Shifts in Charity Health Care

By The Editorial Board
The New York Times, June 8, 2014

Health care reform was supposed to relieve the financial strain on hospitals that have provided a lot of free charity care to poor and uninsured patients. The reform law, known as the Affordable Care Act, was expected to insure most of those patients either through expanded state Medicaid programs for the poor or through subsidized private insurance for middle-income patients, thereby funneling new revenues to hospitals that had previously absorbed the costs of uncompensated care.

In return for the new income streams, hospitals that treat large numbers of the poor and get special subsidies to defray the cost would have those subsidies reduced on the theory that they would no longer need as much help.

But after the Supreme Court ruled that the reform law could not force states to expand their Medicaid programs, 20 or more states declined to do so. That failure has hurt some big urban hospitals, because their charity care burden remains essentially the same even as their federal aid has been cut. Even in California, which has expanded its Medicaid program, public hospitals that serve the poorest patients could face a big funding shortfall in future years, according to a study just published by researchers at the University of California at Los Angeles.

A recent report in The Times by Abby Goodnough found that some hospital systems have started tightening the requirements for charity care in efforts to push uninsured people into signing up for subsidized health plans on the insurance exchanges created by the reform law. In St. Louis, for example, Barnes-Jewish Hospital has started charging co-payments to uninsured patients no matter how poor they are. Those at or below the poverty level ($11,670 for an individual) are charged $100 for emergency care and $50 for an office visit.

But some medical centers have seen their charity care costs decline. A report late last month in Kaiser Health News and USA Today said that Seattle’s largest “safety net” hospital, run by the University of Washington, saw its proportion of uninsured patients drop from 12 percent last year to a surprisingly low 2 percent this spring, putting the hospital on track to increase its revenue by $20 million this year from annual revenues of about $800 million.

How all of this will shake out is still uncertain. Some vulnerable groups may find it even harder to get the care they need. Through a quirk in the reform law, residents below the poverty line in states that have failed to expand Medicaid are not eligible for either Medicaid or for subsidized coverage on the insurance exchanges. Undocumented immigrants are not eligible for Medicaid or the subsidized coverage. And some low-income people who have enrolled in subsidized health plans may have trouble paying their cost-sharing.

There are some ways to address these gaps. All states ought to expand their Medicaid programs since the federal government is offering very generous matching funds. Hospitals should move aggressively to help people enroll in Medicaid or in subsidized plans on the exchanges. And federal health officials need to review regularly whether health plan co-payments are actually affordable to those living on very modest incomes.

Reader Comments:

NYT Picks
paradocs2, San Diego

It has been little appreciated that one of the most important accomplishments of the Affordable Care Act was to create universal national health insurance for all poor legal residents of the United States who earned less than 138 percent of the federal poverty level. This magnificent and compassionate action of social innovation and national unity was frustrated by the insensitive, tragic and immoral decision of the Supreme Court. The consequences described in this editorial go beyond costs and inefficiencies to the persistence of the lack of medical services in many areas of our country with appallingly poor health statistics. The problem is more than “the financial strain on hospitals that have provided a lot of free charity care to poor and uninsured patients,” for it extends to the suffering of those millions of people excluded from ongoing medical care. In addition, the circumstances described in this editorial highlight the conundrum of our country’s health care system, based as it is on on a commercial market model and profit generating insurance companies. The best solution to these problems, both the economic inefficiencies and the human suffering, is the creation of a universal, national, single payer health system looking like Medicare expanded to cover all residents. It is profoundly upsetting that our individualistic contemporary culture and the politicians who represent it are blind to both the moral and economic consequences of their position.

http://www.nytimes.com/2014/06/09/opinion/shifts-in-charity-health-care….

PNHP’s Jeoffry Gordon, MD (paradocs2, above) stated it so well that no additional comment is being provided today.

