By Bill Knight
Pekin (Ill.) Times, Oct. 24, 2013
Americans for years have been annoyed and angered by escalating health-care costs, declining insurance coverage and millions of neighbors who haven’t been able to get health insurance, and the Affordable Care Act has started to cope with the latter problem.
But it does too little about controlling medical costs, pharmaceutical prices, and the driving force behind much health-care inflation: escalating medical costs and profit-driven insurers.
Amid the Tea Party tantrums about the new law being government taking over the health care too much, the opposite is true: Government hasn’t taken over enough of the U.S. health care system.
So it’s too little. But it’s not too late.
There’s a practical approach — a single-payer health-care system. House Resolution 676: Expanded and Improved Medicare for All, is sponsored by U.S. Rep. John Conyers (D-Mich.) and 50 co-sponsors.
The nation has remained a republic with a free-market economy although the federal government for decades has ensured health care for citizens 65 and older. Won’t the country remain strong and free if government ensures health care for citizens younger than 65?
HR 676 would institute a single-payer health care system simply by expanding Medicare to everyone. It would cover everyone for all necessary medical care, including prescriptions, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery), mental health, home health, physical therapy, rehabilitation (including substance abuse), vision care, hearing, chiropractic, medical equipment, palliative care, podiatric care, and long-term care.
It would end the big speed bump that the newly insured are discovering: co-payments and deductibles. And HR 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry.
“[It’s a] struggle to build a nation where health care is a human right, where this right is not on the negotiating table to be traded against a decent living wage, and where the rich can’t get richer by blocking your ability to get your medicine, to see your doctor, and to have your life saved in a hospital,” said Dr. Ed Weisbart, an M.D. and chair of the Missouri chapter of Physicians for a National Health Program.
For employers and unions, “Medicare for All” would remove from negotiations a huge compensation problem: health care costs, which have been part of bargaining since World War II, when that benefit was a way to reward workers during a wartime wage freeze.
Eliminating health care from labor relations would let companies and unions concentrate on bargaining over real wages, hours and working conditions, and pay could rise economically for management, and for employees faster than the cost of living and any taxes needed to support Medicare for All.
Medicare has not been the threat the right-wing says it’s been. It’s popular and effective. However, for people not in Medicare, the threat has been the ridiculous and relentless increase in medical costs including drugs, and insurance premiums, deductibles and co-pays. Americans pay far more than people in other countries, says the International Federation of Health Plans – the United States spends twice as much per capita as other developed nations.
So, insurers pass these ever-rising medical expenses on to employers through more expensive premiums. Employers pass the costs to workers through diminished benefits. The cycle must stop. The buck “starts there,” with consumers, and we cannot continue.
Personally, my adult son broke his nose playing basketball a week before his new job’s benefits started. Anesthesia to deal with a hematoma alone cost him $600; his final bill for the outpatient procedure will be more than $3,000. I was hospitalized for an infection requiring an antibiotic IV for a couple of days. My bill is $5,600. My Dad needed a stent in one leg, an outpatient procedure that took about an hour. His bill is $50,000, but covered by Medicare.
In an open letter to Congress and President Obama, the AARP said, “It is clear that older Americans want the focus of the debate to be on reducing overall health costs.”
Despite the gridlock on Capitol Hill, there are precedents for more and better government involvement than the Affordable Care Act. The concept of controlling costs exists in Medicare reimbursement rates, based on a “sustainable growth rate” (SGR), set up to connect doctors’ pay to growth in the U.S. economy. Further, Medicare already negotiates with drug companies for prescription rebates — but ONLY in Medicare.
Organizing and action are required, and it’s beginning in some quarters. This fall, an Illinois Jobs with Justice chapter endorsed HR 676, according to retired union carpenter David Johnson, a delegate to the chapter from the Illinois Single Payer Coalition.
Again, the Affordable Care Act is too little, but it’s not too late.
Bill Knight is opinion columnist at the Pekin Times. He can be reached at Bill.Knight@hotmail.com.
http://www.pekintimes.com/article/20131024/OPINION/131029746/0/NEWS#ixzz2ikEtqB00
Rural areas not benefitting from exchange plan competition
Health Care Law Fails to Lower Prices for Rural Areas
By Reed Abelson, Katie Thomas and Jo Craven McGinty
The New York Times, October 23, 2013
As technical failures bedevil the rollout of President Obama’s health care law, evidence is emerging that one of the program’s loftiest goals — to encourage competition among insurers in an effort to keep costs low — is falling short for many rural Americans.
While competition is intense in many populous regions, rural areas and small towns have far fewer carriers offering plans in the law’s online exchanges. Those places, many of them poor, are being asked to choose from some of the highest-priced plans in the 34 states where the federal government is running the health insurance marketplaces, a review by The New York Times has found.
Of the roughly 2,500 counties served by the federal exchanges, more than half, or 58 percent, have plans offered by just one or two insurance carriers, according to an analysis by The Times of county-level data provided by the Department of Health and Human Services. In about 530 counties, only a single insurer is participating.
The Obama administration, while not disputing the findings, responded to the analysis in a statement that the marketplaces “allow insurers to compete for customers based on price and quality.”
Observers cautioned against drawing too many conclusions from the current landscape, noting that several major insurers were waiting to see what happens next.
http://www.nytimes.com/2013/10/24/business/health-law-fails-to-keep-prices-low-in-rural-areas.html?hp&pagewanted=all
Polis fights sky-high rates as ski town signups stall
By Katie Kerwin McCrimmon
Solutions, October 23, 2013
Health insurance rates are so high in Colorado’s mountain resort areas that U.S. Rep. Jared Polis plans to seek waivers from the federal government so people who skip buying insurance in 2014 won’t face financial penalties.
