificate? Oops! Sorry. I can’t sign you up for this policy.

Why can’t I sign you up? That’s a very good question to ask your elected representatives in Washington. They are responsible for the disaster we refer to as the “Affordable Care Act.” Everyone in the country should have access to the policy I describe above. No need for networks, exchanges, or sky high out of pocket expenses.

What? Oh, sorry. I forgot to mention that the “company” is the U.S. government and the policy is Medicare. You might like to suggest to your congressional representatives that “Medicare-for–All” would be a really good idea.

Dr. Stan Gutelius resides in Auburn.

http://auburnpub.com/news/opinion/mailbag/letter-medicare-for-all-would-be-affordable/article_8ceb6431-bddc-523c-b004-4b0d0f7faa33.html

How ACA fuels corporatization of American health care

By Philip Caper, M.D.
Bangor (Maine) Daily News, Nov. 20, 2014

A new Harvard study has found that Americans’ trust in the medical profession has dropped dramatically in recent years and lags behind that in many other wealthy countries. At the same time, doctors are becoming increasingly unhappy with our profession. In his new memoir, “ Doctored,” Dr. Sandeep Jauhar eloquently explains why: More and more doctors are coming to view our profession as just another job.

We now have a situation where patients are losing confidence in their doctors, while doctors are losing confidence in our ability to do the right thing for our patients. We have a health care system becoming more hostile to doctors and patients and more friendly to health care corporations.

These trends are collateral damage caused by another trend: our increasingly corporatized, commodified and commercialized U.S. health care “industry” that is being put into hyper drive by the Affordable Care Act. The ACA is accelerating an ongoing wave of hospital consolidations and acquisition of doctors’ practices by large corporations, such as Eastern Maine Healthcare Systems and MaineHealth.

As we continue down this road, doctors see our clinical autonomy disappearing as more and more of us become corporate employees subject to pressure to meet corporate financial goals that often differ from what is best for our patients. Patients sense that pressure as they are rushed through exams and are subject to more tests and procedures, some of them of questionable clinical value. They can almost hear the cash registers ringing as they move through their doctors’ offices, as more wealth is transferred from patients to those selling health care goods and services.

Why is American medicine, once the crown jewel of American professionalism and a proud and respected calling, becoming just another commercial enterprise? In his 2010 book “ Hijacked,” Dr. John Geyman, chairman emeritus of the department of family practice at the University of Washington, explains how during the year-long Congressional debate leading up to enactment of the ACA, the interests of the public, including doctors and patients, were subverted to those of large health care corporations.

The highjacking of health care reform is paying off handsomely. Robert Pear of the New York Times recently described how the federal government and the commercial health insurance industry have morphed into one big fan club for the ACA. He quotes the libertarian Cato Institute’s Michael Cannon explaining that since the ACA’s enactment, “Insurers and the government have developed a symbiotic relationship, nurtured by tens of billions of dollars that flow from the federal Treasury to insurers each year.”

Pear goes on to report that, “Since Mr. Obama signed the law, share prices for four of the major insurance companies — Aetna, Cigna, Humana and UnitedHealth — have more than doubled, while the Standard & Poor’s 500-stock index has increased about 70 percent.”

Pharmaceutical companies also have done very well. The ACA contains no authority for the government to negotiate pharmaceutical prices but continues the federal prohibition on the importation by U.S. residents of lower priced prescription drugs from many foreign countries.

This situation won’t change anytime soon. Congress is gridlocked. What is widely recognized as a drafting error in the ACA — which, in saner times, could have been fixed quickly without attracting much attention — is now headed to the Supreme Court.

Of course, health care is just one of many examples in which the welfare of corporations has been put ahead of the interests of the public, but it may be the poster child. Health care is now more than a sixth of our economy, and human lives and dollars are at stake.

Corporate stranglehold of our public policy traces back to the increasingly corrupt way our political campaigns are financed. The recent midterm elections were a stark reminder of that, setting record levels for corporate spending, even on local races, and saturating voters with negative, intrusive and often obnoxious messages.

What’s at stake is the future of health care and many other issues that will determine what kind of a country our children will live in. That future depends on how active and informed the public is willing to become in electing public officials who place the welfare of their constituents ahead of the wishes of their corporate contributors.

The results of the recent elections are not encouraging. But what’s becoming clearer is that our struggle is not between Democrats and Republicans, liberals and conservatives, or occupiers and tea partiers. It is between real American people and corporations.

I, for one, intend to continue pointing that out. That’s where our attention should be focused.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com or through his website at philcaper.net.

http://bangordailynews.com/2014/11/20/health/blogs-and-columns/how-aca-fuels-corporatization-of-american-health-care/print/