Doctors, hospitals and insurers team up

By Bernard J. Wolfson
Orange County Register, May 1, 2014

In an office building across the street from St. Joseph Hospital in Orange, midlevel managers from Blue Shield of California gathered around a conference table last week with representatives of St. Joseph Heritage Healthcare. The setting was unremarkable, but the conversation that took place was part of an increasingly common collaboration between a larger insurer and one of its key medical providers.

Christy Mokrohisky perked up when Nancy England, a senior pharmacist at Blue Shield of California, proposed a pilot program in which pharmacists would be parachuted into the clinics and physician offices of St. Joseph Heritage Healthcare to manage the prescriptions of sick patients for doctors who are too busy to do it.

For Mokrohisky, who oversees St. Joseph’s performance improvement efforts, the idea spoke directly to one of her driving ambitions: to keep chronically ill patients out of the hospital and away from the emergency room.

“We all know that issues around medication are the number one or close to the number one reason for trips to the ER or admissions to the hospital,” said Mokrohisky, giving voice to the consensus around the table.

The weekly meeting is only one manifestation of the huge upgrade in communication and information sharing between the two groups that has resulted from a 2-year-old alliance known, in the techno-jargon of the industry, as an accountable care organization, or ACO.

The main goal of the ACO is to improve the quality of patient care and save money through closer attention to patients’ needs, monitoring of their compliance with doctors’ orders and avoidance of unnecessary treatments.

Early signs indicate the Blue Shield-St. Joseph ACO is paying dividends. In its first year, it produced a sharp reduction in patient admissions, length of hospital stays, emergency room visits, outpatient surgeries and readmissions, according to in-house data from the insurance company. The group saved a total of $11.5 million, some of which the parties divvied up.

The financial windfall aside, people in both organizations say this kind of ongoing collaboration between an insurance company and a large medical group – virtually unheard of a few years ago – has changed the way they do business with each other.

“It sounds kind of hokey, and sometimes when I say it out loud I have to roll my eyes at myself, but it has created something I have never seen,” says Kristen Miranda, who oversees Blue Shield’s 15 ACOs statewide. “It absolutely has changed the way we interact with these providers and the way they interact with each other. We all now see ourselves as coming together to look at this population as if we are on the same side instead of just battling it out at the negotiating table every year.”

Blue Shield views the kind of orchestrated care it is offering through its ACOs as a competitive wedge against Kaiser Permanente, a health care giant in California that has a built-in advantage because its doctors, hospitals and insurance are integrated.

Some industry observers say ACOs are little more than traditional HMOs in new clothing.

(Glenn Melnick, a health economist at USC) worries that the ability of ACOs to save health care dollars may be time-limited.

“At some point, you are going to reduce inpatient days and other measures as low as they can possibly go,” he says. “Then the question becomes whether these ACOs will be able to generate additional savings from other areas that might be more difficult.”

http://www.ocregister.com/articles/blue-612097-shield-care.html

****

Comment:

By Don McCanne, MD

So now with ACOs, insurers and providers are “coming together to look at this population as if we are on the same side instead of just battling it out at the negotiating table every year.” They are sharing a “financial windfall” by having accomplished “a sharp reduction in patient admissions, length of hospital stays, emergency room visits, outpatient surgeries and readmissions, according to in-house data from the insurance company.” The insurers and providers have conspired to split the gains from not providing care. No wonder the person overseeing Blue Shield’s 15 ACOs has to “roll my eyes” since it seems so “hokey.”

No more hokey. Let’s have a financing system geared to patients, not to insurers – a single payer national health program.

Doctors, hospitals and insurers team up

By Bernard J. Wolfson
Orange County Register, May 1, 2014

In an office building across the street from St. Joseph Hospital in Orange, midlevel managers from Blue Shield of California gathered around a conference table last week with representatives of St. Joseph Heritage Healthcare. The setting was unremarkable, but the conversation that took place was part of an increasingly common collaboration between a larger insurer and one of its key medical providers.