Health coverage guides working to enroll Summit County residents in new health plans through Colorado’s health exchange have been deeply disappointed. They have not enrolled a single new client since Colorado’s health exchange launched on Oct. 1.
http://www.healthpolicysolutions.org/2013/10/23/congressman-fights-sky-high-rates-as-ski-town-signups-stall/
Comment:
By Don McCanne, M.D. Another flaw in Obamacare is the failure in rural areas to make premiums affordable through health plan competition, primarily because the markets are too small to attract enough insurers to promote competition. An example is found in the Colorado mountain resort areas such as Summit County where not one person has been enrolled through the exchange. How many times do we have to say it? The Affordable Care Act was the wrong model for reform. It leaves in place our profoundly expensive, administratively inefficient, fragmented, dysfunctional health care financing system. Compared to what needed to be done, the improvements were only marginal, and some of the problems actually increased, such as underinsurance – plans that provide less health security and less financial security than many of us had before. Besides, even in areas with greater plan competition, health care costs are still out of control. A publicly-administered single payer program is far more effective in getting health spending right than is health insurer competition.
]]>Ed Kilgore: The Restive Single Payer Tribe
The Restive Single Payer Tribe
By Ed Kilgore
Washington Monthly, Political Animal, October 21, 2013
But if I were in the White House, I’d keep an eye on one issue they might not have thought much about in quite some time: the revival of progressive hostility to Obamacare on grounds that the law reflected a “sell-out” of the obvious single-payer solution to the problems of the health care system.
I’m not going to relitigate the whole single-payer-versus-managed-competition debate that’s been going on for decades, or even the argument that a managed competition model requires a “public option” to function properly. But whatever else it is, a single-payer system is a whole lot simpler and more predictable than anything that not only accepts but insists upon a publicly regulated and subsidized private health insurance marketplace.
Single-payer fans (or those strongly favoring a public option in a hybrid system) are never going to have much in common with conservatives who don’t believe in universal access to affordable health care and want to disable or repeal the public programs we already have. But if the one thing they do have in common — disdain for the messy hydraulics of any hybrid system — becomes the center of attention and stays there, watch out!
Ed Kilgore is a contributing writer to the Washington Monthly. He is managing editor for The Democratic Strategist and a senior fellow at the Progressive Policy Institute.
http://www.washingtonmonthly.com/political-animal-a/2013_10/the_restive_single_payer_tribe047438.php
Comment:
By Don McCanne, M.D. It is fair to say that Ed Kilgore represents the views of neoliberals who have taken control of the Democratic Party and moved it to the right: that is, he represents centrist views. What is striking about his message is that the intensive political attacks on Obamacare by the conservatives are assisting single payer advocates who are busy exposing its profound policy deficiencies. With their noise, and our reasoned policy prescriptions, middle America may be ready to move to single payer much sooner than expected.
]]>State Sen. Eldridge: Single-payer health care saves money
By Lisa Hagen
Lowell Sun, Oct. 23, 2013
BOSTON — While critics complain that Obamacare, and the Massachusetts model for the federal plan involve too much government, a state senator says it is time for more government involvement in paying for health care.
On Tuesday, Sen. James Eldridge, D-Acton, again proposed a single-payer system to the Committee on Health Care Financing that would eliminate private health-insurance companies and have the government reimburse doctors, hospitals, and nurses.
“As much as Massachusetts has an excellent system, it is the most expensive in the country,” Eldridge said. “When talking to constituents, they still feel the quality of care is largely controlled by companies.”
Eldridge said the single-payer system would function similar to Medicare, alleviating the burden small businesses face in providing health-care plans to employees. He said the money saved by eliminating private insurance companies can then be used to hire more nurses and primary care physicians.
Benjamin Day, director of organizing at Healthcare-NOW, an advocacy group for single-payer health care, said there is evidence from countries such as Canada, England, and France that this type of system works.
“There are measured steps legislators can take to let us learn from other countries that have this,” Day said. “They have much better cost control than we do and we can use (single-payer) as a back-up plan.”
Eldridge, a House member when the 2006 universal health-care law was passed, said Obamacare was modeled after the state’s law requiring residents to purchase health insurance. Both laws also provide subsidies to those who cannot pay their full insurance premiums.
More than 97 percent of Massachusetts residents now have health insurance, but Eldridge said the system still has a high administrative cost and requires a lot of insurance paperwork for hospitals, doctors, and consumers.
“Consumers can go to doctors and hospitals with a (government-issued) health-care card and all costs would be paid for by the government so there would be no bill in the mail,” he said.
But Daniel Foley, legislative counsel for Massachusetts Association of Health Underwriters, said the state should continue on the same track, noting the progress in both health-care coverage and cost control. He warned that single-payer systems can delay treatment for some patients.
“From a personal standpoint, I don’t want to be in situation where I need special treatment or a special doctor and to have to wait six, eight, nine months down road,” Foley said. “If I have serious situation, I want to see the specialist now.”
Even though removing third-party insurers would cut those jobs, Eldridge said that part of the bill would devote money to train these workers to become nursing assistants or other jobs within the health-care field.
“I don’t think it would negatively affect the job environment, but these people would have to be retrained for a different profession,” he said.
Eldridge is also sponsoring a bill that would enable residents to choose a public option if they were unhappy with health care from an employer. He hopes this would stimulate competition between the government and private insurance companies and encourage cost reduction and increased quality of care.
“We need a more efficient system and Massachusetts has the opportunity to remain an innovator in health care and reform,” he said.
But some of his legislative colleagues aren’t completely sold on these health-care changes.
Sen. Eileen Donoghue, D-Lowell, said in an interview that she wants to further look into the cost of converting to a single-payer system since health-care finances are an issue that impacts both individuals and small businesses. She said cost containment is one of her biggest concerns since passage of a bill aimed at holding down medical charges in 2012.
“In theory, direct pay and not having middleman seems to indicate cost savings,” Donoghue said. “Health care is taking a bite out of paychecks and small businesses, and in reality, we need to understand how the (numbers) translate.”
Rep. Marc Lombardo, R-Billerica, labeled both single-payer and public option as a “terrible idea” because it would require too much government involvement. He suggested an option that would eliminate state-mandated coverage of certain treatments to accommodate consumers’ different needs as well as allowing residents to purchase health care outside the state as a way to boost competition.
