PNHP

Dr. Claudia Chaufan: Hispanics worst served by Affordable Care Act

Dr. Claudia Chaufan: Hispanics worst served by Affordable Care Act

By Silvia Casabianca
VOXXI News, June 18, 2012

An Argentinean medical doctor, Claudia Chaufan arrived in California as a single mom of a 7-year-old in 1997. She had been accepted to a one-year postgraduate training in science and medical communication. Destiny had it that she’d fall in love with a man that eventually became her husband, and with a cause that is now her passion.

She changed plans and stayed in the United States to get a doctorate in sociology at the University of California in Santa Cruz and now works as an assistant professor of sociology and health policy at the Institute for Health and Aging of the Department of Social and Behavioral Sciences at the University of California in San Francisco.

Chaufan gives presentations on diabetes and on comparative health policies, and writes for the general public and for expert audiences in the United States and abroad. She is also active in professional and community organizations, among them the Physicians for a National Health Program (PNHP).

Experiencing a single-payer health care system

Chaufan just returned from teaching a one-term course on Comparative Health Care Systems at the Taipei Medical University in Taiwan. There she got to experience first hand what she preaches about every day – that single-payer health care systems might be the best option.

“We had just arrived in Taiwan and my husband had this extremely bad headache,” Chaufan recalls. “I thought he had a ruptured brain aneurysm. The next day the headache was still there. I didn’t know what to do. We were staying next door to the hospital where I was teaching. We walked into the emergency room and I said we needed a doctor who could rule out the possibility of such and such.”

After a wait of only 20 minutes a doctor came. He agreed that an aneurysm was a possibility and ordered a CAT scan right away.

Fortunately the results were negative.

“The whole ordeal took us barely 90 minutes,” said Chaufan who was ready to pay in cash whatever the cost of the services were. Even though she knew the system really well, she had never experienced it by herself and she was surprised when she got the bill.

“I was thinking to myself, a CAT scan costs thousands in the United States. They asked us for our insurance card and we said we didn’t have one. They charged us $205. Two doctors had seen my husband, plus the stay at the hospital, and all they had asked us for was a name and an address!”

The medical system is simply not there for Hispanics

Before setting her residence in California, Chaufan’s medical practice had focused on clinical diabetes. She had attended medical conferences in the United States and briefly visited public hospitals.

Since in Argentina the health care system is underfunded, when compared, the hospitals in the U.S. looked great, clean and spacious to Chaufan.

“I thought they were wonderful,” Chaufan said. “I had seen unequal access to care in my country and thought the system here was great.”

But then she started to hear stories from people.

An NGO hired her to do diabetes education with Latino communities and she found that immigrants – documented or undocumented – had basically no access to health care.

“I felt embarrassed to talk to these people. How do you tell them to go eat broccoli when they could hardly make ends meet? Economy has not been working for them. It’s not the crisis. They live in a recession forever! They can’t even pay for transportation [to go to the doctor], and if they have a car, it’s falling apart.”

Chaufan decided to quit this job.

“I realized the problem was not education, it was poverty,” Chaufan said. “The medical system was simply not there. These people needed strips to test their blood sugar, they needed medication!”

Affordable Care Act (ACA) is not the way out

Chaufan started to rethink the health care system in the United States. She saw the problems and wanted to participate in solutions but didn’t know how until she found the PNHP.

“ACA doesn’t grant equal access to health – it excludes undocumented immigrants, who would not be allowed to buy insurance even with their own money,” said Chaufman. “People need to know that Latinos are the worst-served, and will be the worst affected by the reform.”

“If ACA is overturned, in whole or in part, I predict that the ‘liberal’ media is only going to talk about the role of the ‘bad Republican’ opposition, and ignore that 50 PNHP doctors (myself included) presented an Amicus Brief that also challenges the constitutionality of ACA,” she added. “And we did not do it because we are pushing for an imaginary free health care market, but because we wanted to make the point that you can bring universal affordable care to all Americans with a publicly financed health care system.

“They won’t mention that, because it is not in their interest. Everybody, Democrats, Republicans and the media are in bed with insurance companies and Big Pharma.”

Chaufan believes the ACA would institutionalize the worst of the current health care system.

“It makes people buy their junk. Even if it were universal insurance, as it is presented, with 26 million that will not be covered – according to a 2019 estimate – it’s underinsurance.”

The Argentinean health care system is underfunded and not strong, Chaufan said, but there exists a public hospital network where everybody can go.

“As a medical student, I went to one of those hospitals for services. Everyone who walks in gets care,” she said. “Non-profit mutual funds created by unions offer services to the community. There are also prepaid medical services, not cheap but never the horror that I see here with the price for tests, seeing a doctor, pharmaceuticals.”

The Affordable Care Act won’t eliminate financial barriers, she affirmed.

“Every country has a standard, including Taiwan,” Chaufan said. “If it’s publicly financed, the government says, you put a certain percentage of your salary, we buy services in bulk, buy for the whole country or the whole province, like in Canada. Here, we don’t know – it all depends on the individual insurance … that, the administration will not change.”

http://voxxi.com/dr-claudia-chaufman-hispanics-worst-served-affordable-care-act/

Massachusetts model fails to provide financial security for the sick

SICK IN MASSACHUSETTS: Views on Health Care Costs and Quality

Harvard School of Public Health/WBUR/Blue Cross Blue Shield of Massachusetts Foundation/Robert Wood Johnson Foundation
June 2012
This poll examines the views of sick adults in Massachusetts regarding the cost and quality of health care in the state as well as their perceptions about their own health care in the past year. “Sick” adults in Massachusetts (27% of adults) are defined as those who said they had a serious illness, medical condition, injury, or disability requiring a lot of medical care or had been hospitalized overnight in the previous 12 months. Focusing on the experiences and opinions of those who have had significant recent medical care yields special insight into the current problems and opportunities facing Massachusetts’ health care system.
Today most sick adults in Massachusetts see the cost of health care as a serious problem for the state, and they view the problem as having gotten worse over the past five years. Sick adults are more troubled by costs than they are by quality.
Although Massachusetts has nearly universal health insurance coverage, the costs of health care are a serious financial problem for many sick adults and their families. Some sick adults report having been refused medical care for financial or insurance reasons. Additionally, some sick adults say they did not get needed medial care because they could not afford it. Taken together, these finding suggest that insurance coverage does not protect some Massachusetts residents against the financial hardships of illness, likely reflecting recent trends in higher deductibles and co-payments.
http://www.scribd.com/doc/96682782/Sick-in-Massachusetts

This survey is particularly important because it provides the real life health care financing experiences of patients who have serious medical problems – precisely those for whom the system should be designed to serve.
In Massachusetts, “Forty percent of sick adults in the state said the out-of-pocket costs of medical care are a ‘very serious’ (16%) or ‘somewhat serious’ (24%) problem for them.” Obviously the financing system is not serving well those individuals with major medical needs.
Another significant finding: “About a quarter of sick adults (24%) who have been insured at any time during the past year say they have had a problem with their insurance paying a hospital, doctor, or other health care provider in the past 12 months.” Thus the insurers are not doing their job either.
Since the Affordable Care Act uses a financing design similar to that of Massachusetts, we can anticipate the same miserable performance for the nation, or more likely even worse because of other design flaws in ACA.
At a minimum, we should expect the health care financing system to work well for those with serious problems. The ACA design won’t cut it. We really do need a single payer national health program that would work well for all of us.