Christy Mokrohisky perked up when Nancy England, a senior pharmacist at Blue Shield of California, proposed a pilot program in which pharmacists would be parachuted into the clinics and physician offices of St. Joseph Heritage Healthcare to manage the prescriptions of sick patients for doctors who are too busy to do it.

For Mokrohisky, who oversees St. Joseph’s performance improvement efforts, the idea spoke directly to one of her driving ambitions: to keep chronically ill patients out of the hospital and away from the emergency room.

“We all know that issues around medication are the number one or close to the number one reason for trips to the ER or admissions to the hospital,” said Mokrohisky, giving voice to the consensus around the table.

The weekly meeting is only one manifestation of the huge upgrade in communication and information sharing between the two groups that has resulted from a 2-year-old alliance known, in the techno-jargon of the industry, as an accountable care organization, or ACO.

The main goal of the ACO is to improve the quality of patient care and save money through closer attention to patients’ needs, monitoring of their compliance with doctors’ orders and avoidance of unnecessary treatments.

Early signs indicate the Blue Shield-St. Joseph ACO is paying dividends. In its first year, it produced a sharp reduction in patient admissions, length of hospital stays, emergency room visits, outpatient surgeries and readmissions, according to in-house data from the insurance company. The group saved a total of $11.5 million, some of which the parties divvied up.

The financial windfall aside, people in both organizations say this kind of ongoing collaboration between an insurance company and a large medical group – virtually unheard of a few years ago – has changed the way they do business with each other.

“It sounds kind of hokey, and sometimes when I say it out loud I have to roll my eyes at myself, but it has created something I have never seen,” says Kristen Miranda, who oversees Blue Shield’s 15 ACOs statewide. “It absolutely has changed the way we interact with these providers and the way they interact with each other. We all now see ourselves as coming together to look at this population as if we are on the same side instead of just battling it out at the negotiating table every year.”

Blue Shield views the kind of orchestrated care it is offering through its ACOs as a competitive wedge against Kaiser Permanente, a health care giant in California that has a built-in advantage because its doctors, hospitals and insurance are integrated.

Some industry observers say ACOs are little more than traditional HMOs in new clothing.

(Glenn Melnick, a health economist at USC) worries that the ability of ACOs to save health care dollars may be time-limited.

“At some point, you are going to reduce inpatient days and other measures as low as they can possibly go,” he says. “Then the question becomes whether these ACOs will be able to generate additional savings from other areas that might be more difficult.”

http://www.ocregister.com/articles/blue-612097-shield-care.html

So now with ACOs, insurers and providers are “coming together to look at this population as if we are on the same side instead of just battling it out at the negotiating table every year.” They are sharing a “financial windfall” by having accomplished “a sharp reduction in patient admissions, length of hospital stays, emergency room visits, outpatient surgeries and readmissions, according to in-house data from the insurance company.” The insurers and providers have conspired to split the gains from not providing care. No wonder the person overseeing Blue Shield’s 15 ACOs has to “roll my eyes” since it seems so “hokey.”

No more hokey. Let’s have a financing system geared to patients, not to insurers – a single payer national health program.

The Medicare Advantage Money Grab

The Center for Public Integrity, June 4, 2014

Why Medicare Advantage costs taxpayers billions more than it should

By Fred Schulte, David Donald and Erin Durkin

(Medicare Advantage) plans have sharply driven up costs in many parts of the United States — larding on tens of billions of dollars in overcharges and other suspect billings based in part on inflated assessments of how sick patients are, an investigation by the Center for Public Integrity has found.

Dominated by private insurers, Medicare Advantage now covers nearly 16 million Americans at a cost expected to top $150 billion this year. Many seniors choose the managed-care Medicare Advantage option instead of the traditional government-run Medicare program because it fills gaps in coverage, can cost less in out-of-pocket expenses and offers extra benefits, such as dental and eye care.