“Most people select what’s important to them, and right now they don’t have enough options,” Lombardo said. “With a mandate-light option, they can find the appropriate value they want to spend their dollars, so families who need lesser options can find a lighter plan that fits their cost needs.”
Lisa Hagen is Statehouse correspondent.
http://www.lowellsun.com/news/ci_24368475/eldridge-single-payer-health-care-saves-money
Are we ready for ACOs?
Predicting ACO Formation: Two Studies With More In Common Than It Might Seem
By Valerie Lewis, Carrie Colla, and Elliott Fisher
Health Affairs Blog, October 22, 2013
At a time when policy makers, providers and payers are all trying to make high stakes decisions about how respond to the proliferation of Accountable Care Organizations (ACOs), divergent research findings might feel as welcome as rain on the fourth of July.
Two recently published studies, one by our group at Dartmouth and one by David Auerbach and coauthors in Health Affairs, both examined predictors of ACO formation. On the surface, they appear to have some inconsistent findings. Their core conclusions, however, are similar, and differences in the results are readily explained. Most importantly, policy implications are well aligned: there is much we can do to help the transition to accountable care succeed.
A common set of policy implications
The findings in both studies also point to challenges that deserve further attention by policy makers. How can providers without experience in risk-based contracts or who are in smaller, more fragmented practices get the additional support they may need to become an ACO? Models like the Medicare Advance Payment model are one move to support these types of providers, but our results here and elsewhere suggest that policymakers should be further developing programs to support the financing of these systems, along with the development of analytic and care coordination capabilities that are likely necessary for ACO success.
Another important question
How can spending and quality benchmarks be refined to encourage broader participation? Some (including us) have suggested that paying for improvement rather than absolute performance on quality may encourage underperforming systems to join the ACO model. Careful thinking is necessary from health economists and health care finance experts on how to set cost targets that do not penalize providers already on the low end of the cost spectrum.
The imperative of continued learning
Perhaps the most important conclusion, however, is to acknowledge the many uncertainties that remain. The transition to performance-based payment systems has barely begun – and better information on what is working and what isn’t would make successful reform more likely.
http://healthaffairs.org/blog/2013/10/22/predicting-aco-formation-two-studies-with-more-in-common-than-it-might-seem/
Comment:
By Don McCanne, M.D. If you are holding your breath to see if accountable care organizations (ACOs) are the answer to our quality and cost issues, I have some life-saving advice for you. Don’t wait, but breathe immediately! Elliott Fisher from the Dartmouth Institute has been credited with coining the term, accountable care organization. Look at what he and his colleagues have to say: The most important conclusion is that many uncertainties remain. One of the more important reasons for the uncertainties is that there remains a conflict between those who support better integration of health care (a noble goal) and those who support a business model that smacks of MBA-driven managed care (an ignoble goal). There are no uncertainties with the single payer model. We should proceed immediately to the enactment of an improved Medicare for all, and then we can afford to take years to study variations of the ACO model to see if we can improve health care delivery.
]]>The ACA is the Wrong Direction, Time for Medicare for All
By Margaret Flowers, M.D.
Green Shadow Cabinet, Oct. 21, 2013
In what is perhaps the greatest corporate scam ever, not only did the health insurance corporations write the federal health law, called the Affordable Care Act (ACA), to enhance their profits, but now they also have the government and non-profit groups doing the work of marketing their shoddy products. The foundation of the ACA, the mandate that uninsured individuals purchase private insurance if they do not qualify for public insurance, begins in 2014 and the state health insurance exchanges where people can purchase that insurance opened on October 1. A new non-profit organization called Enroll America was created to organize and train grassroots activists to seek out the uninsured (they even provide maps) and assist them in using the exchanges.
Billions of public dollars and tremendous efforts are being spent to create new health insurance markets, advertise them, subsidize their products and actively solicit buyers for them. But the United States, as the only industrialized nation to use a market-based health care system, has already proven over the past 40 years, that this system doesn’t work. It is the most expensive, leaves the most out and leads to poor health outcomes. It means that people only receive the health care they can afford, not what they need.
Market competition does not improve health outcomes because it consists of health insurance corporations competing for profit by selling policies to those who are the healthiest and denying and restricting payment for care. And regulation of insurers doesn’t work either. Although rules in the ACA give the appearance of changing insurance company behavior, insurers are already working around them.
Defense of the ACA ignores the long history of private insurance influence and domination and is based on the hope that this time things will be different. But the ACA has not changed the fact that private insurance companies view their plans as products and have no more allegiance to human health than does Big Energy which will stop at nothing to drill, frack and blow-up the planet for profits.
Experience at the state level with previous similar reforms and a look at current health trends show that the ACA will leave tens of millions without insurance, will increase the percentage of people who are underinsured, will increase financial barriers to necessary care and will further privatize health care. Cutting out the multitudes of insurers and creating a single publicly-financed universal health care system, Medicare for all, is the only way to solve our health care crisis.
The ACA fails to solve our health care crisis
· The ACA leaves tens of millions without coverage. There are currently 48 million uninsured people in the US. At its best, the Congressional Budget Office estimates that the ACA will leave 31 million people without health insurance when it is completely rolled out. And even that estimate may be too low. Experience at the state level showed that none of the similar plans hailed as comprehensive met their coverage goals before they failed due to costs. Without effective cost controls, care remains unaffordable.
· The ACA lowers the bar on what is considered to be acceptable insurance coverage. Plans sold through the new health insurance exchanges will pay for as little as 60 to 70 percent of covered services and carry high out-of-pocket costs. Because subsidies towards the purchase of insurance are inadequate, most people who are currently uninsured will be forced into the low coverage plans.
· The ACA continues the problem of financial barriers to care. Considering that 76 percent of Americans are living paycheck to paycheck without significant savings, the money simply isn’t there to pay the out-of-pocket costs for visits to the doctor, tests or prescriptions. A health survey by the Commonwealth Fund last year found that 80 million people reported not getting care due to cost, 75 million were having difficulty paying medical bills and 4 million (over 2 years) went into bankruptcy as a result.
