PNHP

Women’s Access to Health Care: How the fight for national health insurance is a feminist issue

Increased risk of death among uninsured neonates

Increased Risk of Death among Uninsured Neonates

By Frank H. Morriss Jr
Health Services Research (HSR), August 2013

Abstract

Objective

To estimate the contribution of health insurance status to the risk of death among hospitalized neonates.

Data Sources

Kids’ Inpatient Databases (KID) for 2003, 2006, and 2009.

Study Design

KID 2006 subpopulation of neonatal discharges was analyzed by weighted frequency distribution and multivariable logistic regression analyses for the outcome of death, adjusted for insurance status and other variables. Multivariable linear regression analyses were conducted for the outcomes mean adjusted length of stay and hospital charges. The death analysis was repeated with KID 2003 and 2009.

Principal Findings

Of 4,318,121 estimated discharges in 2006, 5.4 percent were uninsured. There were 17,892 deaths; 9.5 percent were uninsured. The largest risks of death were five clinical conditions with adjusted odds ratios (AOR) of 13.7–3.1. Lack of insurance had an AOR of 2.6 (95 percent CI: 2.4, 2.8), greater than many clinical conditions; AOR estimates in alternate models were 2.1–2.7. Compared with insureds, uninsureds were less likely to have been admitted in transfer, more likely to have died in rural hospitals and to have received fewer resources. Similar death outcome results were observed for 2003 and 2009.

Conclusions

Uninsured neonates had decreased care and increased risk of dying.

From the Discussion:

Effects of Insurance Status

As expected, the predictors with the largest adjusted risks for death during hospitalization of neonatal patients estimated using the KID 2006 database were clinical conditions commonly encountered in neonatal intensive care units, that is, PT/LBW/IUGR, IVH, hypoxia, NEC, and congenital malformation. In this analysis, uninsured status was the next largest adjusted risk for death, for which the AOR, 2.6, was greater than those for sepsis, obstetrical conditions and complications, RDS, multiple birth, and male gender. Lack of insurance was also a significant predictor of death in analyses of both the 2003 and 2009 KID databases. The estimate of the effect of insurance was not changed in models for the outcome of death that excluded the hospital variable, indicating that the disparity is a within-hospital disparity.

Socioeconomic Position, Relative Isolation, and Race

Socioeconomic position, place of residence, race, and health insurance status are interrelated factors, each of which may independently predict the hospital death of a newborn, adjusted for clinical predictors and each other. However, it is difficult to separate the effect of lack of health insurance in the United States from socioeconomic conditions that may predispose to that condition. A significant unadjusted association exists in this analysis between uninsured status and the distribution of median household income indicated by ZIP code toward lower quartiles; a separate association exists between uninsured status and rural residence. Measures of poverty, income inequality, and social deprivation, not including health insurance status, have been associated with adverse neonatal or infant survival risks (Singh and Kogan 2007; Olson et al. 2010).

http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12042/full

Comment:

By Don McCanne, M.D.

Although socioeconomic factors play an important role in neonatal mortality, it is clear that lack of health insurance is an important contributor to these tragic deaths. We have much to do as a society to correct these injustices, but perhaps the easiest first step would be to ensure that everyone is automatically insured, including neonates. The Affordable Care Act will not do that, whereas enacting a single payer national health program would.

Transferring patients to Medicaid managed care

Transitioning Beneficiaries with Complex Care Needs to Medicaid Managed Care: Insights from California

The Kaiser Commission on Medicaid and the Uninsured, June 2013

Between June 2011 and May 2012, the California Medicaid program (known as Medi-Cal) transitioned just under 240,000 seniors and persons with disabilities (SPDs) from fee-for-service to mandatory Medicaid managed care (MMC) as part of its “Bridge to Reform” Medicaid Waiver. Goals of the transition were to increase plan and provider accountability and oversight, improve beneficiary access to care, and make costs more predictable. This study examined how health service providers, plan administrators, and community-based organizations (CBOs) in Contra Costa, Kern, and Los Angeles counties experienced the transition of SPDs to MMC. Below are some key study findings that may help inform future transitions to managed care for populations with complex health needs.

TRANSITION READINESS: BENEFICIARY DATA AND INFORMATION SHARING

* Incomplete or out-of-date contact information for SPDs was an obstacle to notifying beneficiaries of the transition to MMC.

* Health plans experienced barriers contacting beneficiaries by phone to complete Health Risk Assessments.

* The transfer of health and prescription history information from the state to health plans and providers was not timely.

* The delay in obtaining medical records also made it harder for providers to effectively care for new patients.

* Delegation to other health plans or IPAs sometimes caused further delays in data transfer as well as confusion about which entity was responsible for covering certain types of care.

* The SPD transition disrupted established communication channels between primary and specialty care providers.

PROVIDER NETWORKS: BUILDING ADEQUATE CAPACITY

* Health plans experienced barriers recruiting primary care providers with expertise in complex care management.

* Health plans faced challenges recruiting specialty care providers, particularly given the wide range of conditions among the SPD population.

* The reluctance of FFS providers to join plan networks was a major barrier to network expansion.

CARE COORDINATION: NEW RESPONSIBILITIES AND EXPECTATIONS

* Primary care providers have more responsibility for care coordination for SPDs patients but feel unprepared and untrained for this activity.

* Health plans are providing care coordination to SPD who called the member services line up to 4 times as often as other beneficiaries.

