Summary: Today’s post by a visiting blogger reflects on recent policy think tank reports on medical debt, and bemoans the lack of attention to a much-needed major financing makeover.

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Comment:

By Ana Malinow, M.D.

It always goes like this: excellent reporting and analysis from the best health policy think tanks detailing how the US health care system is failing, building up to a crescendo that surpasses credulity, followed by a conclusion full of banal suggestions as to how we can address these failures. The storyline never deviates.

Take the Urban Institute’s Which County Characteristics Predict Medical Debt? (covered yesterday in HJM), which maps the geographic distribution and drivers of medical debt, a problem unknown in other high-income countries. To our dismay, we find that “the county’s prevalence of chronic conditions is the strongest predictor of a county’s medical debt in collections.” That means, these human beings and their families, who should be worried about their health, are instead worried about their bills.

And the policy insights to address this unimaginable suffering? Let’s see: first, because many of the counties with the highest rates of medical debt are from states which didn’t expand Medicaid, let’s expand Medicaid, the country’s racialized, second-class health care system for the poor. Forget that these people with chronic illnesses will have to prove their poverty month after month to meet criteria.

What else does the Urban Institute suggest? Consumer protections against surprise bills, even though the Kaiser Family Foundation just wrote that “surprise bills” represent just a fraction of the unexpected and large medical bills many Americans face. Oh, and yes, increase these poor people’s access to more credit, so they can become even more indebted.

What Urban Institute also finds, yet never elaborate upon, is that “counties with a higher share of the population ages 65 and older have lower rates of medical debts in collections.” That’s the age when people become eligible for Medicare – near universal coverage for the elderly. Not worth highlighting, apparently.

I can’t say with certainty what’s driving these very modest policy proposals rather than system-changing reform. I do know that Urban Institute funding is from mainstays of the current system. According to their 2020 Annual Report, that’s 35% federal government (including HHS and MedPAC), 34% foundations (including Merck, Walmart, Gates, Charles Koch Institute, and Walton Family), and 20% corporations (including JP Morgan Chase, Wells Fargo, Bank of America, Salesforce, AARP, Amazon, GM, Microsoft, QuickenLoans, Blue Shield Blue Cross Massachusetts, H&R Block, Lyft, National Associations of Realtors, etc).

And while we are on the subject of excellent reporting and analysis with lame conclusions, the Kaiser Family Foundation, in their recent publication on the burden of medical debt (covered in HJM) goes through excruciating detail describing who has medical debt: just about anyone in the US, but especially people with disabilities, those in worse health, those who live in poverty, Black Americans, people living in the South, and again, people living in Medicaid non-expansion states. At least the KFF has the integrity to write that “simply expanding coverage” will not solve the problem of medical debt in the US. But they refuse to connect the dots they so painstakingly displayed to major system change.

A national, single payer, universal, comprehensive, accessible, equitable health care system would abolish medical debt. Think about it. Why not just come out and say it?

Dr. Malinow is a pediatrician, former president of PNHP, and lead organizer for National Single Payer.

http://healthjusticemonitor.org…

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Summary: Recently we reported on a national survey of medical debt. A new report uses credit bureau data to describe which local factors predict high levels of medical debt in collections. They are: being in the South, % of population with 4 or more chronic medical conditions, % low birth weight, % uninsured, % Black, low average income, and high medical spending.

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Which County Characteristics Predict Medical Debt?, Urban Institute, June 15, 2022, by Fredric Blavin, et al.

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Medical debt is a critical challenge to Americans’ financial stability and well-being. We use unique Urban Institute credit bureau data on more than 10 million consumers to investigate (1) where people are more likely to have medical debt in collections and (2) which county-level socioeconomic and health characteristics predict medical debt. We find that 79 out of the 100 counties with highest levels of medical debt in collections are in states that have not expanded Medicaid under the Affordable Care Act. These counties are mostly concentrated in Georgia, North Carolina, and Texas. We also find that a county’s prevalence of chronic conditions is the strongest predictor of medical debt in collections. In addition, counties with high shares of uninsured, low-income, or Black populations have higher rates of medical debt in collections. We offer a few insights on policies that can reduce medical debt, such as Medicaid expansion and consumer protections through the No Surprises Act.