· The ACA will circumvent the requirement to cover people with pre-existing conditions. One way that insurance companies are doing this is by restricting their networks to avoid places where sick people go such as large medical centers and public hospitals and by limiting the number of providers. This will push people to use out-of-network providers and bear more or all of the cost. Another method will be to raise premiums or stop selling insurance plans in areas where they do not make a profit. Insurers can’t charge more for policies because of pre-existing conditions, but they can charge more based on age and location.
· The ACA allows insurers to receive waivers from provisions in the law. Since the ACA was passed in 2010, insurers and others have received thousands of waivers from the Department of Health and Human Services (HHS) to exempt them from requirements. One of the most recent was to waive the cap on out-of-pocket spending because insurers claimed that their computer systems were not ready to handle the caps. We will watch and see what insurers do over the coming years. We can expect them to justify charging higher premiums and to push for lower levels of coverage or fewer required services. And we can expect that HHS and state insurance commissioners will be compliant, as they have been.
· The ACA moves our health system towards greater privatization. The ACA lacks provisions to stop the consolidation of ownership of health facilities by large for-profit entities, something that large insurers are doing more. It also cuts funding to safety net hospitals and shifts those funds to subsidize private insurance. In Massachusetts where a similar health law was passed in 2006, the need for safety net programs has not fallen as people, even with insurance, face financial barriers to necessary care.
· Under the ACA, public insurances are being privatized. More states are moving their Medicaid patients into managed care organizations (MCOs). MCOs are for-profit administrators that compete with each other to cover the healthiest patients and are incentivized to cut care. Currently 75 percent of Medicaid patients are in MCOs and that number is expected to increase further under the ACA. And one of the early goals of the ACA was to cut back on Medicare Advantage plans which are essentially private insurance plans paid for through Medicare. The Advantage plans primarily insure the healthiest seniors and cost more than traditional Medicare. Instead of cutting back, the Obama Administration boosted payment to the Advantage plans. And enrollment in the plans has increased by 30 percent since 2010.
Not the reform we need
Looking at the ACA from a distance, it is difficult to see it as anything more than a law designed by and for the health industries that profit from the current health system. The regulations can be circumvented or waived. The insurers can continue to find innovative ways to avoid the sick and paying for care. And overall the system is becoming more privatized, which is the opposite direction from the real solution, Medicare for all.
The United States is already spending more per person each year on health care than any other industrialized nation. We are spending enough to provide lifelong high-quality comprehensive care to every person living in the U.S. If we see the U.S. market-based health care system as an experiment, it has failed and should be ended for ethical reasons.
If we move immediately to a publicly-funded national Medicare for all, there would be no need for insurance exchanges and the massive increase in bureaucracy that goes with them. Every person would be in the health system. Any
person who sought care would be covered without requirements for payment before care. Medicare for all is the most effective, most efficient and fastest way to create a health care system that is about health rather than profit. It is also the most just.
We cannot cross our fingers and hope that the ACA “works.” That attitude means hundreds of thousands will suffer and die from preventable causes and millions of families each year will continue to go bankrupt because of medical illness and costs. The moral imperative is to realize that health care never has been and never will be a commodity and to stop treating it as such by taking it out of the marketplace altogether. We need Medicare for all now.
Dr. Margaret Flowers serves as Secretary of Health in the General Welfare Branch of the Green Shadow Cabinet of the United States.
http://greenshadowcabinet.us/statements/aca-wrong-direction-time-medicare-all
Antonia Maioni explains why Obamacare makes single payer impossible to attain
Obamacare vs. Canada: Five key differences
By Antonia Maioni
The Globe and Mail, October 2, 2013
Despite the partisan war in Washington that shut down the federal government this week, President Barack Obama has succeeded in implementing the first major health reform in the United States in nearly 50 years, as the Patient Protection and Affordable Care Act goes into effect. Even though its most virulent critics raise the spectre of “Canadian-style” health care, “Obamacare” does little to change the enduring differences between the two health care system. What, exactly, does “Obamacare” look like compared to Canada?
Not single-payer
Canadian critics tend to rail against “two-tiered” medicine, but in fact, the U.S. has a multi-tiered system. And despite the hype on both sides of the Congressional aisles, Obamacare keeps the same complex structure in place, while adding another layer through the introduction of health care “exchanges” for uninsured Americans. But the majority of Americans will continue to access care through a variety of health insurance plans made available or subsidized by their employer; nearly 50 million elderly and disabled through the federal Medicare program; another 60 million lowest-income through state-federal Medicaid arrangements.
Not universal coverage
Health care in Canada is based on a simple proposition: every legal resident is covered through a publicly-financed provincial or territorial plan. The individual mandate, derived from a Republican precedent in Massachusetts, stands in stark contrast to Canada’s universality principle. Even though Obamacare broadens coverage, the individual mandate relies on a fundamental insurance principle – care depends on type of coverage – and compels Americans to purchase insurance to access care. Americans now have more affordable insurance options and subsidies to cover their costs, and the lowest-income may be eligible for public coverage through the expansion of Medicaid. Still, despite the crush of online traffic as enrolment began Tuesday, only half of the estimated 40-plus million uninsured will be affected by Obamacare.
