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A right to health care in Colorado?

A right to health care in Colorado?

Ballot drive would establish constitutional right in Colorado

By Peter Marcus
The Colorado Statesman, May 31, 2013

Proponents of a universal health care system in Colorado are expected to kick off a ballot drive Saturday that would establish a state constitutional right to health care.

The question would appear on the 2014 ballot, asking Colorado voters to approve, “As a matter of human right and public good for all residing in Colorado, access to an appropriate single standard of high quality health care without financial barrier.”

The single health insurance program would essentially put out of business the for-profit, private health insurance industry in Colorado, which includes about a dozen providers.

More insurance carriers could come to the state as part of the Connect for Health Colorado exchange, an online marketplace for health insurance made possible by the federal Patient Protection and Affordable Care Act and by subsequent state legislation. The exchange is scheduled to launch on Oct. 1.

But proponents say it is time for the private health insurance industry to find other ways to make its money. “Quality health care as a part of our individual and collective quality of life shall not be treated as a private, for-profit commodity in Colorado,” states the final text of the proposed “Right to Health Care” initiative.

Proponents are modeling their drive similar to how marijuana activists designed Amendment 64 last year. The question would simply ask voters to make health care a constitutional right. It would then be up to the legislature to implement a framework for operating a universal system.

Premiums would be collected by the Department of Revenue and controlled by the state. Proponents expect that a 9 percent income tax would cover costs. The initiative would cap premium costs at 9 percent of an individual’s income, but the legislature could ratchet that down, if possible. Lawmakers would need to send to voters a separate tax question under the Taxpayer’s Bill of Rights.

The state would still be eligible for federal assistance, including Medicaid and Medicare, but it would need to apply for a waiver, which it can do in 2017 under the Affordable Care Act.

Proponents must collect 86,105 valid signatures to place the question on the ballot. They will kick off that effort Saturday at First Plymouth Congregational Church in Englewood.

“I do think that voters will see that there will be some improvements under the Affordable Care Act… but a lot of people are going to see that their costs are going to keep rising, and what they’re able to get is going to be backing off, and folks are not going to be happy about that,” explained Donna Smith, author of the proposed ballot question and executive director of Health Care for All Colorado. “They’re going to be wanting something different.

“Coloradans are basically fair people,” she continued. “We don’t like to see people suffer when it’s not their fault.”

Smith knows something about suffering. She is a two-time cancer survivor, most recently battling carcinoid syndrome.

She and her husband have been married 37 years. They have six kids and 15 grandchildren. The couple always had health insurance, which helped her husband with heart complications and her through cancer treatment. But even with the insurance, it wasn’t enough. The couple became flooded by copayments and deductibles.

“We hung on as long as we could, but then we went under,” described Smith.

Her heart-wrenching story caught the attention of documentarian Michael Moore, who featured the saga in “Sicko,” his 2007 brutal expose on the health insurance industry. Smith and her husband were forced to sell their house in order to pay for bills and everyday living expenses. Still, they went bankrupt.

“That’s not something folks aspire to do in life, to be featured in a Michael Moore film, because that usually means something pretty horrible has happened in your life,” declared Smith. “He didn’t shoot us because we were unique… he chose us because we represent so many Americans who are struggling — even with insurance — and not able to have the care they need, and not have the financial coverage they need.”

Nathan Wilkes, co-author of the proposed ballot initiative, has a similar heartbreaking story to tell. His drama began in 2003 when his son, Thomas, was born with severe hemophilia. The illness quickly exceeded $1 million in treatments.

“The struggle that we dealt with in maintaining coverage and keeping him healthy was mind boggling,” explained Wilkes, who was also appointed to the Colorado Health Benefits Exchange Board.

His story caught President Barack Obama’s attention in 2009 while the administration pushed the Affordable Care Act. Wilkes introduced the president at a town-hall meeting in Grand Junction in August of that year and he was flown the next month to Washington by the White House to be a guest at Obama’s address to a joint session of Congress on health care reform. Wilkes sat in the presidential box, directly two rows behind First Lady Michelle Obama.

He said parts of the Affordable Care Act helped, including a ban on lifetime benefit caps. But Wilkes believes there are still significant gaps that need to be addressed, which is why he is pushing for the ballot question. Much of that has to do with cost as insurance premiums continue to rise.

“Nothing has addresses the medical costs… nothing has addressed the exorbitant administrative bureaucracy,” he explained. “Still, our biggest fight day in, day out is dealing with medical bills and denials and insurance problems…”

Wilkes said universal health care in Colorado is necessary from an economic standpoint. Proponents point out that health care expenditures in the United States are about 18 percent of gross domestic product. Also, of 1.2 million personal bankruptcy filings in 2012, about 62 percent were linked to a medical crisis. Of those, about 75 percent had insurance.

“The fiscally responsible position is to fix this health care crisis,” said Smith. “It’s not fiscally responsible to continue to throw money at a system that’s broken. That’s not good.”

Insurance industry expresses concern

The health insurance industry says that it doesn’t disagree that the system is in need of repair. It just doesn’t believe a universal system is the answer.

“The reforms aren’t perfect, but we’ve been on record now for years saying the system was broken and has to be fixed,” explained Ben Price, executive director of the Colorado Association of Health Plans. “The changes being implemented now are a great start.”

The industry is concerned that a proposal for universal health care is premature given the fact that the Affordable Care Act is still being implemented, including an exchange. Recent filings show that providers in Colorado have gone all-in with the new Connect for Health Colorado exchange.

“On Oct. 1, Coloradans will be able to begin comparing plans, and on Jan. 1, many Coloradans who couldn’t get insurance before will be able to get covered,” said Price.