* While care coordination has expanded on all fronts, the transition to managed care added complexities that generated even greater need for coordination.

* The mental health services “carve-out” poses barriers to care coordination.

ORGANIZATIONAL RESOURCES: ENSURING ADEQUATE TRANSITION SUPPORT

* Providers reported that the SPD transition taxed their staff resources.

* Providers reported providing unreimbursed care during the transition to prevent potentially dangerous disruptions in care.

* Some plans reported that Medi-Cal capitation rates for SPDs do not account for the much higher utilization rates of the population.

*  Community-based organizations (CBOs) used resources to assist SPDs with the transition to managed care.

The usage of Medicaid managed care delivery models have been increasing nationally, a trend which is likely to continue due to the coverage expansion under the ACA. Even when steps are taken to mitigate anticipated issues and concerns prior to the transition, as was the case with California, unanticipated challenges are likely to arise. Learning from California’s experience with their SPD transition, this brief presents considerations for states, health plans, CBOs, and providers as they prepare for managed care expansions. Particularly salient are the findings around timing, communication, and coordination, including the establishment of partnerships that enable plans and providers to deliver efficient and effective care that meets beneficiaries’ health care needs.

http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8453-transitioning-beneficiaries-with-complex-care-needs.pdf

Comment:

By Don McCanne, M.D.

Although transferring patients to Medicaid managed care plans is supposed to improve access to care, this report shows that access was impaired as patients lost the choice of their health care providers, and experienced disruption in the continuity of their care. Although some of the problems were transitional, many represent substantial impairment in the quality and delivery of health care services. It’s disgraceful.

We need to return these patients to the health care professionals and institutions of their choice, while providing first dollar coverage for their care. In fact, we need to do that for all of us. Think single payer.

Anthony Weiner's single-payer plan is progressive, but not single-payer

By Reid Pillfant
Capital New York, July 3, 2013

Advocates for a single-payer health care plan see plenty of reasons to like Anthony Weiner’s proposed overhaul of the city’s health system. They just think it’s mislabeled.

“Well as I understand his proposal, it’s not what I would call a single-payer proposal, but it has some useful elements,” said David Himmelstein, a professor of public health at Hunter College, and a co-founder of Physicians for a National Health Program.

Weiner has made health care the key component of his mayoral campaign so far, pledging to implement a single-payer plan like the one he loudly argued for during the national debate over health care back in 2009.

Back then, Weiner seemed motivated primarily by a desire for national publicity, actually delivering a message on health care that served him well politically but was at odds with the president’s agendaand that of more serious Democratic advocates of universal health care in Congress. 

While Weiner clearly sees a political opportunity in health care reform now as well, he is at least advocating something that, as mayor, he’d theoretically have a chance of putting into practice.

“Single-payer health care is on the ballot,” Weiner proclaimed in the subject line of a fund-raising email last month, a few days after Weiner devoted his first big policy speech to his health care plan, at an event his campaign dubbed “Big Thought Thursday.”

A subsequent email to a list of Hillary Clinton’s 2008 alumni asked, “Will you help Anthony stand up for single-payer health care?“

Weiner’s basic idea is to convene a task force of city department heads and nonprofit leaders to design an overhaul of the city’s health care system, in order to consolidate the nearly $16 billion the city spends each year on health care into a single system overseen by a deputy mayor for health care innovation. 

“We should make New York City the single-payer laboratory for the rest of the country,” he said at his policy speech.

By his own admission, the plan is a rough sketch, with details to be filled in by the task force. 

But the crux of the idea is that municipal workers and retirees could be united under a single health insurance plan, overseen by the city, which could also cover undocumented immigrants not covered by President Obama’s new health reforms, with an eye toward one day opening the city’s plan to all New Yorkers.

That’s something advocates of universal health care would certainly regard as progress, even if it’s not anything they’d recognize as single-payer.

“Single-payer really means there’s just one payer left in the health care system,” said Himmelstein. “You can’t really do that as the mayor of New York, because Medicare would still exist and private employers, private plans would still exist, so there would still be multiple payers. But I think having a large public plan that encompasses a large piece of the market makes a lot of sense.”

Asked by WNYC’s Brian Lehrer on July 3 whether the plan could accurately be billed as single-payer, Weiner responded by talking generally about the inefficiencies in the current model, and then said, “I guess the best way to look at this is, this is for city workers, for the uninsured, for retirees, this would be Medicare for all New Yorkers who are eligible. But I’m also going to try to expand this to cover the undocumented who are not going to be covered under Obamacare who are going to cost us a great deal of money if we don’t cover them.”

Health care reformers say the potential benefits of Weiner’s plan are great, with the possibility of expanding coverage to more New Yorkers, while reducing the profit-making role of insurance companies and utilizing the city’s leverage to reduce rates and drive down premiums.

“His thinking on health coverage is certainly in the right place,” said Assemblyman Dick Gottfried, who has repeatedly sponsored bills in Albany to create a statewide single-payer system (and who has not endorsed anyone for mayor). “And part of that thinking is the notion that a publicly run plan with as broad a base as possible can do a much better job than relying on insurance companies as a middle man.”

But the potential implementation could be difficult.

Himmelstein said insurance companies would “fight tooth and nail to stop this from happening,” since any talk of containing costs is essentially “cost-containment from their hide.”

Weiner has been dismissive of that kind of opposition.