Not “national” health insurance One of the hallmarks of health care in Canada is that, although each province and territory administers a health plan, everyone can expect to be covered for a comprehensive range of services, no matter where they live. And the federal government is expected to chip in to provincial coffers to make this happen. There’s plenty of intergovernmental friction as a result, but nothing like the fractured federalism of the United States. The implementation of Obamacare will further exacerbate regional and state differences, mainly as a result of the Supreme Court decision to curtail the federal government’s obligation for states to expand their Medicaid coverage. As a result, only about half of the states have chosen to sign on to the new Medicaid program. Not equal access There’s been some controversy in Canada lately over wait times and access to timely care, but this pales in comparison to the wide gulf that exists in access to care in the United States. Obamacare tries to address this in its provisions for insurance reform, such as lifting pre-existing conditions and limits on co-payment. But for all of the emphasis on affordable care, the new law reinforces the notion that access depends on how much you can afford, not how much you need. In the health insurance exchanges, the price of premiums will depend on your age, health, income, and on whether you opt for a bronze, silver, gold or platinum coverage. In Canada, access to necessary health care services is not a competitive sport. Not cost containment The sharpest critics of Obamacare argue it does little to address the fundamental challenge of cost control. The new law includes a review of Medicare reimbursement and the expansion of Accountable Care Organizations to reward cost-effective care. But it doesn’t grapple in a systematic fashion with the overall inefficiencies in health care delivery and financing, the administrative burden of multiple payers, providers and plans, and the cost pressures of defensive medicine. Governments in Canada know that health care is a searing financial responsibility, but they have at their disposal cost containment measures – monopoly fee negotiations with providers, global budgets for hospitals – that remain unfathomable in the American context. Obamacare is a huge step in American health reform and, if it seen to improve the system, will represent a major victory for Democrats. Like other major reforms of the past, however, it will entrench the private nature of the system, and likely render national health insurance, or anything remotely like “Canadian-style” health care, impossible to attain. Antonia Maioni is an associate professor at McGill University http://www.theglobeandmail.com/commentary/obamacare-vs-canada-five-key-differences/article14657740/ Brief bio of Professor Maioni: http://www.mcgill.ca/politicalscience/sites/mcgill.ca.politicalscience/files/antonia_maioni_bio_en_2012.pdf
Comment:
By Don McCanne, M.D. It is frequently said that Obamacare will lead to a Canadian-style single payer system – a statement of optimism by some supporters, and a threat by opponents. McGill University Professor Antonia Maioni explains why Obamacare will do no such thing. Many of the Quote of the Day messages describe very serious flaws in the Obamacare model – flaws that perpetuate high costs, administrative excesses, impairments in access, and many other unjust inequities inherent in our system. I frequently receive messages stating that I should cease criticizing Obamacare, and, instead, I should be supporting Obamacare measures as incremental steps leading to single payer. Although we do not want to reject even minimal improvement in our system, most of the serious structural flaws cannot be corrected with simple remedial legislation. Professor Maioni explains some of the fundamental structural defects in the U.S. financing system that cannot be merely tweaked to get it right. As Professor Maioni states, “Obamacare… will entrench the private nature of the system, and likely render national health insurance, or anything remotely like ‘Canadian-style’ health care, impossible to attain.” The incremental path to single payer through Obamacare has no bridge across the chasm. It would be a tragedy to spend a decade or two, standing on one edge of the chasm, looking across and trying to figure out how legislative patches can build a bridge to the other side, when patches cannot repair a bridge that doesn’t even exist. Only a new infrastructure will do. We must begin building a single payer system with all due haste.
]]>Obamacare vs. Canada: Five key differences
By Antonia Maioni
The Globe and Mail (Toronto), Oct. 3, 2013
Despite the partisan war in Washington that shut down the federal government this week, President Barack Obama has succeeded in implementing the first major health reform in the United States in nearly 50 years, as the Patient Protection and Affordable Care Act goes into effect. Even though its most virulent critics raise the spectre of “Canadian-style” health care, “Obamacare” does little to change the enduring differences between the two health care system. What, exactly, does “Obamacare” look like compared to Canada?
Not single-payer: Canadian critics tend to rail against “two-tiered” medicine, but in fact, the U.S. has a multi-tiered system. And despite the hype on both sides of the Congressional aisles, Obamacare keeps the same complex structure in place, while adding another layer through the introduction of health care “exchanges” for uninsured Americans. But the majority of Americans will continue to access care through a variety of health insurance plans made available or subsidized by their employer; nearly 50 million elderly and disabled through the federal Medicare program; another 60 million lowest-income through state-federal Medicaid arrangements.
Not universal coverage: Health care in Canada is based on a simple proposition: every legal resident is covered through a publicly-financed provincial or territorial plan. The individual mandate, derived from a Republican precedent in Massachusetts, stands in stark contrast to Canada’s universality principle. Even though Obamacare broadens coverage, the individual mandate relies on a fundamental insurance principle – care depends on type of coverage – and compels Americans to purchase insurance to access care. Americans now have more affordable insurance options and subsidies to cover their costs, and the lowest-income may be eligible for public coverage through the expansion of Medicaid. Still, despite the crush of online traffic as enrolment began Tuesday, only half of the estimated 40-plus million uninsured will be affected by Obamacare.
Not “national” health insurance: One of the hallmarks of health care in Canada is that, although each province and territory administers a health plan, everyone can expect to be covered for a comprehensive range of services, no matter where they live. And the federal government is expected to chip in to provincial coffers to make this happen. There’s plenty of intergovernmental friction as a result, but nothing like the fractured federalism of the United States. The implementation of Obamacare will further exacerbate regional and state differences, mainly as a result of the Supreme Court decision to curtail the federal government’s obligation for states to expand their Medicaid coverage. As a result, only about half of the states have chosen to sign on to the new Medicaid program.
Not equal access: There’s been some controversy in Canada lately over wait times and access to timely care, but this pales in comparison to the wide gulf that exists in access to care in the United States. Obamacare tries to address this in its provisions for insurance reform, such as lifting pre-existing conditions and limits on co-payment. But for all of the emphasis on affordable care, the new law reinforces the notion that access depends on how much you can afford, not how much you need. In the health insurance exchanges, the price of premiums will depend on your age, health, income, and on whether you opt for a bronze, silver, gold or platinum coverage. In Canada, access to necessary health care services is not a competitive sport.