But billions of tax dollars are misspent every year through billing errors linked to a payment tool called a “risk score,” which is supposed to pay Medicare Advantage plans higher rates for sicker patients and less for those in good health.

Government officials have struggled for years to halt health plans from running up patient risk scores and, in many cases, wresting higher Medicare payments than they deserve, records show.

The Center’s findings are based on an analysis of Medicare Advantage enrollment data from 2007 through 2011, as well as thousands of pages of government audits, research papers and other documents.

Federal officials who run the Medicare program repeatedly refused to be interviewed or answer written questions.

Key findings:

• Federal officials have made billions in “improper” payments to Medicare Advantage plans traced to risk score errors.
• Medicare Advantage risk scores rose much faster than the national average in hundreds of counties nationwide between 2007 and 2011. That rise in risk scores cost taxpayers more than $36 billion; critics attribute that more to aggressive billing than sicker patients.
• Though federal health officials have recently disclosed some Medicare billing data, key financial records of Medicare Advantage plans have been kept under wraps.
• The failure to crack down on health plans that overbill doesn’t bode well for the Affordable Care Act, which relies on a similar risk scoring system.

Thomas Scully, who helped get the program running under President George W. Bush, said rates were generous in hopes of enticing insurers to expand their Medicare business and not shy away from people in poor health.

“We very intentionally tried to overpay them a little bit,” said Scully, now a Washington lobbyist with numerous health care industry clients.

http://www.publicintegrity.org/2014/06/04/14840/why-medicare-advantage-costs-taxpayers-billions-more-it-should

“The Medicare Advantage Money Grab”: http://www.publicintegrity.org/health/medicare/medicare-advantage-money-grab

****

Comment:

By Don McCanne, MD

Medicare Advantage is a program in which our government has conspired with insurers to privatize Medicare, even though it costs far more when private insurers are inserted as intermediaries than it does when Medicare is administered as a public program. This report from The Center for Public Integrity is just the latest that has exposed this outrageous use of our tax funds.

The program was set up to deliberately overpay the plans so that they could offer additional benefits that would entice Medicare beneficiaries into the private plans (see Scully’s comment above). Recognizing these overpayments, Congress included in the Affordable Care Act gradual reductions. Not to be outdone, the insurance industry has conspired with the Obama administration and has enlisted individual members of Congress to fight these reductions. In response, the Obama administration has used dishonest budgetary manipulations to offset a portion of the reductions for 2013, 2014 and 2015.

Even more outrageous is that the private insurance industry has used “innovations” to selectively enroll healthier beneficiaries, yet used “touch of illness” serious diagnostic codes to game risk adjustment, which has rewarded the insurers handsomely for claiming that their beneficiaries were much sicker than they really were. According to this report, federal Medicare officials refused to answer questions about these perverse practices.

The insurance industry has been very successful in framing this as “cutting payments for Medicare,” while mobilizing citizens to demand that these cuts be prevented. The cuts are not in Medicare, but they are a reduction of overpayments to private insurers. Yes, those who sign up with the private plans often have lower out-of-pocket costs, but the rest of us are paying for that through higher taxes and through our Part B Medicare premiums that are partially transferred to the private insurers.

Since we are paying for it, we should be receiving in the traditional Medicare program the same benefits of reduced out-of-pocket expenses. Let the people enrolled in Medicare Advantage keep the same level of benefits, but increase the benefits in the traditional Medicare program to the same level, then fire the private insurers that have been responsible for most of the cost overruns in the Medicare Advantage program.

The politicians seem to agree that we should be spending these excess funds on Medicare, so let’s be fair and spend them equitably on an improved Medicare, but not on insurer profits and waste. While we’re at it, let’s make that an improved Medicare for all.

The Medicare Advantage Money Grab

The Center for Public Integrity, June 4, 2014

Why Medicare Advantage costs taxpayers billions more than it should

By Fred Schulte, David Donald and Erin Durkin

(Medicare Advantage) plans have sharply driven up costs in many parts of the United States — larding on tens of billions of dollars in overcharges and other suspect billings based in part on inflated assessments of how sick patients are, an investigation by the Center for Public Integrity has found.

