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.
]]>ACA's bungled rollout aside, government health insurance works
By Dr. Philip Caper
Bangor (Maine) Daily News, Oct. 17, 2013
The lead story in the Oct. 13 New York Times details the ongoing problems of the Affordable Care Act’s websites intended to facilitate access by individuals to the law’s hallmark online health insurance marketplaces. Those problems continue. To summarize, many of the state-run and all of the 36 federally run websites are currently experiencing significant problems providing access to the exchanges, and nobody seems willing or able to predict when they will be fixed. This failure to launch President Barack Obama’s signature domestic achievement is hugely embarrassing for the administration, and will undoubtedly provide a great deal of fodder for late-night comedians. It will also provide an almost unlimited source of talking points for tea partiers and other government-haters, who will cite this unfolding fiasco as more evidence that “government can’t get anything right.” That would be incorrect. In 1965 and the years following, I witnessed the implementation of Medicare, which enrolled 19 million beneficiaries almost seamlessly in less than a year, despite the formidable opposition of Southern hospitals wary of its requirements that they desegregate their wards. As I wrote last month, the problem with the ACA is not that the federal government is involved, but that literally thousands of private insurers have their fingers in the cookie jar, resulting in a law that is much too complicated for what it needs to accomplish, and too complex for anybody to administer efficiently and effectively. Together, Medicare and Social Security — both run by the federal government — have been successfully providing access to private health care and income security for millions of seniors and the disabled for almost 50 years. They have been a major factor in keeping seniors in our country out of poverty. Both programs are overwhelmingly popular with doctors, patients, the general public and most politicians. Medicare is also much more successful than private, for-profit insurance in holding down the prices paid for medical services and products and overhead costs — 6 percent compared with 20 percent or more. But Medicare is still not doing nearly enough to control costs. It is estimated that there is at least $750 billion worth of waste in the U.S. health care system. Politics is the only credible reason for retaining the complex and confusing web of private insurance plans in a health care system that aspires to cover everybody. In order to gain congressional approval, the ACA had to first accommodate the interests of the corporate medical-industrial complex, putting the interests of the American people in a distant second place. Congress’ approval rating now hovers around five percent. We can do better. It took over 50 years from the time President Theodore Roosevelt first proposed national health insurance until Medicare and Medicaid were enacted. It took almost another 50 years for the ACA to be enacted, expanding insurance coverage and enacting some protections against some of the insurance industry’s predatory practices. We have had to endure almost 100 years of acrimonious political debate, name-calling, disinformation and outright lies — much of it designed to protect and defend some doctors’ incomes and corporate health care companies’ windfall profits — to even approach what all other wealthy countries take for granted: health care as a human right. We need expanded and improved Medicare-for-All. And we need to vote any politician who won’t advance us toward that goal out of office. We’re moving in the right direction. But we can’t afford to take another 100 years to get there. Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com. http://bangordailynews.com/2013/10/17/health/acas-bungled-rollout-aside-government-health-insurance-works/
]]>The High Cost of Asthma in America
By Elizabeth R. Rosenthal, M.D.
The New York Times, Letters, Oct. 15, 2013
Re “The Soaring Cost of a Simple Breath” (“Paying Till It Hurts” series, front page, Oct. 13):
Your excellent article about the soaring costs of prescription drugs reveals how successful Big Pharma has been in protecting its bottom line even if it leaves millions gasping for breath because they cannot afford their asthma medicine. Through its tremendous lobbying power, this consistently profitable industry has punished American consumers with drug prices way above those of any other country.
As a volunteer Medicare rights counselor, I have seen elderly people who must choose between buying their prescription medications and buying food. It is shameful that our government allows this to continue.
If all members of Congress had to pay top dollar for their prescription drugs and those of their spouses and children, maybe they would understand. Maybe then we would have sensible negotiation of drug prices.
Dr. Elizabeth Rosenthal is a dermatologist. She resides in Larchmont, N.Y.
http://www.nytimes.com/2013/10/16/opinion/the-high-cost-of-asthma-in-america.html?_r=0
The activist-doctor Quentin Young is still in
A new film project tries to capture the life of the physician who takes care of Chicago
By Ben Joravsky
The Reader (Chicago), October 15, 2013
In his long and distinguished career as an activist and doctor, Quentin Young has fought to integrate the medical staff at Cook County Hospital, treated the wounds of Dr. Martin Luther King Jr., and infuriated Mayor Rahm Emanuel by thwarting his attempt to waste taxpayer dollars on Wrigley Field.
He’s a living illustration that the fight for fairness is full of setbacks as well as victories, but that it continues to this day.
I’ve had Dr. Young on my mind since filmmaker Al Nowakowski called to tell me about the Kickstarter campaign he and his filmmaking partners have undertaken. They need to raise $30,000 to finish “The Good Doctor Young,” a documentary about Young’s life.