Not cost containment: The sharpest critics of Obamacare argue it does little to address the fundamental challenge of cost control. The new law includes a review of Medicare reimbursement and the expansion of Accountable Care Organizations to reward cost-effective care. But it doesn’t grapple in a systematic fashion with the overall inefficiencies in health care delivery and financing, the administrative burden of multiple payers, providers and plans, and the cost pressures of defensive medicine. Governments in Canada know that health care is a searing financial responsibility, but they have at their disposal cost containment measures – monopoly fee negotiations with providers, global budgets for hospitals – that remain unfathomable in the American context.
Obamacare is a huge step in American health reform and, if it seen to improve the system, will represent a major victory for Democrats. Like other major reforms of the past, however, it will entrench the private nature of the system, and likely render national health insurance, or anything remotely like “Canadian-style” health care, impossible to attain.
Antonia Maioni is an associate professor at McGill University.
http://www.theglobeandmail.com/commentary/obamacare-vs-canada-five-key-differences/article14657740/
Why a single-payer health system would be better than Obamacare
By Paul F. deLespinasse
The Daily Telegram (Adrian, Mich.), Oct. 20, 2013
Recent efforts to defund Obamacare evoked hot air from both sides of the aisle. Perhaps it is now time for serious talk instead of talking points.
While it has some good aspects, there are four principal problems with Obamacare:
1. It is outrageously complex, confronts individuals and employers with decisions they are poorly equipped to make, and requires government to pull together vast amounts of information in determining eligibility for subsides.
2. It leaves millions uninsured, especially since the Supreme Court eviscerated Medicaid expansion by allowing states to ignore it without losing federal funding for their existing Medicaid programs.
3. It perpetuates employment-based insurance (while undermining it for some). People who become too sick to work will continue to lose their insurance, and their loss of income will make it impossible to buy insurance privately without prolonged paperwork at the exchanges.
4. Under Obamacare insurers are gaming the system, offering low prices on the exchanges but restricting coverage to very limited “networks” of doctors and hospitals, making it harder for people to get care.
There is an obvious solution to these problems: a taxpayer-funded, single-payer insurance system, “Medicare For All.”
Medicare For All could be very simple, with low administrative costs. Individuals could participate without having to make complicated decisions requiring them to consult accountants, lawyers … and psychiatrists.
The system would cover everyone without any exceptions, and would allow overlapping systems like Medicaid to be phased out.
People wouldn’t depend on employment for insurance. Those too sick to work would not lose coverage. Employers would have no incentive to move toward part-time work or to avoid hiring older people, whose medical costs tend to be higher.
Under single-payer there would be no “out of network” doctors and hospitals. People could chose doctors and hospitals to their taste and convenience.
The major political obstacle to a single-payer system is that it would require higher taxes. But the average person’s out of pocket costs for insurance would be reduced by more than their taxes would increase, leaving more in their pockets.
Single-payer eliminates payment of personal insurance premiums. It also eliminates the premiums now paid by employers, money by necessity subtracted from the wages they pay. (That is why low-paid workers are not provided with insurance, since their wages cannot be reduced below the legal minimum, and why the employer mandate drives employers of low-paid workers to make them part-time to avoid insuring them.)
To retain qualified workers, employers will have to redistribute these savings as increased wages.
By greatly reducing administrative costs and eliminating private profits and the magnificent salaries of insurance executives, single-payer’s total cost would be less than Obamacare and less than the pre-Obamacare system. This lower system cost is why the average person will retain more in-pocket even after paying increased taxes.
Having given up on defunding, John Boehner now says he will continue fighting Mr. Obama’s health care law, but in a different manner. Perhaps he should consider supporting a replacement that would incorporate the conservative values of simplicity, uniformity and efficiency: a single-payer system paid for with taxes, Medicare For All.
Paul F. deLespinasse, who now lives in Corvallis, Ore., is professor emeritus of political science at Adrian College.
http://www.lenconnect.com/article/20131019/OPINION/131019313/1007/OPINION
24 million will be permitted to remain uninsured without penalty
Implementing Health Reform: The State Of The Exchanges, Income Verification, And More
By Timothy Jost
Health Affairs Blog, October 16, 2013
Information collection.
On October 11, 2013, HHS published a notice of information it was intending to collect to establish individual mandate exemptions.
There is nothing new in this notice, but the scope and number of exemptions from the ACA’s individual responsibility requirement are truly impressive. In addition to the religious conscience, health care sharing ministry, incarceration, Native American tribe membership, and lack of affordable coverage exemptions, there is an extensive list of hardship exemptions, including:
* Homelessness;
* Eviction in the previous 6 months or the threat of eviction or foreclosure;
* A utility shut-off notice;
* Recent death of a close family member;
* A fire, flood, or other natural or human-caused disaster that caused substantial property damage;
* A bankruptcy filing in the last 6 months;
* Medical expenses in the past 24 months that could not be paid;
* Unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member;
* The presence in the household of a child claimed as a tax dependent who was denied coverage in Medicaid and CHIP where another person is required by court order to give medical support to the child. In this case, the penalty need not be paid for the child;
* A favorable eligibility appeals decision that makes an individual eligible for enrollment in a qualified health plan (QHP) through the Exchange, lower the costs on monthly premiums, or provides cost-sharing reductions, which removes the penalty for the time the individual was not enrolled in a QHP through the Exchange; or
* Residence in a state that fails to expand Medicaid if the individual would have been eligible for Medicaid.