Small businesses support beneficial health reform policies

Small Business Owners’ Views on Implementing the Affordable Care Act

Small Business Majority
June 14, 2012

Executive Summary

The rising cost of health insurance has been and continues to be one of the biggest problems facing American small business owners. To help relieve them of that financial burden, the Affordable Care Act was signed into law on March 23, 2010—a piece of legislation that is already reining in Americans’ health coverage costs. More than two years later, the law’s fate rests in the hands of nine Supreme Court justices who are expected to issue their decision this month in the case against the law. According to scientific opinion polling, only one-third of small business owners would like to see them overturn it. On the other hand, half would like to see it upheld with, at most, only minor changes. This support grows after learning more details about its key provisions.
 
The poll, conducted in eight states with diverse political profiles—Florida, Illinois, Louisiana, Michigan, Missouri, New York, Texas and Virginia—found that once small business owners hear more about the healthcare law, their support for keeping it intact—either as is or with minor changes—rises to a 56% majority, while the desire for repeal falls to 28%—a 2:1 margin. Moreover, entrepreneurs strongly support many of its key provisions affecting small business owners.

One of the law’s crucial components, which has tremendous small business support, is the health insurance exchange—an online marketplace where small business owners will be able to pool their buying power when they purchase coverage. By a striking 8:1 ratio, owners say they would use their state exchange or at least consider using it, compared to those who say they would not consider using it when they provide benefits. The majority of entrepreneurs find possible features of the exchange very appealing, and, by a 2:1 ratio, they support their state applying for federal funds to set one up.

Furthermore, half of entrepreneurs report they’d be more likely to purchase insurance through the exchange beginning in 2014 when the small business tax credit will be available only to those using the exchange. That’s more than three times the number (14%) who say they’d be less likely to purchase from the exchange. Of respondents who fall into the basic qualification parameters for the tax credit, more than half are already taking advantage of it. Of eligible employers who aren’t claiming it, nearly half say it’s because they are not aware it exists. And nearly half of entrepreneurs say that if their company qualified for the credit, they would be more likely to provide or continue providing healthcare to their employees.

Significant majorities of small business owners also support nearly all the other provisions we asked them about: medical loss ratio, rate review, pre-existing condition exclusion bans, eliminating annual dollar limits on insurance benefits, preventing rating based on health status or sex and more.

Finally the poll revealed a strong interest (67%) in workplace wellness programs, if these programs would help lower coverage costs.

http://www.smallbusinessmajority.org/small-business-research/downloads/Small_Business_Owners_Views_on_ACA.pdf

Comment: 

By Don McCanne, MD

Rather than asking about a broad spectrum of health reform policies, this poll was limited to questions about policies contained in the Affordable Care Act. From this poll no conclusions can be drawn about opinions of policies specific to single payer, but we can conclude that small business owners clearly do want reform that serves them and their employees better than the status quo in health care.

It remains our task to inform them that the policies of the single payer model will serve them far better than the meager policies of the Affordable Care Act. The majority of small business owners would support an improved Medicare for all if they had a clear understanding of the policies behind it, since it’s far better for them than ACA.

Let’s get to work and let them know the possibilities.

Poorer nations push for universal health coverage as U.S. squabbles

By Philip Caper, M.D.
Bangor Daily News (Maine), June 14, 2012

A few weeks ago, an article by Noam Levey of the Los Angeles Times caught my eye. It was titled “Global Push to Guarantee Health Coverage Leaves U.S. Behind” and it described how “even as Americans debate whether to scrap President Obama’s health care law and its promise of guaranteed health coverage, many far less affluent nations are moving in the opposite direction — to provide medical insurance to all citizens.”

Among those other countries are China, Thailand, Mexico, Rwanda and Ghana. The article went on to explain that, “Two decades ago, many former communist countries in Eastern Europe and elsewhere dismantled their universal health care systems amid a drive to set up free-market economies. But popular demand for insurance protection has fueled an effort in nearly all of these countries to rebuild their systems. Similar pressure is coming from the citizens of fast-growing nations in Asia and Latin America, where rising living standards have raised expectations for better services.”

Many other countries are moving full speed ahead to guarantee health care for all their citizens, not only because it is morally and ethically right but because it is a powerful economic development tool that will ensure these countries have healthy populations and an efficient and effective health care system.

Meanwhile, the U.S. seems stuck in a state of political paralysis and may soon move full speed astern. What explains this striking and unfortunate example of American exceptionalism?

I attribute it to motivators often used to explain the behavior of Wall Street: fear and greed.

I would also add a third: ignorance. There are those who still believe (or claim to), despite all the evidence to the contrary, that the U.S. has the best health care system in the world. This belief is demonstrably contradicted, both by the facts and everyday experience. We have the most expensive health care system in the world and some of the fanciest technology, but our arrangement for getting health services to our people ranks far down the scale, behind about 40 other countries.

Fear is a major factor in the political stalemate we are now witnessing surrounding health care reform. About 50 million people in the U.S. are uninsured and increasing numbers are badly underinsured. Bankruptcies and other financial hardships due to medical costs are becoming more and more common.

Despite this, we are treated almost daily to distracting arguments, many unfounded and ridiculous, about “death panels,” “government tyranny,” “rationing” and other largely mythical or irrelevant threats to our well-being. Some of the critics responsible for these fear tactics are simply misinformed, but others are dissembling to pursue obstructionist political agendas.

Much of the fear-mongering around the health care reform debate is induced by the second motivator: greed. Health care in the U.S. is almost a $3 trillion industry. It is credibly estimated that about a third of our spending does not contribute to the health of our people in any meaningful way. The proof is that other wealthy nations provide health care to their people for about half of what we spend yet get better results.

Elimination (or more accurately redirection) of some of that money would mean moving funds away from a few people and toward the rest of us, thereby reducing the income of influential industries such as large pharmaceutical and medical supply companies and corporate providers of health care services. Many of these companies are enjoying windfall profits thanks to American public policy. Greed and the political muscle that goes with money are a major source of resistance to changes that would benefit the vast majority of Americans.

Our market-driven health care system is disintegrating. Many are being harmed in the process. How can people of good conscience allow this to continue? We need to change the ways we finance, pay for and deliver health care.