In his speech, Weiner said the city could leverage its power within the existing private insurance structure, or that it could wholly control the plan, or a hybrid option, with the city contracting an insurance company for administrative costs, like Medicare and Medicaid do. But he made clear that he wasn’t at all concerned with preserving their profits in the current system.

“It’s not my burden as the mayor of the city of New York to protect that,” he said. “My burden as the mayor of the city of New York is to get reasonable costs for high-quality care.” The first line of his fund-raising email touting single-payer read as follows: “If you are a health insurance executive, you may want to stop reading right here.”

He has also struck a combative posture with regard to municipal unions, who he has suggested should pay 10 percent of their own premiums (25 percent for smokers). Weiner has framed the contributions as way of reducing costs and saving the city money that might then be put toward new union contracts that include raises. But the unions, which are some of the most politically powerful in the city, might prefer the raises without the new system, or the added contributions.

“The experience of doing this in other contexts has been challenging because the employees are not always happy to move into whatever plan the city might set up,” said Dr. Sherry Glied, a professor at Columbia’s Mailman School of Public Health and a former Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services under President Obama.

(Himmelstein and Gottfried both suggested Weiner’s fixed-rate contribution was less desirable than a system that spreads the costs, since Weiner’s proposal would extract roughly the same contribution payment from, say, a highly paid CUNY chancellor as it would an administrative assistant or bus driver, who earns significantly less.)

Asked about the need for state or federal support, Weiner, referring to his proposed task force, said “there is no one who is sitting at that table who really needs to get a go-ahead from the state or federal government.”

But any attempts to extend his proposals beyond municipal workers, toward a more robust public plan that would be open to all New York City residents—something more akin to a single-payer system or a public option—would have to navigate a thicket of state and federal regulations.

Covering the undocumented population also presents its own set of problems, since undocumented immigrants are expressly barred from receiving any of the federal subsidies that generally apply to other low-income populations.

Medicaid and Medicare are largely covered by state and federal requirements, with Maryland as the only state that currently en
joys a federal waiver to negotiate its own rates (a waiver the state is fighting to preserve). 

“I think if there’s going to be a single-payer system, given the way that health care is regulated in our country, it will have to be at a state level at the least, or at the federal level,” said Glied, who suggested the city’s efforts might be better focused on enrolling the uninsured in the national reforms set to take effect next year. “It would just be very difficult to manage it, given the governance structure of health insurance and health care delivery, at a city level.”

http://capitalnewyork.com/article/politics/2013/07/8531448/anthony-weiners-single-payer-plan-progressive-not-single-payer

PNHP note: For additional commentary on Weiner’s proposal, see Leonard Rodberg’s blog posting titled “Should we support Anthony Weiner’s ‘single-payer’ plan?“

Idaho AFL-CIO endorses H.R. 676, national single-payer health care

By Kay Tillow
Single Payer News, July 1, 2013

Rian Van Leuven, president of the Idaho State AFL-CIO, announced that on June 12, 2013, the delegates to the 55th Annual Idaho State AFL-CIO Convention passed a resolution to publicly endorse and support H.R. 676, single-payer health care.

Further the resolution states, “That the Idaho State AFL-CIO will develop working relationships with community organizations in Idaho which advocate for single-payer health care and Medicaid expansion.”

Louis Schlickman, M.D., an Idaho physician who practices in Meridian and is co-chair of the Physicians for a National Health Program state chapter, showed the movie “Escape Fire” and made a single-payer presentation to the convention prior to the passage of the resolution.

After the resolution for H.R. 676 was passed by the Idaho State AFL-CIO Convention, Dr. Schlickman stated, “Collectively we are all realizing that unions in general can play a huge role in helping others, not just union workers, see the merit in a single-payer financing system of care.”

Dr. Schlickman observed that union members “have seen how one unexpected illness or injury leads to significant catastrophes of health and income status. And most important, they understand the issue of solidarity.”

Idaho is the 43rd state AFL-CIO federation to endorse H.R. 676, which was introduced into the 113th Congress by Representative John Conyers, D-Mich. The bill is subtitled “Expanded and Improved Medicare for All.”

*****

H.R. 676 would institute a single payer health care system by expanding a greatly improved Medicare to everyone residing in the U. S.

H.R. 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long-term care.

H.R. 676 ends deductibles and co-payments. H.R. 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

In the current Congress, H.R. 676 has 43 co-sponsors in addition to Rep. Conyers.

H.R. 676 has been endorsed by 604 union organizations including 145 Central Labor Councils/Area Labor Federations and 43 state AFL-CIOs (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA, RI, NH, & ID).

For further information, a list of union endorsers, or a sample endorsement resolution, contact:

Kay Tillow, All Unions Committee for Single Payer Health Care—H.R. 676, c/o Nurses Professional Organization (NPO), 1169 Eastern Parkway, Suite 2218, Louisville, KY 40217. Phone: (502) 636-1551, E-mail: nursenpo@aol.com. www.unionsforsinglepayer.org

Administrative costs and profits from crowdfunding

Turning To The Web To Help Pay Medical Bills

By Caroline Mayer
Kaiser Health News, July 2, 2013

Even with Stage IV lung cancer, there are moments when 32-year-old Chip Kennett feels blessed. Over the course of two weeks in April, those moments were many, as 325 friends and family members contributed $56,800 over the Internet to help defray his out-of-pocket medical costs.