“The work isn’t done — health care costs are skyrocketing and health insurance premiums are simply a reflection of those costs — we have to work together to tackle cost if the health care system is going to be sustainable,” he continued. “Clearly, our work is cut out for us.”

Rather than eliminate for-profit health insurance, Price believes the answer is free market economics. He said that is evident in Colorado.

“In many states, only one or two insurance carriers are operating, but in Colorado, consumers have a dozen major carriers, each offering multiple different types of plans
, all competing for Coloradans’ business,” described Price. “In fact, we’re the fourth most competitive state in the nation in terms of health insurance.”

He said proponents would be better off waiting to see how the exchange is implemented.

“We’re ahead of the curve here in Colorado, one of the few states that will be launching a state and not federal-run exchange in 2014, putting the real numbers and real information in front of consumers and employers, offering them a clearer picture of what they are choosing,” said Price. “In our opinion, choice and competition is a positive, with this alternative proposal being ‘same care’ for all.”

Markets impact community rating

Geography affects premiums on California health insurance exchange

By Jim Sanders
The Sacramento Bee, June 5, 2013

For the same health coverage from the same insurer, a 40-year-old Sacramentan will pay $78 more per month than a Los Angeles County resident through the state’s new insurance exchange.

In rural Mono County, the disparity will be even larger: $150 per month, nearly 60 percent higher than for identical benefits and co-pays offered in Los Angeles County.

The premiums provide relatively basic coverage from Anthem Blue Cross, but similar regional differences exist in plans proposed by other insurers. The numbers reflect new rate-setting standards: How sick you are no longer matters, but where you live does.

A 25-year-old can buy the least expensive level of coverage – bronze – at prices ranging from $147 to $274 per month, depending on location.

For the first time, Californians soon will be able to compare regional pricing because federal law requires insurers selling policies on state exchanges to offer identical benefits with rates based only on age, location and household size.

A key factor in premium price differences, within a region or in comparison to other California communities, is the provider network created by each insurer, officials said.

The willingness of doctors or hospitals to join a network can be affected by rates that insurers agree to pay them. Those are negotiated privately and tend to vary based on the number of health care providers within a region and the intensity of competition for patients.

Tom Epstein, vice president of public affairs for Blue Shield of California, said costs for medical care generally are higher in Northern California than in Southern California.

“There are a number of large hospital systems that dominate the Northern California market, whereas there are many smaller hospitals and hospital systems in Southern California that compete,” Epstein said.

http://www.sacbee.com/2013/06/04/5471469/geography-affects-premiums-on.html

Comment:

By Don McCanne, M.D.

Although, with guaranteed issue, health plans will no longer be able to adjust premiums based on the health status of the applicant, they will still be able to adjust them through community rating.

Insurers can charge higher premiums in communities that have a less healthy population enrolled in their plans. But market forces also play a major role. In communities in which physicians and hospitals have greater market clout, they can demand higher payment rates when contracting to become part of the insurers’ networks. The differences can be very significant.

This is yet one more example of why it is irrational to try to fund our health care system through a specific premium assigned to each individual or family and administered by an expensive administrative intermediary – a private insurer.

As many other studies have shown, the private insurers have not been very effective in controlling health care spending anyway. Why would we want to keep them in charge?

We should replace these wasteful, ineffective intermediaries with a publicly-administered single payer program. Payments would be based on legitimate costs with fair margins, using global budgeting and various forms of administered pricing or capitation. Our public stewards would sit down with the health care professionals and administrators and see what they really need, and pay that – no more, no less.

For those who don’t believe that would work, simply look at the other OECD nations. They all have government oversight through some form of social insurance and are able to provide health care to everyone at an average of half the price that we are paying for a system that leaves tens of millions out.

Who says this isn’t feasible? It’s the status quo under Obamacare that isn’t feasible.

NHIS: Problems paying medical bills

Problems Paying Medical Bills: Early Release of Estimates From the National Health Interview Survey, January 2011–June 2012

By Robin A. Cohen, Ph.D.; Whitney K. Kirzinger, M.P.H.; and Renee M. Gindi, Ph.D.
National Center for Health Statistics, CDC, June 2013

The percentage of persons under age 65 who were in families having problems paying medical bills decreased from 21.7% (57.8 million) in the first 6 months of 2011 to 20.3% (54.2 million) in the first 6 months of 2012.

In the first 6 months of 2012, among persons under age 65, 36.3% of those who were uninsured, 14.0% of those who had private coverage, and 25.6% of those who had public coverage were in families having problems paying medical bills in the past 12 months. (Coverage status applies only to the day of the interview.)

The “private health insurance coverage” category includes persons who had any comprehensive private insurance plan (including health maintenance and preferred provider organizations).

The “public health plan coverage” category includes Medicaid, Children’s Health Insurance Program (CHIP), state-sponsored or other government-sponsored health plans, Medicare, and military plans.

Problems paying medical bills in past 12 months—Based on the following question: “In the past 12 months did [you/ anyone in the family] have problems paying or were unable to pay any medical bills? Include bills for doctors, dentists, hospitals, therapists, medication, equipment, nursing home or home care.”

http://www.cdc.gov/nchs/data/nhis/earlyrelease/problems_paying_medical_bills_january_2011-june_2012.pdf

Comment:

By Don McCanne, M.D.

As we already knew, about one-fifth of people under 65 are in families that have problems paying medical bills. In the United States we are used to that. But why should people in public plans have greater problems than those with comprehensive private insurance?

Most people under 65 with comprehensive private plans have incomes and can bear some limited out-of-pocket expenses for health care, though 14 percent still have problems paying medical bills.