It sounded to me like a noble endeavor. So last week I took a break from Mayor Emanuel’s school closings, budget cuts, and TIF deals and headed south to Hyde Park to visit the doctor, who’s 90 years old.
It was the first time we’d met and I wasn’t disappointed. As Nowakowski’s partners—Cat Jarboe and Jeff Bivens—filmed us, Young chatted amiably for over an hour, charming, good-humored, and gracious.
I intended to zero in on my obsession—the business about Mayor Emanuel and Wrigley. But you know how it goes. You start talking about this, and you wind up talking about that. Before I knew it, Young was giving me a condensed version of his life story.
He was born and raised on the south side, not far from where he currently lives. He’s as Chicago as Augie March himself.
Young swears up and down that he was for a single-payer health system going back to when he was a 13-year-old freshman at Hyde Park High.
After high school, Young enrolled at the University of Chicago. “There was a war going on and I was antifascist,” he says. “I volunteered for the army when I was 19. I was put in the medics.”
Following the war, he earned his medical degree at Northwestern University and went to work at Cook County Hospital, eventually rising to the position of chairman of medicine.
As the years wore on, Young was on the front lines of just about every single left-of-center cause, from the antiwar movement to the drive for single-payer health care.
On his wall is a framed photo of an open-housing march in the mid-60s. Young is standing in front of Al Raby, a local civil rights activist so legendary a high school was named after him.
Just in front of Young is King and in front of King is Jesse Jackson, wearing a porkpie hat that would fit in perfectly today among the hipsters of Logan Square. In front of Jackson is Reverend James Bevel, another legendary civil rights activist, wearing his trademark yarmulke. Man, what a time.
When Dr. King brought his civil rights campaign to Chicago in 1966, Young was his personal physician. He says King was sick twice during those months from bad colds.
“I would make a 15-minute visit that would last for two hours,” Young says. “He was clearly a man with a mission.”
After King was hit in the head with a rock during the infamous open-housing march in Marquette Park, Young tended his wound. “King was not fearless,” Young says. “He felt he was going to die. But he didn’t have a sense of immortality. . . . He knew his vulnerability and exposure. He lived accordingly. That makes him even more of a hero in my book.”
Young also had the chance to see the city’s political establishment at work, including the first Boss Daley. “Old man Daley was basically a business-supported guy who tried to keep the city as it was. It was segregated and racist and blacks were at the bottom of the heap.”
Young wasn’t Mayor Harold Washington’s doctor, but they were neighbors and good friends for years. Mayor Washington appointed Young president of the Board of Health.
“Harold is the most remarkable person I’ve met,” says Young. “But he would not do what I said.”
In particular, Young urged Washington to eat better and exercise more. Alas, Washington died of a heart attack in 1987.
Eventually, we got to the story that I just had to hear—how Young and Governor Quinn teamed up to stop Mayor Emanuel from wasting good taxpayer money on Wrigley Field.
In 2012, the mayor was negotiating with the Cubs on a subsidy to rehab the ballpark. Such a handout requires approval by the Illinois Sports Facilities Authority, a body made up of four appointees by the governor and three by the mayor.
Last October Mayor Emanuel moved to take control of the authority by getting Manny Sanchez, a Quinn appointee, to join his trio in voting for a new, handpicked executive director.
At the last moment, however, Governor Quinn pulled a fast one: he replaced Sanchez with Young. Sanchez didn’t know he’d been replaced until he showed up for the meeting, ready to vote for Emanuel’s appointee.
Man, Chicago is a tough town.
“Four beats three every time,” Young says.
You should have heard the mayor’s appointees huffing and puffing at that meeting about Quinn’s low-down, dirty deeds. It was like they were shocked—shocked, I tell you—to discover that politicking goes on in this city.
I wish they’d been around to raise a ruckus as Mayor Emanuel pulled his own fast one this summer, when he officially got the City Council to move forward with his South Loop basketball arena/hotel deal on a voice vote that aldermen didn’t even know they were taking.
For the record, Mayor Emanuel says he wasn’t going to support a handout for the Cubs. If you say so, Mr. Mayor. I guess it was just a coincidence that it wasn’t until January that the Cubs officially announced they were giving up on a handout and planning to rehab Wrigley on their own.
Ironically, Mayor Emanuel has been bragging ever since about how he’s held the line on a Wrigley handout. He’s probably going to use it as one of the centerpieces of his reelection campaign—if the Cubs ever get around to starting the actual construction.
I tell you—you can go far in this world if you have no shame.
I think the mayor should take that public money he saved on Wrigley and use it to reopen some of the mental health clinics he closed in high-crime neighborhoods. He could even name one of the clinics for Dr. Young.