The Kennett family of Alexandria is one of thousands turning to the Internet to raise money for medical bills. The sites that host these campaigns operate much like online business fundraising sites such as Kickstarter. It takes only a few keystrokes for a family to set up a Web page, where they tell their story and state a fundraising goal; later, they can spread the word on social media sites such as Facebook. Donations can be made with credit cards or via PayPal.

The contributions, which can be given by name or anonymously, typically range from the very small (as little as $5) to the extremely generous ($1,000 and up). In the Kennetts’ case, donations ranged from $10 to $2,000. Most sites are for-profit and charge a fee, between 3 and 12 percent of the money donated, to cover the processing costs and the expenses of running the Web site.

The Kennetts acknowledge they are lucky to have good health insurance. (Sheila has a federal employee policy through her job at the Senate.) Even so, the Kennetts have paid thousands of dollars in out-of-pocket expenses, including the insurance plan’s co-pay requirements and its $5,000 annual deductible ($7,000 for out-of-network doctors) for both 2012 and 2013.

Medical fundraising sites are growing in number and profitability. In the first 12 months after it launched in 2008, GiveForward raised $225,000 for 359 campaigns; this year, it raised more than $20 million for more than 15,000. Company officials said GiveForward had more than $1.4 million in revenue in 2012 and has raised more than $47 million for families since it began.

When it launched, GiveForward also raised money for other causes — “scholarships, art projects, whatever,” says co-founder Ethan Austin. But the “hugbacks” — calls or messages from users — from medical fundraisers were so appreciative, “we decided, ‘Why do anything else?'”

Austin says he is not surprised at the rapid growth of crowd-funding for medical costs, citing a 2011 National Bureau of Economic Research study that found that half of American adults say they would not be able to come up with $2,000 in the event of a medical emergency. This, taken along with another recent study showing that the average cancer patient incurs as much as $8,500 a year in expenses not covered by insurance, further explains why so many ailing Americans are seeking outside help to pay their expenses, according to Austin.

http://www.kaiserhealthnews.org/Stories/2013/July/02/online-fundraising-to-help-pay-medical-bills-takes-hold.aspx

Comment:

By Don McCanne, M.D.

Crowdfunding: the collective effort of individuals who network and pool their money, usually via the Internet, to support efforts initiated by other people or organizations (Wikipedia).

What a nice gesture – friends, acquaintances and caring strangers joining together to pay medical expenses not covered by a federal employee health policy available through the United States Senate (FEHBP), one of the highest quality private insurance plans available in the United States.

What? Cost sharing has become so prevalent – even amongst the best of our health plans – that people with significant health care needs insured by these plans have to turn to charity to pay their bills? Not even cake sales will do. They need real money. (Isn’t this what insurance is supposed to prevent?)

And who moves in? Entrepreneurs who set up for-profit organizations that provide administrative services for this crowdfunding. Just what we need in a health care system already tremendously overburdened with administrative waste – more administrators who profit from our highly dysfunctional, fragmented health care financing system.

PwC reports that next year 44 percent of employers are considering high-deductible plans as the only option for their employees. The benchmark plans in the Marketplaces (exchanges) are high-deductible plans. The new national standard in health care coverage will leave far too many individuals exposed to financial hardship in spite of having a health care plan.

The logical solution would be to reverse this trend and provide coverage that protects individuals from medical debt. But that’s not the American way. We bring in more administrators and pay them richly, further adding to our almost intolerable national health expenditures.

Hey! Is anybody reading these messages? Single payer. Single payer! SINGLE PAYER!

A doctor who embraces change, personally and politically

By Stacey Butterfield
ACP Internist, July/August 2013

In an era when even small changes to the health care system are highly controversial, leading a campaign for a single-payer system might seem like a daunting task to some. But Andrew D. Coates, MD, FACP, the new president of Physicians for a National Health Program (PNHP), has already tackled unusual challenges in his career.

Dr. Coates didn’t start medical school until he was in his 30s. Prior to attending Columbia University College of Physicians and Surgeons in New York City, he worked in carpentry, factories and a feed mill. “I did hard jobs. … I had a little bit of an adventure in terms of living in different cities and taking manual labor jobs,” he said. “Then I went to graduate school in history.”Dr. Andy Coates

Switching things up again, Dr. Coates turned down opportunities to turn his MA in history into a PhD and instead applied to medical schools. “When I was young I really wanted to be a doctor. I just assumed by the choices I made in college that after that it wasn’t going to happen,” he said. “I hadn’t taken any science classes since 11th grade, so it was a winding road.”

At the end of that road was internal medicine training, and then practice, in upstate New York. But even after settling down there, with children and lifelong connections, and attaining specializations in hospital medicine and palliative care, he grabbed an opportunity to mix things up.

“I took a temporary job at the Northern Navajo Medical Center in Shiprock, New Mexico, and we went as a family … I needed an interpreter, a cultural interpreter as well as a language interpreter, when meeting specific patients,” said Dr. Coates. “The cultural insights were inspiring. Overall I gained a deeper conviction about what medicine has to offer every human being.”

Today, Dr. Coates offers his services as a community hospitalist in Troy, N.Y. “The needs are enormous and we often work over 200 hours a month. We also take turns doing nights, to make sure that one of our group is always available on the floors as well as to do the admissions. I went there because I wanted the experience of practicing the full spectrum of hospital medicine, and I love it,” he said.

Picking up another piece of the medical spectrum, he also serves as a medical director of a local public nursing home, which he describes as having great clinical care (“In recent years, no patient here has gotten a decubitus ulcer,” he said) but crumbling infrastructure (“The roof leaks”).