Our for-profit insurance and delivery systems must be transformed (not just reformed) into nonprofit ones, like most other countries. Coverage must be expanded to include everybody. Firm, fair and effective cost controls need to be put in place. In order for widespread support for such a system to be sustained, everyone must be in the same system.

In other words, we must replace our existing system sustained by fear, greed and ignorance with one that is fair, inclusive, efficient, effective and mission-driven. Such transformation has occurred elsewhere. Given the political will, we in the U.S., including Maine, could do it too. We’d all be much better off.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2012/06/14/health/poorer-nations-push-for-universal-health-coverage-as-u-ssquabbles/

Small businesses support beneficial health reform policies

Small Business Owners’ Views on Implementing the Affordable Care Act

Small Business Majority
June 14, 2012
Executive Summary
The rising cost of health insurance has been and continues to be one of the biggest problems facing American small business owners. To help relieve them of that financial burden, the Affordable Care Act was signed into law on March 23, 2010—a piece of legislation that is already reining in Americans’ health coverage costs. More than two years later, the law’s fate rests in the hands of nine Supreme Court justices who are expected to issue their decision this month in the case against the law. According to scientific opinion polling, only one-third of small business owners would like to see them overturn it. On the other hand, half would like to see it upheld with, at most, only minor changes. This support grows after learning more details about its key provisions.
The poll, conducted in eight states with diverse political profiles—Florida, Illinois, Louisiana, Michigan, Missouri, New York, Texas and Virginia—found that once small business owners hear more about the healthcare law, their support for keeping it intact—either as is or with minor changes—rises to a 56% majority, while the desire for repeal falls to 28%—a 2:1 margin. Moreover, entrepreneurs strongly support many of its key provisions affecting small business owners.
One of the law’s crucial components, which has tremendous small business support, is the health insurance exchange—an online marketplace where small business owners will be able to pool their buying power when they purchase coverage. By a striking 8:1 ratio, owners say they would use their state exchange or at least consider using it, compared to those who say they would not consider using it when they provide benefits. The majority of entrepreneurs find possible features of the exchange very appealing, and, by a 2:1 ratio, they support their state applying for federal funds to set one up.
Furthermore, half of entrepreneurs report they’d be more likely to purchase insurance through the exchange beginning in 2014 when the small business tax credit will be available only to those using the exchange. That’s more than three times the number (14%) who say they’d be less likely to purchase from the exchange. Of respondents who fall into the basic qualification parameters for the tax credit, more than half are already taking advantage of it. Of eligible employers who aren’t claiming it, nearly half say it’s because they are not aware it exists. And nearly half of entrepreneurs say that if their company qualified for the credit, they would be more likely to provide or continue providing healthcare to their employees.
Significant majorities of small business owners also support nearly all the other provisions we asked them about: medical loss ratio, rate review, pre-existing condition exclusion bans, eliminating annual dollar limits on insurance benefits, preventing rating based on health status or sex and more.
Finally the poll revealed a strong interest (67%) in workplace wellness programs, if these programs would help lower coverage costs.
http://www.smallbusinessmajority.org/small-business-research/downloads/Small_Business_Owners_Views_on_ACA.pdf

Rather than asking about a broad spectrum of health reform policies, this poll was limited to questions about policies contained in the Affordable Care Act. From this poll no conclusions can be drawn about opinions of policies specific to single payer, but we can conclude that small business owners clearly do want reform that serves them and their employees better than the status quo in health care.
It remains our task to inform them that the policies of the single payer model will serve them far better than the meager policies of the Affordable Care Act. The majority of small business owners would support an improved Medicare for all if they had a clear understanding of the policies behind it, since it’s far better for them than ACA.
Let’s get to work and let them know the possibilities.

Artificially creating dysfunctional competition through limited-network plans

Navigating the Health Care Maze

By Abby Goodnough
The New York Times, June 12, 2012

Even if the Supreme Court strikes down the federal mandate, many people believe that some form of exchanges could still be crucial to expanding coverage in a number of states. In Massachusetts, insurers bid to participate in the Connector — offering plans that include some level of hospitalization, prescription drugs, maternity care and other services deemed essential by the state — and the Connector uses its market leverage and unique guidelines to promote innovation and competition among them.

“It can — and it has — helped people find more affordable options than they otherwise knew existed,” said Glen Shor, executive director of the Connector.

A vast majority of the people who have gotten insurance through the Connector since the economic downturn began have not had to worry about deductibles because they qualify for subsidized coverage. In that program, the big challenge has been keeping costs down as enrollment has steadily climbed.

One strategy has been to reward the lowest-cost insurers in Commonwealth Care, the subsidized program, by driving customers to them. (For example, people who pay no premium because of their income can choose between the two lowest-cost insurers.) Some insurers have responded by limiting which doctors and hospitals customers can use.

Such limitations are controversial, but Mr. Shor said limited-network plans are just the kind of cost-saving innovation that exchanges are well-positioned to bring about by promoting competition in the market.

http://www.nytimes.com/2012/06/13/us/navigating-the-health-care-maze.html?pagewanted=2&hpw&pagewanted=all

Comment: 

By Don McCanne, MD

One of the greatest strategic errors in this entire health care reform process has been to fixate on the promotion of competition in the health care market. An example of how deviant this has been is the push to expand limited-network plans.

Think about it. What we want is our choice of hospitals and our health care professionals. What the insurance industry has done is to package their own selection of hospitals and professionals into limited networks, and then prohibit our access to out-of-network care unless we pay prohibitive financial penalties. For this, collectively we are paying even more in wasteful administrative costs. It is totally illogical to pay for extra administrative services designed to artificially take away our choices in the health care market.

Think of what it would be like if we did that with housing. Imagine the government mandating us to select a residential benefits plan. Suppose when we were ready to rent or purchase a residence the third party administrative agency told us that we could have access to only residential buildings within their limited network, though we would have our choice of bronze, silver, gold or platinum houses or apartments. Adding to the insult, collectively we would have to pay extra to this administrative agency that artificially takes away our choices.

What if third parties in the private market were able to corner the food industry and contract with them to create artificial limited-network food plans, with a government mandate that we had to select one of the plans? Within the segregated food market you could shop bronze, silver, gold or platinum selections based on the food insurance premium paid. You could shop outside of the segregated markets, but only by paying large financial penalties.  Again, collectively we would be paying extra to meet the costs of this intrusive third party administrator that would be taking away our choices.

Shifting competition in food markets from producers and retailers to an artificial third party administrator, or shifting competition in housing from the builders or landlords to an artificial third party administrator is about as logical as shifting competition in health care from the hospitals and professionals to an artificial third party administrator, all of which would charge us extra for taking away our choices. We wouldn’t tolerate that in food or housing. Why should we continue to tolerate it in health care?