Most people under 65 who have public health plan coverage qualify for those plans partly on the basis of having inadequate incomes. Their eligibility can vary throughout the year and many of them have intervals with no coverage at all and yet still face medical bills. Even when they have public coverage, they often face out-of-pocket expenses for services and products that may not be included such as medications, dental care, physical therapy, equipment, home care, or care obtained outside of networks (such as Medicaid managed care). These expenses are a problem for one-fourth of those with public coverage.

This demonstrates that it is not enough that we have public plans that serve as safety-nets. These are unstable, fragmented, and incomplete methods of financing health care. Even the private plans are as well, to some extent.

Imagine how this contrasts with a system that would cover everyone, throughout life, and with no deductibles nor coinsurance. You simply get the care you need when you need it. Why do we keep just imaging this? We can have such a system if enough of us demand it.

Obamacare: a fundamentally broken system

Our Continuing Healthcare Crisis, Part 3: The Obamacare Scorecard

By Richard Eskow
Campaign for America’s Future, May 30, 2013

(This is Part 3 of a series on our ongoing – and worsening – national healthcare crisis.)

Conclusion

We’ll be updating this “scorecard” as its provisions take effect, but one thing’s already clear: While the law does some good things, it will only marginally improve upon a fundamentally broken system.

http://blog.ourfuture.org/20130530/introducing-the-obamacare-scorecard

Comment:

By Don McCanne, M.D.

In this article, Richard Eskow of Campaign for America’s Future scores the effectiveness of several features of the Affordable Care Act (Obamacare) as it is being implemented. His take is that Obamacare provides only marginal improvements to a “fundamentally broken system.”

The importance of this observation is that it comes from a prominent and respected organization that provides strategy for the progressive movement. They provided crucial support to Health Care for America Now! (HCAN), a coalition of over 1000 organizations dedicated to achieving quality, affordable health care for all.

HCAN was part of the massive shift of progressives away from single payer to the “politically feasible” Clinton/Obama/Edwards version of the conservative reform model of the Heritage Foundation. They were distracted by the concept that if we could just get a public option, we would be well on our way towards achieving a truly universal, affordable system. Little did it matter that the public option would not have been much different from a traditional Blue Cross/Blue Shield plan. It would have been only a marginal improvement, if that, on a “fundamentally broken system.”

We can’t back up history, but we can assess where we are now, where we are headed, and, most importantly, where we need to go instead. Now that more individuals in the progressive community are acknowledging that Obamacare can have no more than a marginal impact on a  “fundamentally broken system,” we need to dump it and enact a single payer national health program – an improved Medicare for all.

Health benefits should not be tied to jobs

By Pamella S. Gronemeyer, M.D.
St. Louis Post-Dispatch, Letters, June 1, 2013

Last week, physicians and a pharmacy student who are members of Physicians for a National Health Program (Illinois and Missouri chapters) and the Illinois Single Payer Coalition joined thousands of United Mine Workers of America members to support their demand for continuation and fulfillment of the health and pension benefits that the miners have earned as benefits from their long years of working in mines while being exposed to the harmful effects of coal dust, which include the development of black lung disease or carcinomas.

The story of Patriot Coal and its pending bankruptcy hearing is not new but represents another effort of a corporation to both destroy a union and to deprive the laborers of their earned health and pension benefits. As physicians, we have all seen the lung disease created by mining and know how much coal miners need their health benefits. We strongly support them in their continued actions to secure their much-deserved earned benefits.

Once again, this fight points out the need for a Medicare for All program in the United States. If health benefits were not tied to jobs, no one would lose their benefits because an industry felt the need to manipulate the structure of interrelated companies and corporations to insure shareholder return and to subsequently inflict pain and suffering on workers who toiled for many years in underground mines.

Unions have worked very hard to make sure that their members have health benefits. However, they are facing increasing obstructions to their efforts. Deductibles and co-pays are being raised. Plans that eliminate coverage for hospital care are being developed.

If single-payer health care became a reality (HR 676), the American people would be the organized bargaining unit demanding and insuring that health care is a human right for all.

Dr. Pamella S. Gronemeyer resides in Glen Carbon, Ill.

http://www.stltoday.com/news/opinion/mailbag/letters-to-the-editor/health-benefits-should-not-be-tied-to-jobs/article_27a24bd9-9151-5cb7-8c23-fa0c6461321b.html

Medical Debt: A Curable Affliction Health Reform Won’t Fix

By David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H.
Communities & Banking, Summer 2013   

Millions of Americans are deep in medical debt. Unfortunately, the Affordable Care Act (ACA) will throw a lifeline to very few. According to the Congressional Budget Office, even after health reform is fully implemented in 2014, 30 million to 36 million people will remain uninsured. And tens of millions who do have insurance will have coverage that is too limited to ensure financial protection against an expensive illness. Many families will remain just one serious illness away from bankruptcy.

Medical Bankruptcies

In 2001, we began studying medical bankruptcy along with our colleagues Elizabeth Warren and Deborah Thorne. We directly surveyed debtors soon after they’d filed for personal bankruptcy. Back then, illness and medical bills contributed to about 50 percent of all personal bankruptcies and involved about 2.2 million debtors and their dependents.[1]

By 2007, when we repeated our study nationwide, medical bankruptcies had risen to 62 percent.[2] Significantly, most medical debtors were middle class. They had owned homes, had attended college, and had held responsible jobs. Seventy-eight percent even had health insurance, mostly private coverage — at least when they first got sick.

Why are so many middle-class, privately insured Americans swamped by medical costs? The reason is that private coverage has holes — unaffordable deductibles and copayments, as well as brief or nonexistent coverage of medical services like physical therapy. Moreover, since illness often reduces work-related income, families may experience a double whammy, as medical bills arrive just when the paychecks stop.