If he can’t bring himself to do that, he can at least make a personal contribution to Nowakowski’s Kickstarter campaign. It’s a small way to honor one of Chicago’s great crusaders of the last 60-something years.
]]>Improving, expanding Medicare would solve health care problems
By Ed Weisbart, M.D.
St. Louis Post-Dispatch, Letters, Oct. 16, 2013
We should all celebrate the victory of the United Mine Workers of America in their struggle to retain their earned right to retiree health care (“Peabody strikes deal,” Oct. 11).
For decades, UMWA has fought for this because it is physically impossible to work in the mines until the magic age of 65, when Medicare kicks in.
Last year, the mining industry manipulated bankruptcy laws and tried to rob the UMWA of these benefits. The union began a series of rallies in St. Louis, corporate headquarters of both Peabody Energy and Patriot Coal. Last week, UMWA announced that with the overwhelming support of many diverse groups in the St. Louis community, their retiree health care benefits are being reinstated.
Let this stand as a bellwether of social justice in health care. The seemingly impossible has again transformed into historical fact.
Eventually, perhaps tomorrow, we will figure out that the answer to our nation’s health care crisis is to improve Medicare and provide that to every American. Eliminate premiums and deductibles; fund it through our progressive federal taxes. Implement it easily through our Social Security system, which already has much of the infrastructure. The savings from administrative simplification would more than balance the new costs.
We could each go to the physician we select, not the one our employer’s health insurer offers us.
The answer to the American health care crisis is hiding in plain sight: improved and expanded Medicare for all.
Dr. Ed Weisbart is chair of Physicians for a National Health Program-St. Louis. He resides in Creve Coeur.
[PNHP note: You can read the text or watch a video of Dr. Weisbart’s speech to a Sept. 24 UMWA rally in St. Louis here.]
http://www.stltoday.com/news/opinion/mailbag/letters-to-the-editor/improving-expanding-medicare-would-solve-health-care-problems/article_a1e51f77-34c9-56cf-a238-453121f9489a.html
5.2 million people fall into ACA coverage gap
The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid
The Kaiser Commission on Medicaid and the Uninsured, October 2013 The expansion of Medicaid, effective in January 2014, fills in historical gaps in Medicaid eligibility for low-income adults and has the potential to extend health coverage to millions of currently uninsured individuals. This expansion essentially sets a national Medicaid income eligibility level of 138% of poverty (about $27,000 for a family of three) for adults. The expansion was intended to be national and to be the vehicle for covering low-income individuals, with premium tax credits for Marketplace coverage serving as the vehicle for covering people with higher incomes. However, the June 2012 Supreme Court ruling made the expansion of Medicaid optional for states, and as of September 2013, 26 states did not plan to implement the expansion. In states that do not expand Medicaid, over five million poor uninsured adults (5.2 million people) have incomes above Medicaid eligibility levels but below poverty and may fall into a “coverage gap” of earning too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits. Most of these people have very limited coverage options and are likely to remain uninsured. The ACA envisioned people below 138% of poverty receiving Medicaid and thus does not provide premium tax credits for the lowest income. As a result, individuals below poverty are not eligible for Marketplace tax credits, even if Medicaid coverage is not available to them. Individuals with incomes above 100% of poverty in states that do not expand may be eligible to purchase subsidized coverage through the Marketplaces; however, only about a third of uninsured adults (3.2 million people) who could have been eligible for Medicaid if their state expanded fall into this income range. Thus, there will be a large gap in coverage for adults in states that do not expand Medicaid. http://kaiserfamilyfoundation.files.wordpress.com/2013/10/8505-the-coverage-gap-uninsured-poor-adults1.pdf
Comment:
By Don McCanne, M.D. According to this report, “Nationally, over five million poor uninsured adults will fall into the ‘coverage gap’ that results from state decisions not to expand Medicaid, meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits.” That is, they are not eligible for Medicaid, and at an income below 138% of the federal poverty level, they are not eligible for subsidies and therefore cannot possibly afford to purchase private plans. They will remain uninsured, even though they have the least ability to pay out-of-pocket for health care. These individuals falling into the coverage gap represent about one-sixth of the total number of individuals who will remain uninsured (31 million). Supposedly the Affordable Care Act was designed to make health care affordable for everyone, with an emphasis on Medicaid or private plan subsidies for those who could least afford to pay for coverage. By this standard, ACA can be considered a dud. Let’s do it right. Let’s enact a single payer national health program that provides health care for everyone while separating the funding by moving it to the tax system. That would eliminate any connection between receiving health care and having to pay for it. Needing health care is bad enough without being assessed charges (in essence financial penalties) for obtaining that care.
]]>