Another word about our obsession with competition. The policy community recognizes that much of the dysfunction in health care is related to fragmentation of our system – both in financing and in health care delivery. Efforts are being made to integrate health services to provide an efficient, coordinated flow of health care. These efforts require cooperation between the various sectors of the health care delivery system. Competition is a divisive, destructive, evil force when it occurs within a system that should be joining together in cooperation for the public good.

Private insurers compete. Public administrators cooperate. In health care, we need more cooperation. ‘Nuff said?

The Supreme Court Should Rule with the People

By Margaret Flowers and Kevin Zeese
Dissident Voice, June 13, 2012

Six years after Massachusetts enacted the state version of Obama’s health law, the people of Massachusetts are not happy.  According to a June 11th poll in Massachusetts, 78% of patients say the cost of care in Massachusetts is a serious problem and 63% say it has gotten worse in the last five years.  Patients report longer waits, higher premiums, higher co-pays and are less satisfied with health care. The number of bankruptcies due to medical illnessand costs has continued to increase in Massachusetts too.

Despite what the corporate media report, Romney-Care, on which Obama-Care is modeled, is not working.

Americans want the Supreme Court to find the Obama law unconstitutional. More than two-thirds of Americans hope the Supreme Court will overturn some or all of the 2010 health care law, according to a June 7th New York Times-CBS poll. A mere 24% said they hoped the court “would keep the entire health care law in place.” Forty-one percent of those surveyed said the court should strike down the entire law, and another 27% said the justices should overturn only the individual mandate, the requirement that people purchase private insurance if they are not insured or pay a fine.

Overturning the entire law may have less of an impact now that three of the nation’s largest insurers, UnitedHealth, Aetna and Humana, say they will continue popular provisions such as allowing young adults under 26 to gain coverage under their parents’ plans and covering preventive care.

And overturning the law may provide an opportunity to push for a real solution to the ongoing health care crisis, to finally create a national universal and publicly-financed health insurance such as improved Medicare for All.

Perhaps this time around the nation could have a real debate about proven solutions to the fundamental problems causing the health care crisis. Private for-profit insurance and medical corporations are at the heart of that crisis. It was these corporations that heavily influenced and in some cases wrote the Obama health legislation so that it enhanced their profit margins.

For example, emails and other documents recently released by congressional investigative committees find that the Obama administration worked closely with the Pharmaceutical industry, agreeing to a back-room deal that protected their profits by opposing the re-importation of prescription medicines at lower prices. Re-importation was something President Obama supported in his 2008 campaign when he criticized the Republicans’ behind-closed-doors deals with Big Pharma.

Further the White House coordinated their $150 million advertising campaign with major pharmaceutical companies. And nearly $70 million was spent through two Super PACs — political action committees — organized by White House officials. Advocacy groups like Families USA and the unions coordinated their advertising with the White House and Big Pharma too.

The Obama law will not control costs, provide universal coverage or improve the quality of health care. More and more commentators are recognizing thatthere is a constitutional way to do so – remove two words “over 65” from the Medicare law.  This would cover every American and be a major step toward improving health outcomes in the United States.

In an amicus curae brief, we joined 50 doctors to make the case that Congress has already demonstrated it can regulate health care markets effectively by implementing single payer systems such as Medicare or the Veterans Health Administration.

We argued that the mandate was obviously unconstitutional, otherwise Congress could “reform” any failing private industry – whether it be automobiles, coal, pharmaceuticals or any other – by enacting legislation requiring that every American purchase the industry’s goods or services in exchange for some perceived public good the industry provides. As some of the justices noted in oral argument, this would change the relationship between citizen and government. Indeed, forcing the purchase of products is crony capitalism on steroids.

The brief demonstrates the superior efficiencies of single-payer systems. Only 2% of Medicare’s dollars go to administration and overhead, compared to private insurance which spends 16.7%. Under a single payer system, overall administrative costs would fall from the current 33% of health care spending to less than 5%, saving hundreds of billions of dollars. In fact, studies conducted by the nonpartisan General Accounting Office and the nonpartisan Congressional Budget Office have consistently concluded that if a national single payer system were implemented in the United States, administrative cost-savings alone would be enough to guarantee universal coverage without increasing overall health care spending

The brief shows that the cost of Medicare has increased more slowly than the cost of health care generally and more slowly than the cost of private insurance. And Medicare is rated highly by senior citizens, who are its primary beneficiaries.  51% of seniors give their health insurance an “excellent” rating.

Single payer has been supported by super majorities of the American people for more than a decade. This silenced majority of Americans who wanted real universal health care under a national health plan may get another opportunity to push for what they want if the Supreme Court rules with the people and against crony capitalist health care.

Medicare for all saves lives and saves money. Say ‘No’ to Romney/Obama health care and ‘Yes’ to Medicare for all now.

Margaret Flowers, a pediatrician, Kevin Zeese, an attorney, are both are advocates for single payer health care and the co-direct, ItsOurEconomy.US which filed an amicus brief along with Single Payer Action and 50 doctors urging the court to find the mandate unconstitutional. [PNHP note: Physicians for a National Health Program took no position on the constitutionality of the ACA.]

http://dissidentvoice.org/2012/06/the-supreme-court-should-rule-with-the-people/

Artificially creating dysfunctional competition through limited-network plans

Navigating the Health Care Maze

By Abby Goodnough
The New York Times, June 12, 2012
Even if the Supreme Court strikes down the federal mandate, many people believe that some form of exchanges could still be crucial to expanding coverage in a number of states. In Massachusetts, insurers bid to participate in the Connector — offering plans that include some level of hospitalization, prescription drugs, maternity care and other services deemed essential by the state — and the Connector uses its market leverage and unique guidelines to promote innovation and competition among them.
“It can — and it has — helped people find more affordable options than they otherwise knew existed,” said Glen Shor, executive director of the Connector.
A vast majority of the people who have gotten insurance through the Connector since the economic downturn began have not had to worry about deductibles because they qualify for subsidized coverage. In that program, the big challenge has been keeping costs down as enrollment has steadily climbed.
One strategy has been to reward the lowest-cost insurers in Commonwealth Care, the subsidized program, by driving customers to them. (For example, people who pay no premium because of their income can choose between the two lowest-cost insurers.) Some insurers have responded by limiting which doctors and hospitals customers can use.
Such limitations are controversial, but Mr. Shor said limited-network plans are just the kind of cost-saving innovation that exchanges are well-positioned to bring about by promoting competition in the market.
http://www.nytimes.com/2012/06/13/us/navigating-the-health-care-maze.html?pagewanted=2&hpw&pagewanted=all