Medical bankruptcy is actually the tip of a much larger iceberg of medical indebtedness. For years, surveys have found that tens of millions of Americans struggle with medical debts and avoid needed care for fear of the cost. Recent surveys by Consumer Reports, for instance, have found that difficulty paying for medical care (including prescription drugs) is the top financial problem for American households.[3]

The number of Americans who struggle to pay for care has trended upward over time as health-care costs have soared and many health insurance companies have reduced the comprehensiveness of coverage. According to surveys by the Commonwealth Fund, the number of working-age adults (those 19 years old to 64 years old) reporting “problems paying” or “unable to pay medical bills within the past year” rose from 39 million to 53 million between 2005 and 2010.[4] In 2010, 30 million Americans were contacted by a collection agency about a medical bill, and 44 million were paying off medical debts over time.

A survey by the Center for Studying Health System Change estimated that 20.9 percent of all Americans lived in families that experienced a medical bill problem in 2010.[5] As in our bankruptcy surveys, insurance failed to offer enough protection. As many as 20.2 percent of nonelderly insured people lived in a family with medical bill problems.

Even relatively young Americans, few of whom suffer serious illnesses, are at high risk of medical debt. In a 2011 survey of young adults 19 years old to 29 years old, 51 percent of those without insurance reported medical bill or medical debt problems, as did 29 percent of those who were insured all year.[6] Sixteen percent of all young adults reported being contacted by a collection agency about a medical bill within the past year.

Medical bills often compromise more than just financial health. Considerable research, including our own, has found that families that experience medical bill problems are far more likely to delay needed medical care, skip filling a prescription, and report problems paying for other necessities. That is true whether or not the family has health insurance.

The high frequency of medical bankruptcy was often cited by advocates of health reform during the debate over the ACA. Yet the debate largely ignored the fact that most medical debtors actually have coverage. In order to protect Americans from bankruptcy, coverage must be truly comprehensive, that is, it must cover virtually 100 percent of all needed medical care. Unfortunately, the insurance policies mandated under ACA are required to cover only 60 percent of expected health-care costs.

Learning from Massachusetts

Our findings from surveys of debtors in Massachusetts before and after the implementation of that state’s health reform (the prototype of the national reform) make it clear that such limited coverage will do little to prevent medical bankruptcy.

Among Massachusetts bankruptcy filers in 2009, 53 percent cited illness or medical bills as a cause of their bankruptcy, a percentage that was statistically indistinguishable from the 59 percent figure we found before reform. Indeed, because the total number of bankruptcies had risen, the actual number of medical bankruptcies in the state increased from 7,504 in 2007 to 10,093 in 2009.[7] Surveys by others indicate that the reform had little impact on access to care.

Why are so many Massachusetts residents still suffering medical bankruptcies despite health reform? Although health-care reform cut the number of uninsured in the state by more than half (to about 219,000), much of the new coverage is so limited that serious illness still leaves families with medical bills they cannot pay.

Consider that the cheapest coverage available through the state’s health insurance exchange to a single 56-year-old Bostonian who is not eligible for subsidies (in other words, one who has an income above 300 percent of poverty) costs $4,744 and comes with numerous restrictions on which doctors’ and hospitals’ bills it will pay. If the policyholder is sick, the policy doesn’t start paying bills until after the policyholder has taken care of the $2,000 deductible. The patient also is responsible for about 20 percent of the next $15,000 in medical expenses.

Nationally, the Kaiser Foundation estimates that in high-cost regions like New England, the unsubsidized premium in 2014 under the ACA will run $10,585 with additional out-of-pocket costs adding up to $6,250.[8] Such costs will predictably leave tens of millions with large medical debts and drive more than a million into medical bankruptcy every year.

It doesn’t have to be that way. One Canadian study suggested that between 7.1 percent and 14.3 percent of Canadian bankruptcies are attributable to health problems or other misfortunes (such as floods).[9] And when journalist T.R. Reid questioned political leaders and health policy experts in several nations (all of which have some form of national health insurance) about the frequency of medical bankruptcy, he was told that they had none.[10] Other nations have virtually eliminated medical bankruptcy by making coverage both universal (covering everyone) and comprehensive (covering virtually all medical costs).

Given our research, we suggest that single-payer national health insurance should be the ultimate goal. A single tax-funded insurance plan in each region would pay for all needed care, without copayments or deductibles. Tens of billions in savings annually would accrue from reduced insurance overhead as private insurers (whose overhead averages 14 percent) make way for a Medicare-like program. Fee-for-service Medicare’s overhead is 2 percent, and overhead in the single-payer programs in Canadian provinces averages about 1 percent. Health-care providers could redirect the money now spent on billing-related paperwork to expanding and improving care.[11]

A single-payer reform is staunchly opposed by the health insurance industry and by drug companies. Nonetheless, in a recent survey carried out by the Massachusetts Medical Society,
the single-payer approach was the most popular option among Massachusetts physicians.[12] And in 2006, the last time a major poll asked what patients would prefer, 56 percent of the public favored a universal, tax-financed, Medicare-like program.[13]

Alternative health policies could virtually eliminate medical debt and free Americans from the shadow of combined financial ruin and illness — what Edward Kennedy termed the “double disaster.”[14]

David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H., are professors of public health at the City University of New York School of Public Health at Hunter College and visiting professors of medicine at Harvard University. Contact them at swoolhan@hunter.cuny.edu.