A recent proposal to privatize the nursing home holds the potential to damage the quality of care, he worries. “We have a great respiratory therapist and superb wound care and rehab nurses, for instance. For-profit nursing homes simply lack the kind of clinical depth that our patients count upon,” he said. “The nursing home experience has raised my consciousness about why public care is superior to private, for-profit care.”

In his newest role, at the helm of the nonprofit PNHP (his two-year term started Jan. 1), he hopes to raise physicians’, patients’ and policymakers’ consciousness about making a clean break with what he characterizes as the “dysfunctional and wasteful” private health insurance model of financing care.

He sees the present costs faced by individuals as hazardous to health: “The evidence shows that co-pays, deductibles and co-insurance schemes cause our patients to avoid necessary care.”

He doubts that reforms currently under way will reorganize how the profession interacts with society.

“If the goal remains to reduce costs and improve quality, I don’t think these things will work. Eventually, we’ve got to deal with the evidence,” he said. “The elements touted to save costs—electronic health records, accountable care organizations—these are not proven to save costs.”

Dr. Coates and his colleagues in the education-oriented, 18,000-member PNHP advocate for a publicly financed, streamlined single-payer model that he says would reduce costs by slashing administrative waste.

“This would free physicians from a mountain of worry about how our patients’ care will be reimbursed, and thus restore the physician-patient relationship,” he said. “There is no question that we could provide best-quality, comprehensive care to all patients. We have all of the necessary resources—especially great health professionals—to do it. It’s just a question of our consciousness.”

Fast facts

Age: 51.

Something I wish I’d learned in medical school: Economics.

Personal hero: Rudolf Virchow, the 19th century pathologist and public health advocate.

Favorite ways to spend free time: Cooking for our family, hiking mountains.

Most recent book read: “Medicine and Public Health at the End of Empire” by Howard Waitzkin, MD, PhD.

Regret: Not showing as much kindness as I feel toward others.

If I weren’t a physician, I would be: Working for a living (That’s a joke, y’all).
.
Where ACP stands

ACP published a position paper in the Jan. 1, 2008, Annals of Internal Medicine titled “Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries.” The position paper offered several policy recommendations, including the following.

Recommendation 1a: Provide universal health insurance coverage to assure that all people within the United States have equitable access to appropriate health care without unreasonable financial barriers. Health insurance coverage and benefits should be continuous and not dependent on place of residence or employment status. The ACP further recommends that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

1. Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own health care choices.

2. Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.

The full position paper is available online.

http://acpinternist.org/archives/2013/07/profile.htm

We need more than Obamacare

By Neil Shulman, M.D., and Jack Bernard
The Gazette (Cedar Rapids, Iowa), June 30, 2013

The authors of this article have both spent many decades in the health care field. We have seen both the positives and negatives of U.S. health care delivery and financing.

Furthermore, we have thought about how heartless some of us have become over the past few decades. As the most religious developed nation on earth, it is hard to fathom how we as a country can be so callous to our less-privileged citizens.

It is an inconvenient truth that working people in Iowa and around the nation are suffering physically and financially under our current system. Although Obamacare (and Medicaid expansion) is not the option preferred by the authors, as we state below, it is still much better than what we have right now.

In this vein, we were pleased that Iowa’s governor and legislature decided this session to accept Medicaid expansion, via the unique Iowa Health and Wellness Plan. They are to be commended for bucking Tea Party pressures and taking the federal money. If acceptable to the federal government via a “waiver,” the Iowa plan will reduce real suffering for at least some low-income Iowa residents (and improve the financial picture for hard-pressed providers).

Common cases

Many taxpayers are unaware of the suffering, exacerbated by the current health financing system, referred to above. Here are two cases encountered under our existing delivery system; the story is the same in virtually every state:

Case 1 — A 30-year-old small business owner got an object in his eyes. He can’t get it out. So he goes to a large hospital emergency room where he waits to see a doctor so his eye will not become permanently damaged. While waiting, his eye tears up and the object comes out on its own. The doc comes into the examining room, looks in his eye, and miraculously, the object has come out on its own. The patient does not have health insurance, so he is charged more than a patient who is insured: $2,000. The hospital ends up turning over the case to a collection agency.

Case 2 — A 32-year-old woman with an abscess in her liver has the abscess surgically removed. She has insurance under her dad’s policy. However, after the surgery, she loses her coverage and the scar at the site of the surgery is very painful. She cannot get an appointment to see the surgeon without a cash upfront advance payment or insurance. The pain is so bad that she has to get relief in a hospital ER frequently for the next two years — total cost more than $23,000. Now this debt is turned over to a collection agency. And the pain continues.

Many of our state and national legislators continue to be completely disconnected from the underserved segment of the population. They choose to believe that care is readily available and that we have the best health care on earth, regardless of ability to pay. It fits their political philosophy, but, based on the facts, they are 100 percent wrong.

We are the richest and most powerful country on earth. It is up to each of us to step up to the plate. We must tell our elected officials both in Iowa and across the nation that what is morally correct is to have health care as a right of all Americans, not a privilege.

Medicare for all

The best way to achieve that goal will always be Medicare for All.

A bill has been introduced in Congress that promotes single payer. If it is ever adopted, a Medicare For All system would eliminate all the game-playing under our existing system. Medicare has administrative costs that are only 3 percent versus 20 percent to 30 percent for private insurers.