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Comment:

By Jim Kahn, M.D., M.P.H.

Black spots on the US map indicate that >30% of consumers have medical debt in collections. Not just medical debt, but in formal collections processes. Darker blue areas are at 20-30%.

Predictors include high rates of uninsurance, and related to that living in states with no ACA Medicaid expansion. Also the usual markers of vulnerability: % sick with multiple chronic conditions, % low birth weight, % low income, and % Black.

What is wrong with our country that we waste >$600 billion yearly on administrative complexity and profits for a fractured insurance system that torments the most vulnerable among us with financial problems related to getting medical care? We stand alone among wealthy countries in this cruelty.

Our health care financing system is a massive failure — inefficient, unkind, and deadly. No tweaks will fix its fundamental problems. How much clearer could that be?

We must find a way to transform today’s crises into a health system and country we can be proud of.

http://healthjusticemonitor.org…

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Summary: Reflection seems the order of the day. US politics are in turmoil. Health insurance problems and the need for single payer are clearer than ever. How do we put it all together?

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Talk World Radio: James G. Kahn on 300,000 U.S. COVID Deaths from Lack of Universal Healthcare (and other issues), 28 minutes

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Comment:

By Jim Kahn, M.D., M.P.H.

Today we’re sharing an interview about our study on excess COVID deaths caused by high rates of uninsurance. We discussed a wide variety of issues in the framing of health insurance problems and reform.

Meantime, I’m contemplating next steps in the single payer movement, given recent momentous national political developments. More on that soon.

http://healthjusticemonitor.org…

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Summary: Yesterday the Supreme Court reversed 50 years of abortion rights established by Roe v. Wade. This attack on reproductive rights and health is an integral part of a broader half-century undermining of our democratic system. The fights to save democracy and provide universal healthcare are linked.

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Letters from an American, June 24, 2022, by Heather Cox Richardson

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At yesterday’s hearing of the House Select Committee to Investigate the January 6th Attack on the U.S. Capitol, we heard overwhelming proof that former president Trump and his congressional supporters tried to overturn the will of the voters in the 2020 presidential election and steal control of our country to keep a minority in power.

Today, thanks to three justices nominated by Trump, the Supreme Court stripped a constitutional right from the American people, a right we have enjoyed for almost 50 years, a right that is considered a fundamental human right in most liberal democracies, and a right they indicated they would protect because it was settled law. Today’s Dobbs v. Jackson Women’s Health Organization decision overturned the 1973 Roe v. Wade decision that recognized a woman’s right to terminate a pregnancy. For the first time in our history, rather than conveying rights, the court has explicitly taken a constitutional right away from the American people.

These two extraordinary events are related. The current-day Republican Party has abandoned the idea of a democracy in which a majority of the people elect their government. Instead, its members have embraced minority rule.

The Dobbs decision marks the end of an era: the period in American history stretching from 1933 to 1981, the era in which the U.S. government worked to promote democracy. It tried to level the economic playing field between the rich and the poor by regulating business and working conditions. It provided a basic social safety net through programs like Social Security and Medicare …

Now the Republicans are engaged in the process of dismantling that government. …

[The Dobbs decision argued] that the right to determine abortion rights must be returned “to the people’s elected representatives” at the state level, even as states are restricting the right to vote. …

We are still waiting on another potentially explosive decision in West Virginia v. Environmental Protection Agency, in which the court will decide if Congress can delegate authority to government agencies as it has done since the 1930s. If the court says Congress can’t delegate authority, even if it waters that argument down, government regulation could become virtually impossible.

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Comment:

By Jim Kahn, M.D., M.P.H.