Endnotes

[1] David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler, “Illness and Injury as Contributors to Bankruptcy,” Health Affairs, http://content.healthaffairs.org/content/suppl/2005/01/28/hlthaff.w5.63.DC1.

[2] David U. Himmelstein, Deborah Thorne, Elizabeth Warren, and Steffie Woolhandler, “Medical Bankruptcy in the United States, 2007: Results of a National Study,” American Journal of Medicine 122, no. 8 (2009): 741–746, https://pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf.

[3] “Sluggish Economy Forces Americans to Cut Corners to Pay for Medication,” Consumer Reports, September 2012.

[4] Sara R. Collins, Michelle M. Doty, Ruth Robertson, and Tracy Garber, “Help on the Horizon: Findings from the Commonwealth Fund Biennial Health Insurance Survey of 2010” (report, Commonwealth Fund, Washington, DC, March 2011), http://www.commonwealthfund.org/Publications/Fund-Reports/2011/Mar/Help-on-the-Horizon.aspx.

[5] Anna Sommers and Peter J. Cunningham, “Medical Bill Problems Steady for U.S. Families, 2007–2010: Results from the Health Tracking Household Survey” (report, Center for Studying Health System Change, Washington, DC, December 2011), http://www.hschange.com/CONTENT/1268/1268.pdf.

[6] Sara R. Collins, Ruth Robertson, Tracy Garber, and Michelle M. Doty, “Young, Uninsured and in Debt: Findings from the Commonwealth Fund Health Insurance Tracking Survey of Young Adults, 2011” (report, Commonwealth Fund, Washington, DC, June 2012), http://www.commonwealthfund.org/ Publications/Issue-Briefs/2012/Jun/Young-Adults-2012.aspx..

[7] David U. Himmelstein, Deborah Thorne, and Steffie Woolhandler, “Medical Bankruptcy in Massachusetts: Has Health Reform Made a Difference?” American Journal of Medicine 124, no. 3 (March 2011): 224–228, http://www.ncbi.nlm. nih.gov/pubmed/21396505.

[8] See Kaiser Foundation Premium Calculator, http://healthreform.kff.org/ subsidycalculator.aspx.

[9] Jacob S. Ziegel, “A Canadian Perspective,” Texas Law Review 79, no. 5 (2001): 241–256.

[10] See “Sick around the World,” http://www.pbs.org/wgbh/pages/frontline/ sickaroundtheworld/etc/script.html.

[11] Steffie Woolhandler, Terry Campbell, and David U. Himmelstein, “Health Care Administration Costs in the U.S. and Canada,” New England Journal of Medicine 349 (2003): 768–775, https://pnhp.org/publications/nejmadmin.pdf.

[12] See Massachusetts Medical Society Physicians Workforce Study, http://www.massmed.org/AM/Template.cfm?Section=News_ and_Publications2&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=61512.

[13] See “Health Care in America 2006 Survey,” http://www.kff.org/kaiserpolls/upload/7572.pdf.

[14] 14 Edward M. Kennedy, In Critical Condition: The Crisis in America’s Health Care (New York: Simon & Schuster, 1972).

A PDF version of this article is available here.

Communities & Banking is a quarterly publication of the Federal Reserve Bank of Boston. The views expressed are not necessarily those of the Federal Reserve Bank of Boston or the Federal Reserve System. Information about organizations and upcoming events is strictly informational and not an endorsement.

California exchange plans take away provider choice

Insurers limit doctors, hospitals in state-run exchange plans

By Chad Terhune
Los Angeles Times, May 24, 2013

California’s health insurance rates for a new state-run marketplace came in lower than expected this week, but one downside for many consumers will be far fewer doctors and hospitals to choose from.

People who want UCLA Medical Center and its doctors in their health plan network next year, for instance, may have only one choice in California’s exchange: Anthem Blue Cross. Another major insurer in the state-run market, Blue Shield of California, said its exchange customers will be restricted to 36% of its regular physician network statewide.

Paul Markovich, chief executive of Blue Shield, said renegotiating with hospitals and physician groups for lower reimbursements was a key factor for insurers in holding down rates. Medical providers are sometimes willing to accept lower payments in return for higher patient volume from these narrow networks.

And Cedars-Sinai Medical Center, one of Southern California’s most prestigious and expensive hospitals, said it’s not included in any exchange plans at the moment.

Those types of exclusive arrangements, increasingly tight networks and outright exclusions are becoming more common as insurers and government officials search for ways to hold down rising medical costs.

More employers have been adopting these narrower networks and the government’s overhaul of the individual insurance market is accelerating the trend.

http://www.latimes.com/business/la-fi-health-rates-deals-20130525,0,4396720.story

Comment:

By Don McCanne, M.D.

There was quite a celebration amongst Affordable Care Act (ACA) enthusiasts when California, a leader in health care financing innovation, announced that premiums for plans to be offered through the state exchange would not increase sharply over current health plan rates. What is now evident is that the anticipated increases were at least partially offset by further limiting the number of in-network hospitals and physicians, made possible by insurers negotiating lower provider payments in exchange for a promise of greater volume.

This exposes the big lie of the ACA promise of “Choice.” As has been stated so many times, the choice we really want – the choice of health care professionals and institutions – was taken away by the insurers by means of their restricted networks of providers.

Now choice is being restricted even further by narrowing down these networks of providers. These further restrictions in choice are also being adopted in the employer-sponsored market. It can be anticipated that narrow networks will become the new standard in health plans.

At least the traditional Medicare program does not restrict patients to networks, though the private Medicare Advantage plans do. It is true that physicians can totally opt out of Medicare, but very few do. If an improved version of the traditional Medicare program covered all of us, this injustice of taking away patient choice would not exist.