HHS estimates that 24 million Americans will be eligible for individual responsibility exemptions and that as many as 12 million will apply for exemptions through the exchange. In most instances, documentary evidence will need to be supplied to verify the exemption. Unless the federal exchange website is vastly improved in the not too distant future, this could create major problems for the implementation of the individual responsibility requirement.
http://healthaffairs.org/blog/2013/10/16/implementing-health-reform-the-state-of-the-exchanges-income-verification-and-more/
CMS.gov – Supporting Statement for the Information Collection Requirements Contained in the Exemptions Eligibility Information Collection Request (25 pages): http://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS–10466.html
Comment:
By Don McCanne, M.D. The Affordable Care Act includes multiple categories of exemptions from the shared responsibility payment – the penalty for remaining uninsured. This new CMS release defines the category of hardships which would allow you to remain uninsured without having to pay a penalty. When you check the list, it seems that most of these hardships would indicate a greater need for having health care coverage. But instead of seeking ways to fill these gaps, ACA simply cuts these people loose with no coverage at all. The largest category of those who are exempt from the requirement to be insured are those who simply cannot afford to pay for their share of health insurance premiums. That includes families whose incomes are so low that they are not required to file income tax returns, and individuals who would have to pay more than 8% of their incomes for premiums beyond employer contributions or tax credits for the exchange plans. It includes individuals who would have been eligible for Medicaid but are excluded simply because their states elected not to participate in the Medicaid expansion. HHS estimates that 24 million Americans will be eligible for exemptions from the shared responsibility payments. That is, 24 million individuals will have the right to remain uninsured without having to pay a penalty. That is quite a stipulation for an Act that was supposed to bring health care to everyone. 24 million! Clearly our politicians selected the wrong model for reform. We do not have to put up with this. If enough of us protest vehemently, we should be able to get our politicians to replace this highly dysfunctional system with a single payer national health program – an improved Medicare that covers everyone – absolutely everyone.
]]>Even reformers don’t like Obamacare: a conversation with Dr. Quentin Young
By Phil Kadner
Southtown Star (Chicago), Oct. 17, 2013
The Republicans are right. The Affordable Care Act, aka Obamacare, is a mess.
The Democrats are right. The nation desperately needed health care reform, and millions of Americans had no insurance.
Obamacare became what it is today because of both political parties and pressure from the health insurance industry, the pharmaceutical manufacturers and the public.
Reasonable people should have been able to hammer out a workable compromise. But these are not reasonable times. People are for things or against them.
And even the “winners” sometimes feel like “losers.”
Dr. Quentin Young falls into one of those groups, maybe both.
Young, 90, is the chairman and co-founder of the Health and Policy Research Group and has been battling for a single-payer, universal health care system for more than 30 years.
“It’s what every other modern industrialized country in the world has,” Young told me during a telephone conversation on Wednesday. “Health care is a human right, and I don’t understand why people in this country still refuse to accept that. In every other nation, that’s how they look at it.”
Chairman of medicine at Cook County Hospital from 1972 to 1981, Young was president of the American Public Health Association in 1988 and knew President Barack Obama before he became a U.S. senator.
“Back then, he favored single-payer health care,” Young said. “I don’t know what happened, but something changed his mind. By the time he was president he no longer was an advocate of single-payer health insurance, and that was a mistake.
“There are 16 million to 20 million poor people in this country who will not be covered by the Affordable Care Act. You can go broke or die without health insurance.
“Sixty-two percent of people who file for personal bankruptcy in this country go bankrupt not because they can’t manage their money, but because of an illness in their family.”
Controlling medical costs is a key to providing national health care, as far as Young is concerned, and the Affordable Care Act isn’t going to do that.
“From 1950 until now, the cost of health care in this country increased from $22 billion to $2.7 trillion,” he said. “You can’t sustain that. Every other (advanced) nation controls its health care costs through single-payer health insurance, their governments, but we don’t so we’re paying more and we’re getting less.”
According to the World Health Organization, the United States spent more on health care per capita ($8,608) and more on health care as a percentage of gross domestic product (17.9 percent) than any other nation in 2011. That was before Obamacare.
“And one of the reasons we spend more is that billions of dollars are made by private health insurance companies. That does nothing to improve the health of the average American,” Young said. “It’s just profit for the companies that provide health insurance.
“But this thing (Obamacare) won’t change that. The private insurance companies are still going to make their profits.”
Young is quick to point out that he doesn’t want to be associated with the Tea Party Republicans who have been denouncing Obamacare.
“At least under this plan, millions of Americans who had no insurance will get insurance, people with pre-existing conditions can now buy insurance and children are covered longer under their parents’ policies,” Young said. “It’s better than what we had. But I’m not sure, long term, that it’s going to work because it doesn’t control the cost of health care.”
That view of Obamacare’s financial picture is similar to one expressed to me this week by U.S. Rep. Dan Lipinski (D-3rd).
Lipinski said that unless major changes are made to the Affordable Care Act, he fears it will not be financially sustainable.
And that’s one of the core arguments of the Tea Party Republicans, who contend that Obamacare will be the economic ruin of the country.
Of course, those Tea Partiers have never favored universal health care and have never talked seriously about controlling health care costs.
While they blame Obamacare for employers dropping their medical insurance plans, the Tea Party faithful ignore the fact that more than 1 million working Americans had been losing their health insurance each year before Obamacare was passed.
In 2012, before the U.S. Supreme Curt ruling on health care reform, 9 percent of employers planned to drop their health insurance benefit, according to a report by consulting firm Deloitte.
Among those who were not dropping the coverage, most said they planned to make workers pick up more of the costs through higher premiums, co-pays and deductibles.
Yet, the majority of Americans, fearful of socialized medicine, isn’t prepared to back single-payer national health care.
“The insurance industry spent millions of dollars scaring the hell out of them,” Young said.
There’s some truth to that, but I think most Americans are happy with their current health coverage.
But they know that employers could stop offering health insurance, or they could lose their jobs and their insurance, and they wanted to hedge their bets.
Obamacare sounded good, even if they didn’t understand the details, but now many have come to believe the details are a mess.
Lipinski said his fellow Democrats in Congress are finally coming to the realization that the Affordable Care Act is seriously flawed and needs to be changed.
But Republicans seem just as convinced that the law is fatally flawed and needs to be overturned.
“I believe there are some areas of agreement between us that we can work on now,” Lipinski told me.
I’m not as hopeful. All the forces that shaped this deformed law are still at work. Too few Americans understand them.
Of this I’m sure, the battle over health care reform isn’t going away.
pkadner@southtownstar.com
http://southtownstar.suntimes.com/news/kadner/23202889-452/kadner-even-reformers-dont-like-obamacare.html
Will small employers use SHOP exchanges to benefit employees, or themselves?