One of the greatest strategic errors in this entire health care reform process has been to fixate on the promotion of competition in the health care market. An example of how deviant this has been is the push to expand limited-network plans.
Think about it. What we want is our choice of hospitals and our health care professionals. What the insurance industry has done is to package their own selection of hospitals and professionals into limited networks, and then prohibit our access to out-of-network care unless we pay prohibitive financial penalties. For this, collectively we are paying even more in wasteful administrative costs. It is totally illogical to pay for extra administrative services designed to artificially take away our choices in the health care market.
Think of what it would be like if we did that with housing. Imagine the government mandating us to select a residential benefits plan. Suppose when we were ready to rent or purchase a residence the third party administrative agency told us that we could have access to only residential buildings within their limited network, though we would have our choice of bronze, silver, gold or platinum houses or apartments. Adding to the insult, collectively we would have to pay extra to this administrative agency that artificially takes away our choices.
What if third parties in the private market were able to corner the food industry and contract with them to create artificial limited-network food plans, with a government mandate that we had to select one of the plans? Within the segregated food market you could shop bronze, silver, gold or platinum selections based on the food insurance premium paid. You could shop outside of the segregated markets, but only by paying large financial penalties.  Again, collectively we would be paying extra to meet the costs of this intrusive third party administrator that would be taking away our choices.
Shifting competition in food markets from producers and retailers to an artificial third party administrator, or shifting competition in housing from the builders or landlords to an artificial third party administrator is about as logical as shifting competition in health care from the hospitals and professionals to an artificial third party administrator, all of which would charge us extra for taking away our choices. We wouldn’t tolerate that in food or housing. Why should we continue to tolerate it in health care?
Another word about our obsession with competition. The policy community recognizes that much of the dysfunction in health care is related to fragmentation of our system – both in financing and in health care delivery. Efforts are being made to integrate health services to provide an efficient, coordinated flow of health care. These efforts require cooperation between the various sectors of the health care delivery system. Competition is a divisive, destructive, evil force when it occurs within a system that should be joining together in cooperation for the public good.
Private insurers compete. Public administrators cooperate. In health care, we need more cooperation. ‘Nuff said?

2012 health care spending, including administration

National Health Expenditure Projections: Modest Annual Growth Until Coverage Expands And Economic Growth Accelerates

By Sean P. Keehan, Gigi A. Cuckler, Andrea M. Sisko, Andrew J. Madison, Sheila D. Smith, Joseph M. Lizonitz, John A. Poisal and Christian J. Wolfe
Health Affairs, June 2012

2012

$2,809.0 billion – NHE (National Health Expenditures)

$8,952.8 – NHE per capita

17.9% – NHE as percent of GDP

$37.5 billion – Government administration (Note d)

$162.6 billion – Net cost of health insurance (Note e)

d  Includes all administrative costs (federal, state, and local employees’ salaries; contracted employees, including fiscal intermediaries; rent and building costs; computer systems and programs; other materials and supplies; and other miscellaneous expenses) associated with insuring individuals enrolled in the following public health insurance programs: Medicare, Medicaid, Children’s Health Insurance Program, Department of Defense, Department of Veterans Affairs, Indian Health Service, workers’ compensation, maternal and child health, vocational rehabilitation, Substance Abuse and Mental Health Services Administration, and other federal programs.

e  Net cost of health insurance is calculated as the difference between calendar year premiums earned and benefits paid for private health insurance. This includes administrative costs and, in some cases, additions to reserves; rate credits and dividends; premium taxes; and plan profits or losses. Also included in this category is the difference between premiums earned and benefits paid for the private health insurance companies that insure the enrollees of the following public programs: Medicare, Medicaid, Children’s Health Insurance Program, and workers’ compensation (health portion only).

Conclusion

For 2011 through 2013, the lingering effects of the economic recession and modest recovery, mostly in the form of limited growth in incomes, are expected to continue to constrain health spending growth. In 2014 the coverage expansions laid out in the Affordable Care Act for Medicaid and for private health insurance are expected to increase the growth rate for health spending to 7.4 percent, with notable increases expected in spending on physician services and prescription drugs for newly insured patients. By the end of the projection period, higher income growth and the continuing shift of baby boomers into Medicare are expected to cause health spending to grow roughly two percentage points faster than overall economic growth, which is about the same differential experienced over the past thirty years.

http://content.healthaffairs.org/content/early/2012/06/11/hlthaff.2012.0404.abstract

Comment:  

By Don McCanne, MD

This is the annual report that is used most often as a resource for our health care spending.

The numbers to remember for 2012:

National Health Expenditures:  about $2.8 trillion

Health spending per capita:  about $9000

Spending as a percent of GDP:  about 18%

After the transitions of the next decade, health care spending is expected to continue to grow two percentage points faster than overall economic growth – the same differential experienced over the past thirty years. It makes you wonder when Herbert Stein’s principle will kick in (essentially, if it can’t go on, it won’t).

Since we are seeing an increase in the political rhetoric divided over whether the government or markets should be the dominant force in health care financing, it is worthwhile looking at the total administrative costs of these two approaches to financing health care. Although government spending accounts for about half of all health care spending, we are paying private insurers more than four times as much in administrative costs and profits as we are spending on government administration of health insurance programs.

It is true that the net cost of private health insurance includes the administrative costs of private Medicare Advantage plans and private Medicaid and CHIP managed care plans, but this does not begin to account for the four fold differences in total administrative costs between public and private insurance.

Keep this in mind during the national debate over the Affordable Care Act this political season, which will continue to take place regardless of the Supreme Court decision. One side will argue that we need to encourage free markets of private plans plus private options for Medicare. The other side will argue that we need exchanges to provide choices of private plans, while continuing to offer private Medicare Advantage plans. The one side will talk about private markets while condemning the government, whereas the other side simply will avoid rhetoric referencing the government while touting the virtues of nominal ACA reforms of the private insurers. Both sides are wrong!

We need to get rid of the private insurers and switch to a publicly administered single payer national health program. Besides, then we can address more effectively our health care costs that continue to increase at a rate two percent above the growth in our economy – a rate that is intolerable when compounded year after year.

Health Insurance Fine Print Still Written in Blood

By Donna Smith
Common Dreams, Wednesday, June 13, 2012

With great fanfare this week, the Washington Post reported that regardless of how the Supreme Court rules on the individual mandate provision, insurance giant United Healthcare plans to keep intact key consumer provisions of the Patient Protection and Affordable Care Act.

From the June 10th WP article:

“Officials at United Healthcare will announce Monday that whatever the outcome of the court decision — expected this month — the company will continue to provide customers preventive health-care services without co-payments or other out-of-pocket charges, allow parents to keep adult children up to age 26 on their plans, and maintain the more streamlined appeals process required by the law.

“United Healthcare would also continue to observe the law’s prohibitions on putting lifetime limits on insurance payouts and rescinding coverage after a member becomes ill, except in cases where a member intentionally lied on an insurance application.”

It sounds so, well, friendly and reasonable, doesn’t it?  But read it again and then I want to tell you what that really says to America’s patients and to United Healthcare’s policyholders.