Immigrants heavily subsidize Medicare

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, May 31, 2013

This week the prestigious journal Health Affairs published a new study that shows that “immigrants, particularly noncitizen immigrants, heavily subsidize Medicare.” The lead author is Harvard-based Dr. Leah Zallman; her co-authors include co-founders of Physicians for a National Health Program, Drs. Steffie Woolhandler and David Himmelstein, among others.

The article’s title summarizes its overall finding: “Immigrants contributed an estimated $115.2 billion more to the Medicare Trust Fund than they took out in 2002-09.” Appearing at a time when immigration has become a burning issue, the study has been welcomed by the media as a man-bites-dog story.

Across the United States and around the world news items have reported the study’s findings. Perhaps this is because, regrettably, immigrants are still too often portrayed as freeloaders who don’t deserve to compete for jobs and social benefits. It is one thing to recognize such attitudes as abject ignorance or old-fashioned bigotry. It is another to use the federal government’s own data to quantify the contribution made by immigrants to one of the nation’s most important social programs.

Dr. Zallman and her team found that in 2009 immigrants contributed $33.1 billion to Medicare Hospital Insurance Trust Fund, or 14.7 percent of all contributions, and were responsible for $19.3 billion of its expenditures, making a surplus contribution of $13.8 billion that year. Meanwhile contributions and expenditures by the U.S.-born left a $30.9 billion deficit.

As Dr. Woolhandler said of the study: “The numbers completely contradict the widely held misperception that immigrants are a drain on the health system. Reducing immigration would worsen Medicare’s financial woes.”

With Medicare woes also so prominent in the mainstream discussion, we might also note the irony that President Obama’s administration has deported more immigrants per day than any of its predecessors. (The Washington Post mentioned earlier this month that over 1,100 human beings are deported from the United States daily.)

Immigrant rights groups have long pointed to the economic gain the U.S. could realize, both in extra revenue and avoided expenditures if deportations were halted and a path to legal residence and/or citizenship were opened. After all, the great majority of undocumented immigrants not only work, thus generating wealth, but are paid with a paycheck, with taxes removed from their pay like everyone else.

In the Health Affairs article the authors write: “Having ourselves witnessed immigrants dying needlessly because of lack of health care, we (and many of our colleagues) are motivated by the belief that all patients have a human right to health care. But economic concerns — including the worry that immigrants are driving up U.S. health care costs — have often dominated the debate over immigration.”

It is my hope that the needs of human beings — concerns about what kind of society we would like to see for our children and their children — will come to dominate the discussion instead. Everyone living in the United States should have equitable access to comprehensive, high-quality health care, “everybody in, nobody out.”

We all recognize that the intersection between immigration, health care and social policies in the United States has profound human consequences for millions of individuals. And we should also recall that the point of a democracy should be to provide the essentials for life and liberty for all of its inhabitants.

If we take a close look at the economics of immigration and the Medicare program, and take this study’s findings to heart, we can see that the least we might do would be to base health and social policies upon the facts, not ignorance.

The article is available for free at the Health Affairs website until June 3.

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-immigrants-heavily-subsidize-medicare

Help less fortunate, expand Medicaid

By Jack Bernard and Neil Shulman
The Atlanta Journal-Constitution, May 30, 2013

In a fruitless effort, the radical Republicans in the U.S. House of Representatives have once again pushed through a repeal of “socialist” Obamacare — for the 37th time. This is partisan politics at its finest, since Obamacare is simply an update of Romneycare, a thoroughly Republican concept based on private insurance first introduced by former Republican presidential candidate Bob Dole in more reasonable times.

As health care professionals with many decades of experience, we do not believe that Obamacare (the Affordable Care Act or ACA) is the best solution for our ills. Although it will not provide insurance for all Americans, it is at least a move in the right direction regarding access — especially if Republican governors like ours stop playing politics and accept the federal money to expand Medicaid.

We cannot just let our fellow citizens suffer, expecting the free market to miraculously change and take care of the problem of the uninsured, as has been proposed by Reps. Paul Ryan, Paul Broun and others. The percentage of uninsured has risen drastically in the U.S. and even faster in Georgia, where 22 percent of the population is uninsured.

Here are two examples of how the current system simultaneously mistreats patients while wasting money — problems that can be alleviated by immediate Medicaid expansion:

• A woman graduates with huge college debt, getting a job as a waitress with no health insurance. A pimple on her skin turns dark. She goes to an ER, where the doctor tells her to see a dermatologist. Because she’s broke, she applies to Medicaid, which sends her a letter stating that she is ineligible; she has to be even poorer or disabled from her disease. The cancer spreads and, six months later, she is admitted to a hospital on Medicaid. After $100,000 of health care, she is sent to hospice to die. She is 29 years old.

• A 47-year-old security guard is admitted to a hospital with severe shortness of breath and elevated high blood pressure. Within three days, he is discharged, with $68,000 in medical bills. His doctors know that his blood pressure will zoom back up without the needed blood pressure meds. However, he has no money, and the hospital is not required to give him meds, so he doesn’t get any. He is sick, exhausted and alone. His blood pressure zooms back up, and he bleeds in his eyes, becoming blind. Now, he is disabled and eligible for Medicaid.

In the words of the civil rights leader Philip Randolph: “A community is democratic only when the humblest and weakest person can enjoy the highest civil, economic and social rights that the biggest and most powerful possess.”

We must choose what sort of a nation we will be: a country of compassion, or a Darwinian society in which the strong ruthlessly trample the weak. If we Americans view ourselves as the moral beacon of the world, then we must take care of the less fortunate here at home. In the short term, we must fully implement Obamacare, including expanding Medicaid. Longer term, the most effective solution is Medicare for all, not just those over 65.