Other nations that have adopted similar single-payer systems have achieved much more effective health care delivery and financing. Morbidity and mortality rates are much better than in our nation, while per capita costs are often half ours. The World Health Organization ranks the U.S. health care system 37th, behind the rest of the developed world.

Medicare For All would simply take our existing national health insurance program, Medicare, and expand it beyond the elderly. It could be funded via payroll taxes, shared by employers and employees.

More on this topic can be viewed at the Physicians For A National Health Program (PNHP) website: www.pnhp.org.

Dr. Neil Shulman, of Decatur, Ga., a practicing physician for a several decades, is an associate professor at Emory Medical School. He is the author of “Doc Hollywood”, which he also produced as a movie. Jack Bernard of Monticello is a retired senior health care executive who has worked extensively with Iowa hospitals, including the Iowa Health System (now UnityPoint Health).

http://thegazette.com/2013/06/30/we-need-more-than-obamacare/

Hardship? No penalty, but no insurance

Guidance on Hardship Exemption Criteria and Special Enrollment Periods

Centers for Medicare and Medicaid Services, June 26, 2013

The Department of Health and Human Services (HHS) finalized provisions concerning how Marketplaces (also known as “Exchanges”) will determine eligibility for and grant certificates of exemption from the individual shared responsibility payment described in section 5000A of the Internal Revenue Code.

This guidance is intended to describe the circumstances that Marketplaces may use in determining what constitutes a hardship if they prevent an individual from obtaining coverage under a QHP.

We clarify that Marketplaces may consider the following circumstances in determining what constitutes a hardship under 45 CFR 155.605(g)(1) if they prevent an individual from obtaining coverage under a QHP, which include an individual who–

* becomes homeless;

* has been evicted in the past six months, or is facing eviction or foreclosure;

* has received a shut-off notice from a utility company;

* recently experienced domestic violence;

* recently experienced the death of a close family member;

* recently experienced a fire, flood, or other natural or human-caused disaster that resulted in substantial damage to the individual’s property;

* filed for bankruptcy in the last 6 months;

* incurred unreimbursed medical expenses in the last 24 months that resulted in substantial debt;

* experienced unexpected increases in essential expenses due to caring for an ill, disabled, or aging family member;

* is a child who has been determined ineligible for Medicaid and CHIP, and for whom a party other than the party who expects to claim him or her as a tax dependent is required by court order to provide medical support. We note that this exemption should only be provided for the months during which the medical support order is in effect; or

* as a result of an eligibility appeals decision, is determined eligible for enrollment in a QHP through the Marketplace, advance payments of the premium tax credit, or cost-sharing reductions for a period of time during which he or she was not enrolled in a QHP through the Marketplace, noting that this exemption should only be provided for the period of time affected by the appeals decision.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/exemptions-guidance-6-26-2013.pdf

Comment:

By Don McCanne, M.D.

The Affordable Care Act (ACA) requires that individuals who fail to enroll in a qualified health plan (QHP) be required to make a shared responsibility payment (a financial penalty for being uninsured). There are several exemptions that allow the penalty to be waived, and one of these is “individuals who experience a hardship.” This guidance defines what constitutes a hardship.

Supposedly a goal of health care reform was to be sure that everyone had health care coverage, but especially those whose personal finances made purchase of insurance prohibitive. That is why the most important provisions of ACA included the expansion of Medicaid for individuals at or near poverty and the establishment of income adjusted subsidies for purchase of private plans within the insurance exchanges (Marketplace).

The shared responsibility payment penalty was established to encourage those who could afford insurance to buy it, with a goal of approaching truly universal coverage.

When it was realized that there were many legitimate situations in which individuals would not qualify for either Medicaid or the subsidies for the exchange plans and yet could not afford to purchase plans, it was thought that it would be unfair to penalize these individuals for being uninsured, as if that were not enough of a penalty. Thus the exemptions from the penalty were established.

Of the exemptions, hardship is perhaps the most compelling. But think about that. These are individuals who have the greatest need to have the security of health care coverage, yet, instead of establishing measures that would bring them under the insurance umbrella, they are being left bare – exposed to greater financial hardship and greater barriers to health care access.

Is this the best that we can do for these people – waive a financial penalty for the sin of being uninsured – a penalty that they couldn’t pay anyway?

Absolutely everyone should be covered – automatically. How many times do we have to say it? Single payer.

Everything you ever wanted to know about Canadian health care in one post

By Sarah Kliff
Washington Post, July 1, 2013

We spend a decent amount of time talking about the Canadian health care system in our health care debate. Today being Canada Day (yes, really), it feels like a good time to brush up on how our northern neighbors actually deliver health care and how well it works. Without further ado, a completely painless guide to the Canadian health care system.

So, how exactly does the Canadian health care system work?

The Canadian health care system was built around the principle that all citizens will receive all “medically necessary and hospital physician services.” To that end, each of Canada’s 10 provinces and three territories finance and run a statewide health insurance program. There is no cost-sharing for the health care services guaranteed under federal law.

While Canadians are guaranteed access to hospital and physician services, it is up to each province to decide whether to cover “supplementary” benefits, like dental care and drug coverage. About two-thirds of Canadians take out private, supplemental insurance policies (or have an employer-sponsored plan) to cover these services.