Dominated by private insurers, Medicare Advantage now covers nearly 16 million Americans at a cost expected to top $150 billion this year. Many seniors choose the managed-care Medicare Advantage option instead of the traditional government-run Medicare program because it fills gaps in coverage, can cost less in out-of-pocket expenses and offers extra benefits, such as dental and eye care.

But billions of tax dollars are misspent every year through billing errors linked to a payment tool called a “risk score,” which is supposed to pay Medicare Advantage plans higher rates for sicker patients and less for those in good health.

Government officials have struggled for years to halt health plans from running up patient risk scores and, in many cases, wresting higher Medicare payments than they deserve, records show.

The Center’s findings are based on an analysis of Medicare Advantage enrollment data from 2007 through 2011, as well as thousands of pages of government audits, research papers and other documents.

Federal officials who run the Medicare program repeatedly refused to be interviewed or answer written questions.

Key findings:

• Federal officials have made billions in “improper” payments to Medicare Advantage plans traced to risk score errors.
• Medicare Advantage risk scores rose much faster than the national average in hundreds of counties nationwide between 2007 and 2011. That rise in risk scores cost taxpayers more than $36 billion; critics attribute that more to aggressive billing than sicker patients.
• Though federal health officials have recently disclosed some Medicare billing data, key financial records of Medicare Advantage plans have been kept under wraps.
• The failure to crack down on health plans that overbill doesn’t bode well for the Affordable Care Act, which relies on a similar risk scoring system.

Thomas Scully, who helped get the program running under President George W. Bush, said rates were generous in hopes of enticing insurers to expand their Medicare business and not shy away from people in poor health.

“We very intentionally tried to overpay them a little bit,” said Scully, now a Washington lobbyist with numerous health care industry clients.

http://www.publicintegrity.org/2014/06/04/14840/why-medicare-advantage-c…

“The Medicare Advantage Money Grab”:http://www.publicintegrity.org/health/medicare/medicare-advantage-money-…

Medicare Advantage is a program in which our government has conspired with insurers to privatize Medicare, even though it costs far more when private insurers are inserted as intermediaries than it does when Medicare is administered as a public program. This report from The Center for Public Integrity is just the latest that has exposed this outrageous use of our tax funds.

The program was set up to deliberately overpay the plans so that they could offer additional benefits that would entice Medicare beneficiaries into the private plans (see Scully’s comment above). Recognizing these overpayments, Congress included in the Affordable Care Act gradual reductions. Not to be outdone, the insurance industry has conspired with the Obama administration and has enlisted individual members of Congress to fight these reductions. In response, the Obama administration has used dishonest budgetary manipulations to offset a portion of the reductions for 2013, 2014 and 2015.

Even more outrageous is that the private insurance industry has used “innovations” to selectively enroll healthier beneficiaries, yet used “touch of illness” serious diagnostic codes to game risk adjustment, which has rewarded the insurers handsomely for claiming that their beneficiaries were much sicker than they really were. According to this report, federal Medicare officials refused to answer questions about these perverse practices.

The insurance industry has been very successful in framing this as “cutting payments for Medicare,” while mobilizing citizens to demand that these cuts be prevented. The cuts are not in Medicare, but they are a reduction of overpayments to private insurers. Yes, those who sign up with the private plans often have lower out-of-pocket costs, but the rest of us are paying for that through higher taxes and through our Part B Medicare premiums that are partially transferred to the private insurers.

Since we are paying for it, we should be receiving in the traditional Medicare program the same benefits of reduced out-of-pocket expenses. Let the people enrolled in Medicare Advantage keep the same level of benefits, but increase the benefits in the traditional Medicare program to the same level, then fire the private insurers that have been responsible for most of the cost overruns in the Medicare Advantage program.