Jack Bernard, a Republican from Jasper County, is a retired senior health care executive and was Georgia’s first director of health planning. Neil Shulman is associate professor of medicine at Emory University Medical School.

http://blogs.ajc.com/atlanta-forward/2013/05/30/expand-medicaid-2/?cxntfid=blogs_atlanta_forward

Spend money on universal care not costly exchange

By Thomas Gottlieb, M.D.
Health Policy Solutions (Colo.), May 29, 2013

Coloradans need health care. It’s a basic human right. Yet as we get more information about Colorado’s new health insurance exchange, it seems less certain that people will get the health care they need.

The exchange, also called a marketplace, seems more complex every day. I wonder if Coloradans who need the help most will even be able to understand this new system, much less figure out how to get care.

There is a simple solution. We need universal health care, specifically a public single-payer health system that would assure all of us who need care can access it.

The complexity of implementing and understanding the reforms required under the federal Affordable Care Act (ACA) also known as Obamacare, has become more apparent in recent days. Health Care for All Colorado, the state’s leading advocacy group for a universal public single-payer system, contends that this complexity will lead not only to unnecessary confusion for patients and caregivers but also to increased costs for premiums and other administrative costs that will continue to drive the cost of health care ever higher.

Obamacare regulates health insurance companies.  Its major values include 1) a definition of basic health plans, 2) expanding Medicaid, 3) a progressive funding plan, 4) and expanded benefits for Coloradans who previously were excluded.  However, its implementation is complex.

Coloradans need access to quality health care, not more access to the complexity of hundreds of various iterations of for-profit health insurance policies with high premiums, co-pays and deductibles as well as potentially life-threatening gaps in coverage. Watching as the state spends more than $200 million setting up the ACA exchange with all of this complexity defies logic when investing those many millions in the actually providing health care seems so much more logical and critical.

By now, many Coloradans have been seeing the Connect for Health Colorado advertising that precedes the Oct. 1 opening of the Colorado marketplace for health insurance.  While the ads may make it seem as though shopping for insurance will be a wholly positive experience, the release of more details portends more difficult sailing for those wishing to navigate the new waters of the exchanges being set up to comply with the ACA.

It has been widely reported that Coloradans looking for health insurance will have 17 companies competing for their business with more than 800 different plan variations offered through the state’s new health exchange and on the open market.  Yet as more details have come in, the complexity seemed to be increasing.  We also have many questions about costs for premiums and the availability of plans that provide affordable options for quality care which the ACA’s name seems to suggest and its intent seemed to promise.

We must move to a more sensible and simple system to cover everyone in our state.  Our group advocates for a universal public single-payer health system that would cover all Colorado residents and eliminate the need for the complexity of private insurance sold on the exchanges or purchased and provided through employers.

Another one of our leaders, Nathan Wilkes, who also serves on Colorado’s health exchange board, summed it up well when he recently said, “The rates under the ACA are pretty much guaranteed to be slightly higher because insurers are now required to cover higher-risk people they used to turn away before. The insurers will spin any increases as being due to the additional mandates, but studies show that their additional costs should only be minimal. The private insurers are wasteful, irrelevant dinosaurs creating huge, systemic administrative costs while adding little or no value to the provision of actual health care in Colorado.  Where the rates are the same or lower than before, it is likely because the insurers found ways to limit coverage by shifting more medical costs to the people through higher co-pays/coinsurance, higher deductibles, higher cost sharing for prescriptions, reduced provider networks, and other coverage limits.”

A search of Colorado’s Division of Insurance website shows a lengthy list of the companies and plans that have filed for inclusion on the Colorado marketplace/exchange, but searching for the rate filing information and then understanding those documents points to the complexity of the process and the plans. The plan Health Care for All Colorado advocates has no such complexity or huge variation of rates to decipher.

Health Care for All Colorado leaders and members will be educating, advocating and supporting the push to bring ballot initiative No. 12 to the 2014 ballot for Colorado’s voters to take advantage of the state innovation provisions of the ACA and to create a more comprehensive universal sustainable public and truly affordable health system for all Coloradans.

The initiative title reads, “Shall there be an amendment to the Colorado constitution concerning the provision of one public health insurance program to allow all Colorado residents access to a single standard of health care as a matter of human right and public good, and, in connection therewith, requiring the General Assembly to enact legislation creating a public health insurance plan, requiring the Colorado department of revenue to collect a premium not to exceed 9 percent of an individual’s income to fund the plan, and prohibiting the control or administration of premiums by a for- profit, nonpublic entity or corporation?”  If the Colorado Constitution defines health care as a human right, then our governor and legislators will be held responsible to fulfilling this right.

This Saturday, June 1, Health Care for All Colorado will welcome U.S. Rep. John Conyers, Jr., to our annual meeting as our featured speaker and to help us kick off our “Health Care is a Human Right” campaign in Colorado.  Mr. Conyers is the chief author of HR676, the national improved and expanded Medicare for all bill, and he will speak at 7 p.m., at the First Plymouth Congregational Church at Hampden and Colorado Boulevard in Englewood.  The public is welcome. For more information on the public universal single-payer health care system we support, please visit www.healthcareforallcolorado.org

Dr. Thomas Gottlieb is president-elect for the Health Care for All Colorado Foundation. He trained as a biochemist at the University of Colorado Boulder and as a physician at the CU School of Medicine. He worked for the Indian Health Service, the CU Division of Clinical Pharmacology, as medical director for the Denver Neighborhood Health Center and in private practice.

http://www.healthpolicysolutions.org/2013/05/29/opinion-spend-money-on-universal-care-not-costly-exchange/