Even as United Healthcare’s announcement started making the national news, some of its policyholders were seeing the realities of the fine print.  And those realities of the for-profit healthcare business are written in the blood of our children.

I have known Nathan Wilkes of Colorado and his family for a little more than five years now.  I first read about the family in the newspaper and later met him in person until we were both on the capitol steps in Denver as I introduced Michael Moore during the film premiere of SiCKO in 2007.  Nathan spoke about the trauma his own young family faced as they try to make sure his son, Thomas, had access to the care he needed for his hemophilia.  As you might imagine, there’s has been a long and hard struggle.

Nathan is a brilliant and hard-working young man who started his own company and secured healthcare coverage through his business after exhausting many other avenues for finding his family coverage.  He knows the agony of watching his insurance costs soar while keeping a business afloat.  The insurance he eventually secured was through United Healthcare.

Nathan and I saw each other again through the years as he would travel to DC to advocate for those with hemophilia and as we both advocated for a transformed healthcare system under a single-payer model.  Some time ago, when I was asked if I knew someone who had been challenged by “lifetime caps on insurance coverage” and could also do a nice job introducing President Obama as he visited the Western slope of Colorado during the height of the health reform debates in Congress in 2009, Nathan immediately came to mind. He was selected and did a fine job.

But just because I have had the honor of working with Michael Moore, and Nathan has had the honor of meeting and introducing President Obama doesn’t mean we both don’t continue to share the bond of continuing to confront brutal realities at the hands of our for-profit insurance companies.

Just this week, as now 8-year-old Thomas faces a renewed health crisis, the Wilkes family got a letter from United Healthcare.  It told him that the insurance giant was auditing Nathan’s company’s coverage and required additional documentations (tax forms, income statements, etc) and that unless the documents were provided and found satisfactory, the business’ insurance coverage would be terminated July 1, 2012.  While that was awful enough, Nathan then began hearing from the family’s medical providers that United Healthcare went to all Thomas’ healthcare providers and informed those providers that the family’s coverage would be cancelled on July 1.

Imagine that.  Your child is hospitalized.  Your insurance company doesn’t like that your child is hospitalized and needing care – again.  So your insurance company begins to find ways to terminate your coverage for good – like trying to find that one piece of documentation on your application for coverage or your company’s application for coverage that fits their warning as stated in the WP article, “except in cases where a member intentionally lied on an insurance application.”

Let’s not be foolish.  United Healthcare will always find a way to make money, and doing so will mean aggressively finding ways to cull those who need healthcare from the ranks of their policyholders.  And even as they are announcing to the world that they’ll be so consumer-friendly as to retain some provision of the new healthcare law, they are simultaneously working to end the coverage and maybe even a chance at life for one beautiful little boy in Colorado.

Shame on you, United Healthcare and other health insurers who do the same things.  And shame on us all if we do not get on with the business of making sure we have a sane and solid healthcare system under an improved and expanded Medicare-for-All model.   The nurses of National Nurses United will be on a statewide Medicare for all bus tour in California starting next week, and I’ll be with them.  No matter what the Supreme Court decides, we cannot let any more insurance company contract fine print be written in our children’s blood.

http://www.commondreams.org/view/2012/06/13-5

Poll: Mass. health costs ‘a serious problem’ for many

By Martha Bebinger
WBUR (Boston Public Radio), June 11, 2012

BOSTON – We’re hearing from a lot of different groups lately about what’s wrong with health care and how to fix it. But what do patients think? To find out, WBUR asked Massachusetts residents who said they had a serious illness, medical condition, injury or disability requiring a lot of medical care, or spent at least one night in the hospital within the last year.

Our poll, Sick in Massachusetts, finds that 78 percent of patient respondents say the cost of care is a very serious or somewhat serious problem. And 63 percent say the problem has gotten worse over the last five years. (Click through the four charts below for some of the poll’s primary findings. The poll was conducted in partnership with the Harvard School of Public Health, the Blue Cross Blue Shield of Massachusetts Foundation and WBUR.)

* Do you think health care costs are a problem for Massachusetts?

* Costs worse or better over the last five years?

* Major reasons for rising health care costs?

* Gravity of the costs problem?

Selected WBUR Poll Data Points:

On Health Care Costs In Massachusetts:

50% said health care costs are a very serious problem

28% said costs are a somewhat serious problem

15% said costs are not a problem

‘Major Reasons’ For Rising Health Care Costs:

86% said drug companies charging too much money

78% said insurance companies charging too much

73% said hospitals charging too much

On Quality Of Health Care In Massachusetts:

52% said the quality of health care is not a problem

37% said the quality of health care is a problem

Those polled had a serious illness, medical condition, injury or disability requiring a lot of medical care, or spent at least one night in the hospital within the last year.

We’ll bring you several angles on the findings. We begin with the stories of three patients.

The ‘Oh My God’ Moment

Ask a patient about health care costs and they’ll often take you back to an eye-popping moment when they opened the envelope containing a hospital bill. Richard Marggraf, from Amesbury, remembers his “Oh my God” moment.

“Back in 1999, I was diagnosed with testicular cancer,” Marggraf said. “I went through quite a bit of therapy and procedures and what not, and those bills were in excess of $65,000 to $70,000, in 1999.”

Marggraf had a full-time job back then and generous coverage that paid virtually all of his bills. But now he’s working temp jobs and has coverage through the state with a $2,500 deductible. Marggraf can’t afford the CT scan his doctors recommend to make sure his cancer is still in remission.

“It’s a gamble, a little bit of a gamble,” he said. “Hopefully in the near future, when I gain full employment again, I can take care of that right away.”

Well, maybe. More and more employers are switching to plans with deductibles. Forty percent of the patients we polled say medical expenses they had to pay out of pocket last year are a serious problem.

Marggraf said he is more careful about where he goes for tests and procedures now that he is paying for more of the care.

“I have a lot of procedures done on the North Shore rather than going into Boston,” he said. “I think that tries to keep things down a little bit.”

But he’s frustrated by rising costs at his community hospital.

“The CEO that’s been there has increased prices dramatically at that hospital, and they’re profitable now,” Marggraf said. “At the expense of whom? At the expense of the consumer. I owe $1,000, I owe Worcester $500, I owe an ambulance $500.”

Rising Costs Leave Long-Term Bills

Mike Turcotte sat at his dining room table in rural Townsend, near the New Hampshire border, listing bills he must still pay for a one-week hospital stay last November. He’s on a payment plan and praying that he doesn’t have another serious illness anytime soon.

“If I have the same thing happen this year…” Turcotte said. He has insurance through his wife’s employer. Her share recently went up by $50 each week, a 60 percent increase.

“I wouldn’t have minded if I had the same insurance, but aside from that having to meet these deductibles,” he said.

Turcotte’s coverage also added a $2,000 deductible this year. He has Hepatitis C, high blood pressure and problems with his kidneys. He goes to the doctor a lot, takes seven medications every day, and is racking up even more bills.