Small Employer Perspectives On The Affordable Care Act’s Premiums, SHOP Exchanges, And Self-Insurance
By Jon R. Gabel, Heidi Whitmore, Jeremy Pickreign, Jennifer L. Satorius and Sam Stromberg
Health Affairs, October 2013
As of October 1, 2013, companies with fifty or fewer full-time-equivalent employees began signing up for insurance coverage through the SHOP exchange in their state.
SHOP exchanges are electronic marketplaces where company managers can obtain information on each qualified health plan sold in the exchange — including its benefits, premiums, networks, and actuarial value — and sign their company up for the plan of their choice.
Appeal Of Selected SHOP Features
We asked small employers that offered coverage about their interest in a number of features that the SHOP exchanges will have and about various scenarios that could occur if they used a SHOP exchange.
Fifty-six percent of respondents said that they were more interested in “offering workers a choice of plans, with the employer paying a fixed amount, and the employee paying any extra cost for choosing a more expensive plan” (the “employee model”) than in “offering workers one plan with less administrative work for your firm” (the “employer model”).
Small employers showed an interest in narrow-network plans, if using such plans would reduce costs. The survey defined narrow-network plans as those contracting with 25 percent of the doctors and hospitals in the community. If using a narrow network instead of a broad network — one with 80 percent of the doctors and hospitals in the community — would lower premiums by 5 percent, 57 percent of the respondents said they would opt for the narrow network. If the premiums were 10 percent lower, 77 percent would choose the narrow network, and with 20 percent lower premiums, 82 percent would do so.
Self-Insurance
An unintended consequence of the Affordable Care Act is that it may make self-insurance attractive for small firms.
The major drawback to self-insuring has been the financial risk of having a covered person experience a catastrophic illness or injury, and the subsequent substantial increase in the cost for stop-loss coverage that would ensue. Stop-loss coverage is a form of reinsurance that limits the amount of money that employers must pay out for a claim or group of claims.
But self-insurance may become more attractive as the Affordable Care Act takes effect. Because the act eliminates medical underwriting, if one or more insured workers or dependents at a small firm were to incur catastrophic costs in a given year, the next year the firm could move into the fully insured community-rated market on or off the SHOP exchange.
Among firms whose brokers had discussed self-insuring, or firms not using brokers but considering self-insuring, 9 percent said they were “very likely” to self-insure, and 14 percent were “somewhat likely.”
From the Discussion
One clear message from employers is that the cost of coverage is by far the most important factor in their purchasing decisions. The majority of employers not offering coverage identified price points (the highest premium amount they would consider) that were substantially lower than prices in the current market.
Small employers showed strong preferences for the “employee model” over the “employer model,” even if the former involved higher administrative expenses than the latter. As noted above, seventeen of the eighteen state-based SHOP exchanges have chosen the employee model. However, federally run exchanges will not offer that model until 2015.
From the Conclusion
The survey quantified a much-discussed unintended consequence of the Affordable Care Act: a movement to self-insurance, which poses a threat not just to SHOP exchanges but to the entire small-group market. Under the act, self-insured firms do not have the same plan design requirements as fully insured firms. For example, self-insured plans do not have to meet essential benefit requirements of their state. Consequently, some brokers have suggested to small employers that they self-insure and purchase stop-loss coverage at attachment points as low as $10,000. (Attachment points are the dollar amount where stop-loss insurance begins paying for medical expenses.)
Moreover, should a small firm self-insure and incur catastrophic costs, instead of facing prohibitive stop-loss premiums the following year, it could simply move into the fully insured market through a SHOP exchange, where premiums are community rated (with adjustments for age of the workforce and geographic location).
After a few years of converting to self-insurance, the small-group market could reach a tipping point that would leave the fully insured markets with greater risks, higher premiums, and eventually a so-called death spiral — in which costs become prohibitive for most people, so few people enroll except the sick, making per enrollee costs even higher.
http://content.healthaffairs.org/content/early/2013/10/15/hlthaff.2013.0861.abstract
Comment:
By Don McCanne, M.D. Small Business Health Options Program (SHOP) exchanges were created by the Affordable Care Act to provide small businesses with an assured source of affordable health insurance for their employees. This study suggests the likely response of employers to these SHOP exchanges, and it appears that they are more interested in taking care of themselves rather than their employees. The cost of coverage is by far the most important factor in their purchasing decisions. The following three examples will show us where the hearts of employers lie. Employers express a preference for providing a fixed sum (defined contribution) to the employees and allow them to choose plans as long as they pay the full difference in premiums for plans that are less spartan in their benefits. This not only shifts more health care costs to the employees, but it also allows the employer to saddle their employees with future increases in health care costs. Employers are also quite willing to take away employees’ choices of their health care professionals and hospitals by using narrow-network plans that exclude three-fourths of the health care providers in the community, as long as the employers receive discounts on their premiums. Employers are now also showing considerable interest in self-insuring outside of the SHOP plans – providing as little as $10,000 in coverage while purchasing stop-loss insurance for amounts above that. The risk to the employer is that one serious medical problem in an employee or family member could cause a sharp increase in stop-loss premiums. If that were to occur, the employer under ACA now has the out of dumping his employees into a SHOP plan. If enough employers did this (which it seems like many will), then the SHOP plans would concentrate high-cost individuals, driving premiums sky high – the “death spiral” of adverse selection. Small business employers are not mean. They’re businessmen. Employee health benefit costs are almost intolerable for many of them simply because our health care costs are so high. Under our current method of financing health care – the infrastructure of which was left in place by ACA – where are employers to turn? When the industry offers them insurance innovations that address their costs, even if tainted, how could they turn them down? The smart move would be to jump at the chance to eliminate any responsibility of providing health benefits by supporting replacement of our current financing system with an improved Medicare that covered everyone – a single payer national health program. And they are smart. They just need to be better informed on this vastly superi or alternative.
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