Immigrants subsidize our Medicare program

Immigrants Contributed An Estimated $115.2 Billion More To The Medicare Trust Fund Than They Took Out In 2002–09

By Leah Zallman, Steffie Woolhandler, David Himmelstein, David Bor and Danny McCormick
Health Affairs, June 2013

Abstract

Many immigrants in the United States are working-age taxpayers; few are elderly beneficiaries of Medicare. This demographic profile suggests that immigrants may be disproportionately subsidizing the Medicare Trust Fund, which supports payments to hospitals and institutions under Medicare Part A. For immigrants and others, we tabulated Trust Fund contributions and withdrawals (that is, Trust Fund expenditures on their behalf) using multiple years of data from the Current Population Survey and the Medical Expenditure Panel Survey. In 2009 immigrants made 14.7 percent of Trust Fund contributions but accounted for only 7.9 percent of its expenditures—a net surplus of $13.8 billion. In contrast, US-born people generated a $30.9 billion deficit. Immigrants generated surpluses of $11.1–$17.2 billion per year between 2002 and 2009, resulting in a cumulative surplus of $115.2 billion. Most of the surplus from immigrants was contributed by noncitizens and was a result of the high proportion of working-age taxpayers in this group. Policies that restrict immigration may deplete Medicare’s financial resources.

Conclusion

Having ourselves witnessed immigrants dying needlessly because of lack of health care, we (and many of our colleagues) are motivated by the belief that all patients have a human right to health care. But economic concerns—including the worry that immigrants are driving up US health care costs—have often dominated the debate over immigration. Our data offer a new perspective on these economic concerns.

Policies that reduce immigration would almost certainly weaken Medicare’s financial health, while an increasing flow of immigrants might bolster its sustainability. Because Social Security’s eligibility criteria and payroll tax–based funding closely track those of Medicare, our findings support the argument that immigration helps sustain Social Security.

Providing a path to citizenship for currently undocumented immigrants would affect Medicare’s finances in multiple ways. It would likely increase payroll tax collections by reducing immigrants’ “off the books” employment and removing barriers that keep them out of higher-paying jobs. But in the long term it would probably increase the number of immigrants eligible for Medicare, and hence expenditures on their behalf.

However, the age structure of the immigrant population is far more important than either of these factors. Encouraging a steady flow of young immigrants would help offset the aging of the US population and the health care financing challenge that it presents.

http://content.healthaffairs.org/content/early/2013/05/20/hlthaff.2012.1223

Comment:

By Don McCanne, M.D.

Everyone should have health care when needed. Immigrants are taxed to support our Medicare program, yet many of them are prohibited from participating in Medicare, Medicaid, and the state insurance exchanges currently under development. Not fair.

We should have a universal health care financing system – covering all of us – in which we pay in, based on ability, and draw out, based on medical need. As long as immigrants are an integral part of our society, they should be included on the same basis.

A Simpler, Better Solution

By David Himmelstein and Steffie Woolhandler
The New York Times, Room for Debate, May 29, 2013

Gordon Schiff, an expert on medical quality, frequently admonishes: “Avoid workarounds.” It’s better to fix system defects than to force doctors and nurses to squander time and creativity (and to court disaster) by sidestepping problems like broken equipment, missing charts or computer bugs.

The Affordable Care Act is a giant workaround. Overwhelming evidence says that public insurers like Medicare (with overhead costs of 2 percent) are more efficient than private ones (overhead of private Medicare Advantage plans is 14 percent). And multiple insurers means multiple contracts, with varying coverage, billing procedures, documentation requirements, etc. – all of which force doctors and hospitals to waste billions more. The obvious fix is to cut out the insurance middlemen and cover everyone under a single public program paid for by taxes – with equal coverage for all. But the insurance lobby blocked that, so instead the Affordable Care Act took the Rube Goldberg route.

If your income is below $31,321 for a family of four (133 percent of the poverty line), you will get Medicaid (unless you live in a red state that declined the federal assistance, like Texas or Alabama). And “Medicaid” nowadays means a privately run Medicaid H.M.O. But make one dollar more (or if Junior moves out, leaving a family of three) and Medicaid disappears; now you’re shopping for subsidized private insurance in the state-run exchange. That’s not a rare occurrence: 28 million adults cross the 133 percent line annually.

In the exchange, “bronze” plans look cheapest – at first glance. But if your income is under 250 percent of poverty there are special discounts for copayments, but only in “silver” plans.

Move from 400 percent of poverty to 401 percent, and individual premiums rise $2,303. Can’t quit smoking? Add $3,365.

Stop paying your premium? You’ll stay enrolled for three months, but your insurer only has to pay your medical bills for one month.

The health care law’s consumer protections apply to everyone, except the 58.5 percent of private sector workers whose employers self-insure.

Employers who do not offer coverage must pay a fine, unless you work less than 30 hours a week, averaged over three months, or maybe 12 months.

Small employers can get help with premiums, unless they buy coverage through a Taft-Hartley Fund.

Got it? We don’t either. And there’s much more arcane detail that can mean life or death for thousands, penury or plenty for millions.

Government already pays two-thirds of total health costs, but much of that money takes a detour through a maze of private insurers. This manufactured complexity sows confusion and adds huge expense – the cost of a workaround.

David Himmelstein and Steffie Woolhandler are professors at the City University School of Public Health at Hunter College and visiting professors at Harvard Medical School. They are co-founders of Physicians for a National Health Program.

http://www.nytimes.com/roomfordebate/2013/05/29/is-obamacare-too-complicated-to-succeed/a-single-payer-system-would-be-better-than-obamacare