“So do I, should I just stay home, ’til I really get deathly ill?” he asked.

Turcotte said he is grateful for all the money hospitals and insurers have spent on him already. He hopes to beat liver failure long enough to see his daughter graduate from high school.

“I’m so stubborn that I’ll probably be around for them to spend more money on me,” he said.

Turcotte said he doesn’t know who to blame for rising health care costs.

“I hate to say the government ought to do something, because that’s a mess,” he said. “But I would rather have the government take half of this amount and say, ‘OK, you’re covered for family.’ ”

‘I Couldn’t Keep The Home Plus The Medical Insurance’

“I’m a big girl, look at how I’m big. I can do it by myself now,” said tiny Giannie DeJesus, checking her blood sugar in her Disney princess nightgown. She was diagnosed with juvenile diabetes last year when she was just 2 years old.

“It was the worst day of my life, actually,” said Tracy DeJesus, Giannie’s mother. The diagnosis was scary and, DeJesus soon found out, expensive.

“When I checked out of the hospital, they told me to run down to CVS and pick up her medication,” she said. “It was $250.”

That was the first of many bills, even though DeJesus had health insurance through the dental office where she worked. DeJesus looked at her budget and the demands of monitoring Giannie’s blood sugar and made a calculated, but difficult, decision: She quit her job, left her apartment, and moved into a shelter in Chelsea.

“I realized that I couldn’t keep up the home plus the medical insurance,” DeJesus said. “I just can’t afford both. Pretty much we’re here because I couldn’t afford her insurance and I know I won’t be able to for years.”

Mother and daughter are now on MassHealth,
the state’s Medicaid program.

“There’s like really no words, I’m speechless,” DeJesus said. “I’ve struggled, and I’ve tried. I’ve tried to look at every angle, what if I take this away, but this condition that she has, she has to have food, we just can’t take away from something else to give to the insurance.”

DeJesus has just started working part time at a mall. In the future, if she has the option, she’ll take less pay in return for a more generous insurance plan — one with no deductible, low co-payments and no tiered services.

“I really don’t think a medical insurance that I had the year before should even exist,” she said.

The Blue Cross Blue Shield of Massachusetts Foundation, the Harvard School of Public Health (HSPH) and WBUR worked in partnership to produce Sick in Massachusetts. The Foundation commissioned and funded the HSPH poll. An independent research firm, SSRS, conducted the telephone interviews and provided WBUR with the names of poll participants. WBUR met with the partners to review the poll questions and analyze the results. WBUR shared story scripts with Robert Blendon at HSPH for fact checking purposes. WBUR, using internal editing procedures, decided how to frame and expand on issues raised by the poll results.

http://www.wbur.org/2012/06/11/health-care-costs-poll

Undocumented immigrants fight for lifesaving liver transplants

Without insurance, brothers are denied care

[PNHP note: See a related story about transplants and insurance coverage at the end of this article.]

By Jeff Danna
Chicago Tribune, June 12, 2012

Brothers Elfego and Lorenzo Arroyo each suffers from a deadly liver disease. But despite the urgency of their situation, the Chicago residents have struggled to receive organ transplants.

The Arroyo brothers are undocumented immigrants and lack insurance, friends and relatives say. Like others in their situation, they have been denied care that could increase their chances of survival due to their residency status.

“We know there are thousands of Latinos and (non-)Latinos with no documents who are facing the same situation,” Rev. Jose Landaverde said Monday during a news conference at Our Lady of Guadalupe Angelican Catholic Mission in Chicago’s Little Village neighborhood.

Both Elfego, 38, and Lorenzo, 36, attended the news conference and spoke little, but showed photographs of themselves in healthier times. They both have primary amyloidosis, a disease passed from parent to child, said Dr. David Ansell, senior vice president for clinical affairs and chief medical officer at Rush University Medical Center, who is familiar with the Arroyos and their health care dilemma. The disease makes the liver produce abnormal proteins that cause other organs to fail, he said.

“The only cure is a transplant,” Ansell said.

The Arroyos’ mother died a couple of years ago at age 63 of the same disease. Their older brother, Francisco Arroyo, 40, also had the disease, but because he is a legal resident, he received a liver transplant at Rush, Landaverde said.

The Arroyos’ position is not unique in America. About 5 percent to 10 percent of organs donated in the United States come from people who are uninsured, Ansell said. However, “close to zero percent” of the uninsured receive organ transplants.

In December, Landaverde met with Rush officials and discussed the difficulties undocumented immigrants face when trying to get transplants. Since then, Elfego Arroyo has been placed on a wait list for a liver transplant at Rush, where he had been receiving care, Landaverde said.

Lorenzo Arroyo is being treated at the University of Illinois Medical Center at Chicago, but that institution has not agreed to place him on a transplant list, Landaverde said.

When asked about Arroyo’s case, the University of Illinois Hospital and Health Science System issued a statement saying potential transplant patients, including undocumented immigrants, are assessed individually to determine if they meet medical and financial criteria.

If they have a living donor and the means to cover the transplant and follow-up care, they may be eligible for a transplant. The hospital can work to secure alternative funding for those who cannot afford a transplant or are not eligible for health entitlement funds, according to the statement.

Rush officials see caring for the undocumented and uninsurable as a moral issue, Ansell said. Rush plans to urge other institutions to also provide some transplants to the uninsurable on charitable grounds and has recently agreed to fund three transplants, Ansell said.

Once a person clears the transplant hurdle, their health care situation doesn’t always get easier. Post-transplant medications could run $10,000 a year for life, Ansell said.

Rush officials have not yet determined how the institution would help cover those costs.

Members of the Our Lady of Guadalupe community said they will continue to pressure the medical community and legislators for changes in hospital policy on the treatment of undocumented immigrants. Five people, including Lorenzo Arroyo, are currently on a hunger strike to draw attention to the issue.

“They are treating us like criminals,” said Hilda Burgos, 45, who described herself as a friend of the Arroyo family. “We came here looking for opportunities for our families. That is our only crime.”

http://www.chicagotribune.com/news/local/ct-met-immigrant-hunger-strike-20120612,0,7138960.story

The Reward for Donating a Kidney: No Insurance

By Roni Caryn Rabin
The New York Times, June 11, 2012

When Erika Royer’s lupus led to kidney failure four years ago, her father, Radburn, was able to give her an extraordinary gift: a kidney.

Ms. Royer, now 31, regained her kidney function, no longer needs dialysis and has been able to return to work. But because of his donation, her father, a physically active 53-year-old, has been unable to obtain private health insurance.

Like most other kidney donors, Mr. Royer, a retired teacher in Eveleth, Minn., was carefully screened and is in good health. But Blue Cross and Blue Shield of Minnesota rejected his application for coverage last year, as well as his appeals, on the grounds that he has chronic kidney disease, even though many people live with one kidney and his nephrologist testified that his kidney is healthy. Mr. Royer was also unable to purchase life insurance.