Make no mistake about it, yesterday’s Supreme Court decision to reverse Roe v. Wade, clearly an attack on reproductive health and women’s rights, is also integral to a broader attack on democracy. It is latest development in a decades-long concerted effort to deconstruct the federal assertion and protection of rights that started in earnest with FDR 90 years ago, and to exploit our biased electoral system to empower a minority to implement that agenda. The latest twist, we are reminded in the January 6 Congressional hearings, is that the GOP is willing to use big lies and subversion of basic democratic processes to complete their slow coup. Heather Cox Richardson, as usual, sees all the connections. I encourage you to read her full post.

Single payer is profoundly pro-democratic, as I’ve repeatedly written in HJM. It is universal, equitable, economically leveling, and guided by representatives of the people not of corporate shareholders. Thus, the fight for universal healthcare and for real democracy have linked core values. I believe that mending our health care financing will help mend our fractured democracy. But are these two goals linked strategically? Does the fight for single payer bolster efforts to preserve democracy? Does preserving democracy tactically advance the single payer cause? My intuition says yes, but I don’t yet understand the integrated battle plan. I’ll revert on that.

I’ll close with a reminder that this is not just about governance and human rights, it’s also about life and death. Ample research demonstrates that restricting access to abortion raises maternal and even infant mortality. The new decision and subsequent state actions to restrict or ban abortion will cause many hundreds of added deaths per year. The evidence can be seen here, here, here, here, and here.

http://healthjusticemonitor.org…

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Summary: CMS promised that the Medicare REACH ACO program, which supplants Direct Contracting Entities as a capitated replacement of fee-for-service Medicare, would prevent using diagnostic upcoding to drive up payment rates as seen with Medicare Advantage. However, scrutiny of recent guidance to contractors, combined with past CMS regulatory failures, suggest extreme skepticism.

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CMS REACH ACO Financial FAQs, Dated April 2022; Downloaded June 2022

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Q: What is the purpose of the Coding Intensity Factor (CIF) and the ACO-level symmetric 3% cap in risk adjustment?

• Coding Intensity Factor (CIF). The retrospective CIF will ensure that the change in normalized risk scores across all claims-aligned beneficiaries is zero between the baseline year (2019) and the PY. It will be applied uniformly across ACOs for a given risk adjustment model.
• Symmetric 3% cap. A symmetric 3% cap will be applied to ACO-specific risk score growth only for Standard and New Entrant ACOs in PY2021 and onwards, and beginning in PY2024 for High Needs Population ACOs, if significant risk score growth is observed. Risk score growth will be determined at the ACO-level and the symmetric 3% cap applied for each PY relative to an annual rolling risk score reference year. However, starting in PY2024, the application of the symmetric 3% risk score cap will be modified to: 1) adopt a static reference year population for the remainder of the model performance period (as a substitute for the rolling reference year population), and 2) cap the ACO’s risk score growth relative to the ACO’s independently calculated demographic risk score growth …

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Comment:

By Jim Kahn, M.D., M.P.H.

What does this technical mumbo-jumbo mean? Well, CMS and MedPAC acknowledge that the Medicare Advantage program has been plagued by rampant diagnostic upcoding, as compared with traditional Medicare, and inadequate corrective action is leading to hundreds of billions in overpayments to private MA insurers.

So, for the REACH ACO program (rebranded DCEs) CMS promised to hold the diagnostic risk score to a reference year, presumably at the start of the program. No upcoding, they said.

Then come the details. The devil is always in the details.

The first bullet is tricky. What’s key to understand is that “normalized” means counting only the coding growth that exceeds traditional Medicare coding growth. So, it’s not zero coding growth, it’s zero compared with some reference growth rate. But how will that growth rate be calculated? When assessing Medicare Advantage over-coding, the reference comparison was clear – traditional Medicare. Yet REACH ACOs are displacing traditional Medicare. So is the reference the remaining un-REACHed corners of traditional Medicare? Or all of traditional Medicare, including the REACH parts, which leads to a self-referential paradox?

The second bullet says that each ACO will be permitted an annual growth of 3% in risk score, compared with the prior year. That’s huge. Is it 3% absolute, or 3% above “normalized” growth? Critically, the promised static “reference year” kicks in only in 2024, just two years before the program ends. And, if the program changes before 2026, it won’t even happen. Oops, the actual implementation drops the reference year promise. Just like that, poof, gone!