The politicians seem to agree that we should be spending these excess funds on Medicare, so let’s be fair and spend them equitably on an improved Medicare, but not on insurer profits and waste. While we’re at it, let’s make that an improved Medicare for all.

Analysis of Benefit Design in Silver Plan Variations

By Kelly Brantly, Hillary Bray and Caroline Pearson
Avalere Health, June 2014

Both state-based and federally-facilitated exchanges offer financial assistance for low-income enrollees. The assistance takes two forms: advanced premium tax credits and cost-sharing reductions (CSRs). This report focuses on CSR plans, which are available to individuals and families earning between 100% of the federal poverty level (FPL) and 250% FPL.

CSR plans use federal subsidies to increase their actuarial value (AV) and lower cost-sharing for low-income exchange enrollees. Avalere Health conducted an analysis of the standard silver and CSR plans offered in the federally-facilitated exchange (FFE) that spans 34 states.

• Cost-sharing reductions are more often applied across multiple types of benefits
• in 94% and 87% AV plans compared to 73% AV plans. 
• Many CSR plans have MOOP (maximum out-of-pocket) limits lower than the amount required by law. 
• Almost all CSR plans feature lower deductibles than the standard silver plans, though wide variation remains.
• Consistent with standard silver plans, copays for specialist visits are higher than those for primary care visits.
• Low-income consumers may face very high coinsurance for drugs on tiers three and four, which is least likely to be reduced in CSR plans.

The large variation in co-payments, co-insurance, and deductibles required by CSR plans may not be clear to exchange enrollees with limited income.

Across all CSR plans, there is broad variation in how issuers reduce cost-sharing across benefit categories relative to the standard silver plans. Because issuers have a high level of flexibility in designing these CSR plans, cost-sharing amounts vary across services and in some cases mirror the cost-sharing in standard silver plans.

The large variation in how plans apply the cost-sharing reductions across covered benefits may not be clear to consumers while they are shopping and comparing plans.

Notably, consumers with the lowest income who qualify for the highest level of financial assistance (100% to 150% FPL) could encounter some 94% AV CSR plans with cost-sharing requirements for specific services that are identical to standard silver plans. Even for CSR plan cost-sharing that is reduced, out-of-pocket costs could still serve as a barrier to accessing care.

(This analysis was funded by PhRMA.)

At this link, click “Download PDF” for full report: http://avalerehealth.com/expertise/managed-care/insights/avalere-analysis-cost-sharing-reductions-unevenly-applied-across-services-i

****

Comment:

By Don McCanne, MD

This report provides a highly technical explanation of the great variation in cost-sharing provisions for lower-income individuals insured by the various silver plans in the exchanges. This is just another example of the unnecessary increase in administrative complexity brought to us by the Affordable Care Act.

What is particularly egregious is the intolerably high cost-sharing required of low-income individuals who need higher-tier drugs. High cost drugs, such as those used to treat hepatitis C or those that meet the expanded recommendations for HIV prophylaxis, will be unaffordable for individuals with low incomes, in spite of the cost-sharing reductions.

By making these drugs unaffordable, the insurers accomplish two ends: 1) the cost sharing is so high that many lower-income individuals will not fill their prescriptions, saving the insurers those costs, and 2) those with chronic hepatitis C, those at high risk of HIV exposure, or the many others who have  disorders requiring expensive tier 4 drugs will likely select other insurers once they realize that the drugs that they need will be unaffordable (favorable selection). These are some of the newer innovations that the insurers are using since they are now prohibited from using medical underwriting to deny insurance to individuals with greater anticipated health care costs.

More administrative complexity. More insurer chicanery. More inequity in the provision of health care. And this is because our politicians selected the most expensive model of health care reform – one that places insurers and pharmaceutical firms above patients. Many studies have shown that the most efficient and equitable model of comprehensive health care coverage – single payer – is also the least expensive of the comprehensive models of reform. Amongst other important measures, it would put pharmaceutical firms in their place, and it would dismiss the intrusive and wasteful insurers from the scene.