Officials with Blue Cross and Blue Shield of Minnesota refused to discuss Mr. Royer’s case because of privacy laws, but said in a statement that Minnesota residents who are rejected by private insurers can buy coverage through the Minnesota Comprehensive Health Association high-risk pool, which is what Mr. Royer said he did, though he is paying more for less comprehensive insurance.

The officials refused several requests for an interview, saying in an e-mailed statement that “healthy individuals who happen to have one kidney can and do receive coverage” through Blue Cross and Blue Shield as long as their test results are within medically accepted normal ranges.

Mr. Royer said he is baffled by the denial. “From my perspective, I’d be a good risk,” he said. “I’d just be putting in premiums and helping balance the system out.”

There is little data on how often kidney donors have trouble obtaining insurance, but advocates say the fear of being uninsurable may be a powerful deterrent to donation. A 2006 study done by an advocacy organization for transplant professionals found that 39 percent of transplant centers reported that they had had eligible donors who declined to donate because they feared having future insurance problems.

The health of living donors is seldom at issue: Though some research suggests that kidney donors may be slightly more prone to develop high blood pressure as they age, long-term studies have found donors live as long as other healthy people. One study reported that donors live even longer.

Most insurers maintain that prior kidney donation does not affect coverage decisions or premiums, but while transplant cases like Mr. Royer’s are rare, advocates and social workers who work closely with donors say the problem may be more common than is recognized. A review study published in 2007 by Canadian researchers found that as many as 11 percent of them have encountered problems with life and health insurance coverage.

It’s a problem with implications for thousands of people. In 2008, the last year for which figures were available from the National Institute of Diabetes and Digestive and Kidney Diseases, 17,413 kidney transplants were performed, most of them (11,382) from cadavers. But there were 87,820 people awaiting a kidney transplant as of February 2011, and another 2,249 waiting for both a kidney and a pancreas.

While kidney donation relieves society of the expense of dialysis, it does far more than that, experts say, because it dramatically improves patients’ quality of life. Dialysis keeps patients with chronic kidney disease alive, but they are usually too fatigued to work and often are on disability. A transplant usually enables them to resume a full range of activities.

“One patient’s husband compared dialysis to a transcontinental flight three times a week,” said Dr. Jeffrey J. Connaire, a nephrologist at Hennepin County Medical Center in Minneapolis who testified on behalf of Mr. Royer to Blue Cross and Blue Shield. “People come back after receiving a kidney and say ‘Ah, I have energy, food tastes good again, things smell good again.’ The classic sign of kidney failure is a terrible taste in your mouth.”

As of 2008, 382,343 Americans were receiving kidney dialysis, at a cost of $39.46 billion in public and private spending, according to the National Kidney and Urologic Diseases Information Clearinghouse. Dialysis is so expensive, in fact, that transplant surgery pays for itself in two years, according to one estimate.

Donors who aren’t covered through their employer as part of a large group and are buying an individual policy are more likely to encounter problems, experts say.

Linda Bramblett, a 53-year-old self-employed swim instructor from Great Falls, Va., was denied health insurance in 2010 after telling her prospective insurer that she was planning to donate a kidney to her younger brother. She was in good health and had already been approved for surgery, and went ahead with the donation in December 2010, she said.

“For living donors, the insurance thing isn’t exactly what you’re thinking about,” Ms. Bramblett said. “There is teeny fine print when you sign the paperwork, but you don’t really know what it’s like until you go through it.”

Susan Galbreath, a 42-year-old from New Boston, Mich., who is on dialysis, said a friend was going to donate a kidney to her but changed her mind after a conversation with an official from her insurance company, who said her future coverage would be determined on a “claim by claim” basis.

“The conversation left her feeling very very uneasy, and I told her she shouldn’t do it if anything made her uncomfortable,” Mrs. Galbreath said.

Insurance is not the only problem donors may face. Some run into difficulties at work if they need more time to recuperate than anticipated, said Diane Zocchia, a kidney donor who works for the National Kidney Registry, a nonprofit group that assists in living-kidney donation, and who is starting a new organization, Living Kidney Donors Alliance. Women of childbearing age should ask an obstetrician about the implications for future pregnancies of having one kidney, she said.

“Most donors don’t think about these things,” Ms. Zocchia said. “They develop a sort of tunnel vision once they’ve made that decision to be a donor.”

In Mr. Royer’s case, tests found a high creatinine level in his blood, which was interpreted to mean that Mr. Royer had kidney damage. Dr. Connaire told the Blue Cross panel that heard Mr. Royer’s second appeal that creatinine levels are high in most, if not all, kidney donors.

The kidneys clear creatinine from the blood and pass it out in the urine. When kidneys are damaged, the creatinine level in the urine goes down and the blood creatinine level goes up. But while people with compromised kidney function usually have a condition that progresses and ultimately may lead to kidney failure, Dr. Connaire said, Mr. Royer is healthy. He’s just working with one kidney.

“The literature says that if you have kidney problems you’ll have more heart disease, but taking a kidney out in a situation where everything is fine is a very different story,” said Dr. Connie L. Davis, who is chairwoman of the living donor committee of the Organ Procurement and Transplantation Network. “It does not have the same implications.”

More sophisticated kidney function testing would have made this clear, said Dr. Hassan N. Ibrahim, chairman of nephrology at University of Minnesota and director of the kidney transplant program, who has written extensively about the long-term health outcomes of kidney donation.

New research, not yet published, suggests the risk of developing kidney failure is even smaller for living kidney donors than for the general population, he said.

Dr. Connaire said he was especially disturbed that people who commit such a generous and giving act would be penalized for it.

“Kidney donors are some of the finest people you’d ever want to meet,” he said. “I enjoy working with them very much. It keeps my faith in humanity afloat.”

Many advocates believe that living organ donors should be guaranteed lifelong health coverage. The Affordable Care Act, if upheld by the Supreme Court, is supposed to end discrimination based on pre-existing conditions beginning in 2014.

Individuals considering donating a kidney should give the matter of future insurability, for both life and health coverage, careful consideration. Tell your doctor if you engage in contact sports or other risky activities, because you will need to protect your remaining kidney from trauma after donation.

It’s important to maintain continuous coverage and never let health policies lapse. Health coverage provided through a large employer group tends to be more secure, but be aware that circumstances beyond your control — like a spouse’s death, illness, divorce or a layoff — may disrupt coverage.

Do not assume that because you are healthy enough to donate you will be approved for health insurance. Health insurance regulations vary from state to state, so check the laws in your state, but know that some health plans fall under the federal Employee Retirement Income Security Act, or ERISA, regulations.

http://well.blogs.nytimes.com/2012/06/11/the-reward-for-donating-a-kidney-no-insurance/?ref=health