While Canada is traditionally thought of as a publicly financed system, spending on these supplemental benefits means that 30 percent of health spending comes from private sources. One 2011 study found that nearly all Canadian spending on dental care came from non-government dollars, 60 percent covered by employer-sponsored plans and 35 percent paid out of pocket. Some Canadian legislators have made pushes to increase the scope of Canada’s public health plan, to cover more services, but have so far proved unsuccessful.

While Canada’s health care system is publicly financed, many providers are not government employees. Instead, doctors are usually reimbursed by the government at a negotiated fee-for-service rate. The average primary care doctor in Canada earns $125,000 (in the United States, that number stands at $186,000).

How much does it cost? 

In 2009, Canada spent 11.4 percent of its Gross Domestic Product on health care, which puts it on the slightly higher end of OECD countries:

This probably has a lot to do with the lower unit cost of health care in Canada. An MRI that costs, on average, $1,200 in the United States comes in at $824 north of the border. It also has to do with lower administrative costs: A 2010 Health Affairs studyfound that doctors in Ontario, a Canadian province, spent $22,205 each year dealing with the single-payer agency, compared to the $82,975 American doctors spend dealing with private insurance companies, Medicare and Medicaid.

How well does the Canadian health care system work?

The OECD tends to give the Canadian health care system high marks on outcomes in its regular look at international health care systems. “Canada’s survival rates for breast and colorectal cancer are among the highest in the OECD,” the international organization noted in its 2011 report. “Canada also does well in primary care, preventing costly hospital admissions from chronic conditions such as asthma and uncontrolled diabetes.”

Where Canada does not do well is on wait times, which tend to be longer than in other countries, especially to see specialists or obtain an elective surgery. A Commonwealth Fund survey in 2010 found that 59 percent of respondents reported waiting more than four weeks for an appointment with a specialist, more than double the number in the United States:

Canada has recently started taking steps to address this: In 2005, it had each province set evidence-based benchmarks for wait times for various procedures. “Provinces have made considerable progress with efforts to manage and reduce wait times, and many now meet wait-time benchmarks for at least 75 percent of patients,” the Commonwealth Fund found in 2010 report. “Generally, when available, trend data show waits for care are decreasing in the areas of joint replacement, sight restoration, cardiac surgery, and diagnostic imaging scans.”

Do Canadians like their health care system?

Canadians certainly view their health care system as crucial to national identity: 85 percent say that eliminating the public plan would “result in a fundamental change to the nature of Canada.”

That does not, however, mean there isn’t gripping about its shortcomings. A 2007 pollconducted by Queens University in Kingston, Ont. found that, while public opinion had ticked up slightly, “a large majority of Canadians still believe that the system is unsustainable and urgently in need of substantive change.” Most of the concerns had to do with long wait times and difficulty accessing care. The survey also found widespread support for increasing health care spending.

Put into an international perspective, however, Canada’s system looks to be relatively well liked. A 2011 Gallup Poll found that 57 percent of Canadians felt “satisfied” or “very satisfied” with their access to health care services (in the United States, that number stood at just 25 percent).

We need much more than Medicaid expansion

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, June 28, 2013

It is common for people to assume that President Obama’s Affordable Care Act will lead to universal coverage; after all, that was its stated aim.

Coverage under the plan, which will not be fully implemented for seven more years, would be driven by a law making private health insurance compulsory, with an individual mandate to purchase health insurance or else pay a fine, for all but the poor, much like the reform led by Gov. Romney in Massachusetts. For the poor, the goal was to expanding Medicaid eligibility to everyone with an income below 138 percent of the federal poverty level.

But the Supreme Court, when it upheld the law as constitutional overall, also ruled that states could opt out of the Medicaid expansion.

We now know that a significant number state governments will opt out, in the end perhaps more than twenty in all. Texas, Florida, Kansas, Alabama, Louisiana, Mississippi, Georgia and Wisconsin are among the states that have decided not to expand Medicaid to all of the poor.

Some commentators and journalists have laid the blame at the feet the Supreme Court for the fact that the president’s “health care overhaul” will fall far short of universal health coverage for our nation. They cite projections that the reform was designed to enroll 16 million of today’s 50 million uninsured people in Medicaid programs. The point is that that many millions will not become eligible as long as their state governments opt out of expanding Medicaid.

But being eligible for Medicaid is different from enrolling.

In a study published this month on the Health Affairs blog, researchers Rachel Nardin, Leah Zallman and others estimated the impact of Medicaid expansion on the uninsured. They took into account the fact that people have to enroll in Medicaid by basing their estimates upon published take-up rates for public programs, prior publications, and Congressional Budget Office estimates regarding implementation of the president’s health care plan.

They found that the president’s plan, overall, “will minimally alter the demographic composition of the uninsured, regardless of whether undecided states opt-in or out. While Blacks and Hispanics will continue to be overrepresented among the uninsured, the majority will be non-Hispanic, white, low-income, working-age adults, many of them employed. The majority (around 80 percent) of the uninsured will be U.S. citizens, irrespective of states’ acceptance of Medicaid expansion. More than 4.3 million children and nearly 1.0 million veterans will remain uninsured under either scenario.”

The study also looked at the state governments presently undecided about whether to opt in or out of Medicaid expansion. The researchers found “if all currently undecided states opt-in, 29.8 million people will remain uninsured, whereas if all opt-out, the number of uninsured will total 31.0 million, 1.2 million above the opt-in scenario.”