We can still do that.

Analysis of Benefit Design in Silver Plan Variations

By Kelly Brantly, Hillary Bray and Caroline Pearson
Avalere Health, June 2014

Both state-based and federally-facilitated exchanges offer financial assistance for low-income enrollees. The assistance takes two forms: advanced premium tax credits and cost-sharing reductions (CSRs). This report focuses on CSR plans, which are available to individuals and families earning between 100% of the federal poverty level (FPL) and 250% FPL.

CSR plans use federal subsidies to increase their actuarial value (AV) and lower cost-sharing for low-income exchange enrollees. Avalere Health conducted an analysis of the standard silver and CSR plans offered in the federally-facilitated exchange (FFE) that spans 34 states.

• Cost-sharing reductions are more often applied across multiple types of benefits
• in 94% and 87% AV plans compared to 73% AV plans.
• Many CSR plans have MOOP (maximum out-of-pocket) limits lower than the amount required by law.
• Almost all CSR plans feature lower deductibles than the standard silver plans, though wide variation remains.
• Consistent with standard silver plans, copays for specialist visits are higher than those for primary care visits.
• Low-income consumers may face very high coinsurance for drugs on tiers three and four, which is least likely to be reduced in CSR plans.

The large variation in co-payments, co-insurance, and deductibles required by CSR plans may not be clear to exchange enrollees with limited income.

Across all CSR plans, there is broad variation in how issuers reduce cost-sharing across benefit categories relative to the standard silver plans. Because issuers have a high level of flexibility in designing these CSR plans, cost-sharing amounts vary across services and in some cases mirror the cost-sharing in standard silver plans.

The large variation in how plans apply the cost-sharing reductions across covered benefits may not be clear to consumers while they are shopping and comparing plans.

Notably, consumers with the lowest income who qualify for the highest level of financial assistance (100% to 150% FPL) could encounter some 94% AV CSR plans with cost-sharing requirements for specific services that are identical to standard silver plans. Even for CSR plan cost-sharing that is reduced, out-of-pocket costs could still serve as a barrier to accessing care.

(This analysis was funded by PhRMA.)

At this link, click “Download PDF” for full report:http://avalerehealth.com/expertise/managed-care/insights/avalere-analysi…

This report provides a highly technical explanation of the great variation in cost-sharing provisions for lower-income individuals insured by the various silver plans in the exchanges. This is just another example of the unnecessary increase in administrative complexity brought to us by the Affordable Care Act.

What is particularly egregious is the intolerably high cost-sharing required of low-income individuals who need higher-tier drugs. High cost drugs, such as those used to treat hepatitis C or those that meet the expanded recommendations for HIV prophylaxis, will be unaffordable for individuals with low incomes, in spite of the cost-sharing reductions.

By making these drugs unaffordable, the insurers accomplish two ends: 1) the cost sharing is so high that many lower-income individuals will not fill their prescriptions, saving the insurers those costs, and 2) those with chronic hepatitis C, those at high risk of HIV exposure, or the many others who have  disorders requiring expensive tier 4 drugs will likely select other insurers once they realize that the drugs that they need will be unaffordable (favorable selection). These are some of the newer innovations that the insurers are using since they are now prohibited from using medical underwriting to deny insurance to individuals with greater anticipated health care costs.

More administrative complexity. More insurer chicanery. More inequity in the provision of health care. And this is because our politicians selected the most expensive model of health care reform – one that places insurers and pharmaceutical firms above patients. Many studies have shown that the most efficient and equitable model of comprehensive health care coverage – single payer – is also the least expensive of the comprehensive models of reform. Amongst other important measures, it would put pharmaceutical firms in their place, and it would dismiss the intrusive and wasteful insurers from the scene.

We can still do that.