If you’re confused, you’re not alone. I certainly am. The language used obscures as much as it clarifies.

What we’ve seen with Medicare Advantage is that even with crystal clear rules, the insurers influence Congress and CMS to inadequately adjust for known MA over-coding. This failure shifts billions from the government and beneficiaries to insurance stockholders.

Two additional issues:

Note that there’s a separate “demographic” adjuster – another opportunity to increase payments and profits.

And, as we’ve noted before, with the tempting prospect of keeping 100% of the first 25% in savings, REACH ACOs will work hard to suppress utilization, via care denials, “lemon dropping”, and other techniques.

Gilfillin and Berwick recently re-iterated concerns that the corporate nature of REACH ACOs will exacerbate profiteering gaming. These worrisome risk adjustment details compound that fear.

I predict that if REACH continues, within 3-5 years we will see in technicolor how these complex and squishy rules provided the opportunity for ACO contractors to increase payment rates, decrease outlays, and generally fleece the government and Medicare beneficiaries of hundreds of billions of dollars. One could call it, I suppose, my “Exploitation Expectation”.

It’s imperative that REACH is stopped; inserting corporations into traditional Medicare is a travesty.

http://healthjusticemonitor.org…

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Summary: Health savings accounts (HSAs) paired with deductibles are regressive: they yield financial gains mostly for healthy individuals with high income. They are justified as reducing health care costs, but these benefits are minimal. Now that large deductibles are widespread, any pretense of HSA cost-control is gone. When will we end this tax break for the rich?

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Health Savings Accounts No Longer Promote Consumer Cost-Consciousness, Health Affairs, June 2022, by Sherry A. Glied, Dahlia K. Remler, and Mikaela Springsteen

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Abstract:

Two decades ago Congress enabled Americans to open tax-favored health savings accounts (HSAs) in conjunction with qualifying high-deductible health plans (HDHPs). This HSA tax break is regressive: Higher-income Americans are more likely to have HSAs and fund them at higher levels. Proponents, however, have argued that this regressivity is offset by reductions in wasteful health care spending because consumers with HDHPs are more cost-conscious in their use of care. Using published sources and our own analysis of National Health Interview Survey data, we argue that HSAs no longer appreciably achieve this cost-consciousness aim because cost sharing has increased so much in non-HSA-qualified plans. Indeed, people who have HDHPs with HSAs are becoming less likely than others with private insurance to report financial barriers to care. In sum, promised gains in efficiency from HSAs have not borne out, so it is difficult to justify maintaining this regressive tax break.

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Comment:

By Don McCanne, M.D.

After two decades, conservatives are still promoting health savings accounts, in spite of their pronounced regressivity. We have long needed policies that assist lower income individuals, yet health savings accounts and their associated high deductible health plans have failed to protect those with more modest incomes. Only a well-designed single payer Medicare for All system would. So why on earth does support for this unsuccessful policy persist when it works to the detriment of the poor but not the wealthy?

http://healthjusticemonitor.org…

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Summary: Juneteenth commemorates an 1865 US army order to end slavery in Texas. Emancipation was the first essential step to offer Black Americans the opportunity to live a free and healthy life. But even today, 157 years later, the well-being of people of color is compromised by numerous post-emancipation policies that disadvantage them. We offer a framework to understand these issues and advocate for change.

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Comment:

By Jim Kahn, M.D., M.P.H. and Susan Rogers, M.D.

Systemic racism in health is the constellation of policy decisions taken within health care as well as in other policy domains that affect health, regardless of the purported mindset of decision-makers and practitioners. Overt racist intent (e.g., denying Black individuals the same rights as White individuals) is unacceptable and deeply harmful, but is not required for racist consequences. Indeed, many broadly harmful policies derive from racist perspectives dressed up to appear beneficent (e.g., providing inferior public services when the likely users are people of color). What makes racism “systemic” is that structural features foster unequal treatment and outcomes.