Recently in the hospital I met a patient, a woman with limited intellectual ability and serious chronic health issues who had moved from another state so that her sister could help her each day. Applying for Medicaid seemed beyond the abilities of our patient, even with her sister’s help. Yet by enrolling in Medicaid our patient could gain access to medications that would help keep her out of the hospital.

Medicaid expansion will help our nation’s poor and blocking it seems an unnecessary cruelty on the part of state governments. Because the president’s reform also will reduce funding to safety-net hospitals, financial devastation will continue to plague poor Americans who become seriously ill, more so in those states that opt out.

On the other hand, Medicaid remains a poor program for poor people, with poor reimbursement for specialty care and hospital care. State-by-state privatization schemes and funding cutbacks continue undermine access to care for those who have Medicaid. Even if all of the poor were automatically enrolled in Medicaid our health system would still remain indefensible, for it would codify an unjust two-tier system, burdened with deep racial disparities.

The Affordable Care Act will fall well short of providing affordable health coverage to all Americans. Tens of millions of people will remain uninsured. We still need a program that will make sure that everyone receives care, not coverage.

If access to comprehensive care is the goal, as it should be in a great modern democracy, then nothing short of a system of national health insurance – everyone in, nobody out – will work.

Dr. Andrew Coates practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

You can listen to Dr. Coates’ radio broadcast here: http://www.wamc.org/post/andrew-coates-we-need-much-more-medicaid-expansion

Why are health insurance premiums higher for public employers?

Why are Health Insurance Premiums So Much Higher for Public Employers Compared to Private Employers?

Co-author: Tom Buchmueller
Presenter: Alice Zawacki, Ph.D., Senior Economist, Center for Economic Studies, Bureau of the Census
AcademyHealth, 2013 Annual Research Meeting, June 23-25, 2013

Research Objective:

The Great Recession of 2007-2009, which took a major toll on the U.S. economy, was especially hard on state and local governments. The fiscal crises have led to increased scrutiny of public sector compensation practices and renewed debate about how the compensation of public sector employees compares to that of private sector workers. Employer-sponsored health insurance represents a substantial share of non-wage compensation and rising health care costs are a pressing concern for both public and private employers. According to data from the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC), average health insurance premiums in the late 1990s until 2000 were similar for public and private employers. In subsequent years, public sector premiums grew more than private sector premiums. In 2000, premiums for large public sector plans were $705 or 22% higher than premiums for large private sector plans. By 2009, this difference grew to $1580 or 35%. This paper examines changes in employee demographics, plan type and plan benefit design with the goal of explaining why premiums in the private and public sectors have diverged over the past decade.

Study Design:

To study the premium differences between sectors, we conduct regression analyses on plan-level data from the 1996-2009 MEPS-IC augmented with additional worker demographic characteristics we impute from the 2000 Decennial Census and the 2009 American Community Survey. Population Studied: Health insurance plans offered by state and local governments and private sector employers with at least 100 employees.

Principal Findings:

Early work shows that over 40 percent of the premium difference for all plans in 2009 is attributable to demographic factors: public workers are older, more likely to be female and are more educated than workers in the private sector. Some of the gap is also explained by the fact that cost sharing increased more in the private than the public sector.

Conclusions:

These findings are consistent with the idea that private employers were more aggressive in increasing cost sharing in the health plans offered to employees. Increases in cost sharing can lead to lower utilization of services for which benefit is low relative to the cost, implying an increase in economic welfare. Alternatively, if utilization is not significantly affected, increases in deductibles, co-payments and co-insurance will merely shift costs from low risk employees who use relatively little care (but pay premiums in the form of reduced wages) to higher risk employees who use more care.

Implications for Policy, Delivery or Practice:

While the growing gap in health benefits spending in the public and private sector does not necessarily imply that public sector benefits are excessive, it is natural for policy makers to look to health insurance costs as a potential area for reform and savings. It is important that efforts in this area be guided by a clear and detailed understanding of the health benefits that are provided to public sector employees and how those benefits compare to those in the private sector.

http://www.academyhealth.org/files/ARM/2013/All%20Podium%20Presentations.pdf

Comment:

By Don McCanne, M.D.

In the past decade, health insurance premiums for state and local government employers have grown more than premiums for employers in the private sector. Although some of this is due to demographic characteristics, a significant portion has been due to an increase in the use of cost sharing in the private sector. Plans for public employers have maintained the same level of benefits, whereas the coverage in plans for private sector employers has deteriorated.

The policy implications of this should have us concerned. As explained in a message earlier this week, the trend in the private sector has been to expand the use of cost sharing, especially high-deductible plans, with a detrimental impact on employees. It is highly unlikely that private employers would support a reversal of this trend.

State and local governments have faced difficult budget decisions, so it is logical that they would look at the high costs of their employee health benefit programs as a source for reducing budget deficits. Many have already tapped into their programs for retirees. Although unions for public employees have been more effective in protecting benefits, there will be considerable pressure to follow the lead of the private sector and expand the use of cost sharing.

There is a far better option other than simply trying to adjust the differences in plans for public and private employees. Instead of thinking about traditional private insurance design options, especially those that emphasize catastrophic coverage, we should consider changing everyone to a prepaid health care system in which financial barriers to care are removed – a single payer system.

Not only is single payer coverage much better, it also provides the greatest value in health care. If we adopted a single payer system, both public and private employers would no longer be placed in the role of trying to control their budgets by hacking away at employees’ well earned health benefit programs.