Our framework for understanding systemic racism in health starts with health care, including insurance and delivery of care. It then proceeds to broader domains that less obviously, but indeed powerfully, influence health. Our effort in this post is broad, with a few citations. It should not be taken as a definitive academic review on the topic. Instead, we hope it helps clarify the challenges we face in order to reduce and end systemic racism in health.

A note on terminology. Observed differences are often described as “disparities,” which has a neutral tone. We prefer “inequities,” which highlights that these differences are unjust and unfair.

Health insurance: Black and Latino Americans are less likely to be privately insured, and more likely to be uninsured or Medicaid-insured. This is the insurance structure that predisposes them to health care access problems. Our public policy tolerance of low payment rates and poor access under Medicaid differentially harms people of color, and in so doing reveals a fundamental and unacceptable disregard for their welfare.

The Affordable Care Act reduced uninsurance inequities, via the Medicaid expansion. However, the 13 non-expansion states have high Black and Hispanic Medicaid participation, including five of the ten highest states by this metric. Thus state refusals of federal money to expand Medicaid disproportionally hurt people of color.

Inequities in coverage worsened during COVID.

Historical Origins: 20th century health insurance expansions, including the lack of universal coverage, were shaped substantially by the linked issues of states’ rights and racism. Medicaid design and implementation compromises were similarly influenced.

Access to care: Blacks and Latinos are more likely to experience financial barriers to care. This derives from higher rates of uninsurance and Medicaid. In the Medicare program, lower income and race interact to create higher rates of skipped or delayed care. In addition, there are geographic barriers: often no hospitals, clinics, or pharmacies in poor and rural neighborhoods.

Health workforce: People of color are under-represented in the most prestigious professional group in medicine – physicians. Even worse, they remain under-represented among medical students, so the physician mix is not evolving. The American Medical Association excluded blacks until the 1965 passage of Medicare, which desegregated hospitals. A wide variety of racist attitudes and behaviors continue in clinical practice.

Pain management: One often-mentioned issue is different attitudes and use of narcotic pain relief for Black patients, with an example here. This problem is especially difficult to read about for sickle cell anemia, with its excruciating sickle crises.

Quality of care: The literature on race and quality of care is massive. A PubMed search turned up 1,700 systematic reviews, and 200,000 articles. The issue pervades medicine.

Now we discuss issues apparently outside the health realm. Yet they influence health care and health in profound ways.

Law enforcement & incarceration: Our criminal justice system is biased against people of color at all steps: stops, arrests, convictions, and severity of punishment. Blacks and Latinos are vastly over-represented in prisons. The high rate of incarceration creates a “prison penalty” which impairs employment. This, in turn, reduces access to private insurance, among other harms.

Living in areas with concentrated poverty: Blacks are more likely to be poor than are whites. However, the elevated risk of living in areas of concentrated poverty – with scarce resources like supermarkets, well-funded schools, and health care, and greater environmental toxicity – is even greater. Blacks are five times more likely than whites to live in concentrated poverty, 10 times in some cities, and even non-poor Black families are 1.5 times as likely as poor White families to live in concentrated poverty.[1]

Public funding to get ahead: The GI bill after World War II paid for higher education for returning soldiers – if white; black soldiers were mainly excluded. Federal mortgage guarantees were “red-lined”: excluding high risk (read: mainly black) neighborhoods. As a result, Black families were denied the leg up needed to establish family financial stability. Wealth differences are massive by race. This contributes to a greater medical debt burden.

Health effects: Life expectancy is >3 years greater for White than Black babies. At age 60, the difference is 1 year. Both differences increased with COVID, which had much higher death rates among Black than White individuals.

We’ve said it before, and we’ll keep saying it: single payer universal health care will help end inequity in health insurance and thus largely in access. The phrase “health insurance program for the poor” will no longer have meaning. Being Black or Hispanic will no longer feed an “algorithm” to rank health insurance attention to underserved populations. Instead, it will mean that person deserves excellent universal health insurance, just like everyone else.

We should rejoice that the federal government has designated Juneteenth as an official holiday. We have a lot more work to do.

Dr. Susan Rogers is president of Physicians for a National Health Program.

http://healthjusticemonitor.org…

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Summary: A new survey on health care debt quantifies its very high prevalence (41%) and the dire consequences for individuals and families: financial insecurity, reduced access to health care, and being unable to “provide a good life.”

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Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills, KFF (Kaiser Family Foundation), June 16, 2022, by Lunna Lopes, et al

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Executive Summary:

… The KFF Health Care Debt Survey finds that four in ten adults have some form of health care debt. Yet the likelihood of having health care debt is not evenly distributed. Uninsured adults, women, Black and Hispanic adults, parents, and those with lower incomes are especially likely to say they have health care-related debt.

… Most adults with health care debt say the bills that led to their debt were from a one-time or short-term medical expense, which are often unexpected. Indeed, about half of adults … would be unable to pay a $500 unexpected medical bill without borrowing money. …

In their efforts to service or pay off their debt … many report serious consequences like skipping payment on other bills, delaying college or buying a home, or changing their housing situation as a result of their debt.

… These sacrifices have left some individuals feeling as if they could not provide a good life for their families, or with a general sense that they will never be able to extricate themselves from debt. Other reported … being contacted by debt collectors and having their credit scores negatively affected, can lead to additional financial problems such as difficulty buying vehicles needed for work or buying or renting a home.

Health care debt can also affect the ability of individuals to access needed medical or dental care. One in seven adults with health care debt say they have been denied care by a provider due to unpaid bills. In addition, adults with health care debt are more than twice as likely as those without debt to say they or someone they live with have postponed or skipped getting needed health care because of the cost.

[T]hose with lower incomes and people of color (particularly Black adults) are more likely to report being contacted by collection agencies due to health care debt, being denied subsequent care, and making difficult sacrifices like changing their housing situation to pay down their debt.

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Comment:

By Jim Kahn, M.D., M.P.H.

Read this report! KFF did a thorough national survey, and wrote about it clearly and powerfully.

Medical debt statistics are frightening, even for someone like me so familiar with our insurance system’s flaws – how pervasive the problem is, and how severe the consequences for families. It undermines the American dream of economic security and the “pursuit of happiness” from our Declaration of Independence. As we approach Juneteenth, note that Black Americans are especially severely affected.

The situation is, of course, completely inexcusable. And completely remediable – Single payer.

To help you absorb the findings, here’s a summary of the figures. See especially Figs 9, 12, & 16 on consequences. (But read the report!)

• Fig 1: 41% of US adults have medical debt
• Fig 2: Most likely to have debt: Uninsured, Parents, Lower income, Black & Hispanic, Women
• Fig 3: Medical debt is about half <$2500 and half >$2500
• Fig 4: About half expect debt to last 3+ years, 25% forever among the poor
• Fig 5: Debt is mostly due to short-term expenses
• Fig 6: From Diagnostic tests, Doctors, Emergencies, Dental, Hospital stays, Drugs, Ambulances
• Fig 7: Causes similar across age groups
• Fig 8: Reasons: Thought insurance would pay, not enough money, possible bill inaccuracy
• Fig 9: 63% reduced spending on household necessities, and 1/5 – 1/2 did each of these: used up savings, increased credit card debt, worked more, skipped other bills, delayed education or home purchase, took out a loan, sought charity aid, moved in with family or friends
• Fig 10: Lower income: all those percentages are higher
• Fig 11: 54% made “difficult sacrifices”
• Fig 12: 47% contacted by collection agencies, 35% lower credit score, 6% sued, 3% bankruptcy
• Fig 13: 66% of Blacks contacted by collection agencies
• Fig 14: 46% of Blacks lower credit score
• Fig 15: 15% denied care by medical provider due to debt
• Fig 16: 79% with debt skipped or delayed care or drugs due to cost (and 49% without)
• Fig 17: Half would be unable to pay an unexpected $500 medical bill
• Fig 18: 68% support government limits on out-of-pocket costs
• Fig 19: 71% would like consumer assistance programs

http://healthjusticemonitor.org…

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