PNHP

Hospitals' charity obligations

Hospitals' charity obligations

Hospitals Flout Charity Aid Law

By Nina Bernstein
The New York Times, February 12, 2012
New York’s charity care system, partly financed by an 8.95 percent surcharge on hospital bills, is one of the most complicated in the nation, but many states have wrestled with aggressive debt collection by hospitals in recent years. Like New York, several passed laws curbing hospitals’ pursuit of unpaid bills, including Illinois, California and Minnesota.
But a new study of New York hospitals’ practices and state records finds that most medical centers are violating the rules without consequences, even as the state government ignores glaring problems in the hospitals’ own reports.
Hospitals are not legally barred from seeking judgments or liens, but must first offer an aid application, help the patient complete it, and wait while it is pending. Instead, many hospitals turn to collection agencies, and sue when that fails. The unpaid bills — typically reflecting much higher rates than what insurers pay — are then treated as the equivalent of charity care.
Change is now urgent, health care experts agree, because the state pool stands to lose hundreds of millions of federal dollars in 2014, when provisions of the health care overhaul will no longer treat so-called bad debt, based on uncollected bills, as if it were charity care.
http://www.nytimes.com/2012/02/13/nyregion/study-finds-new-york-hospitals-flout-charity-rules.html?_r=1&emc=eta1&pagewanted=all

How much charity care should hospitals be expected to provide? Contrary to the prevailing view, the answer should be, “None.” Let me explain.
With our fragmented, dysfunctional system of financing health care it is inevitable that some individuals will receive essential health care services in hospitals, often on an urgent or emergency basis, even though they lack both the funds and insurance coverage to pay for those services. Charity always has been expected of hospitals, so much so that some even have included “Charity” in their names.
The issue became more acute with a differentiation between nonprofit and for-profit hospitals. Nonprofit hospitals were relieved of tax obligations on retained revenues exceeding their costs in exchange for fulfilling their obligation to provide charity care. These retained excesses could then be used for capital improvements, or for charity care.
For-profit hospitals, as entrepreneurial entities, are taxed on these retained revenues as profits. As such, they usually are not expected to provide free care as part of their mission to profitably serve the health care needs of the community.
Members of Congress have expressed concerns over the fact that many nonprofit hospitals seem to be shirking their responsibilities to provide charitable services. They have been acting more like the for-profit hospitals in that much of their uncompensated care is not for prearranged charitable services but rather represents charges that patients were unable to pay. They then write this off as their charitable obligation, but usually only after vigorous attempts to collect the bills – efforts which often leave those patients in financial ruin forever.
It seems ironic that members of Congress pursue an investigation of the charity practices of nonprofit hospitals while paying their respects to market principles by exempting the for-profit hospitals from such an investigation, though it is understandable when you realize that Congress allows tax policy to trump health policy.
The fundamental flaw in all of this is our dysfunctional health care financing system. Everyone should have comprehensive health care coverage that pays all appropriate costs. There should never be a situation in which a person would require charity care. This is a fundamental principle common to most other wealthier nations in that their systems are designed to see that everyone receives appropriate care without the necessity of negotiating financial barriers. Services outside of the system, such as vanity cosmetic surgery, would be available based on the ability to pay, but would never require a need for charity.
Once again, it’s clear that we need to move forward with enacting an efficient, comprehensive, equitable single payer national health program. Why do we keep putting it off when the need is so clear?

Insurers shift more out-of-network costs to patients

Consumers Hit By Higher Out-of-Network Medical Costs

By Julie Appleby
Kaiser Health News, February 8, 2012

Consumers have long complained about the cost of going outside their health plan’s network, but …

Now, instead of paying a percentage of the “usual and customary” charges from physicians and other providers, insurers are basing reimbursements on a percentage of what Medicare pays, which can be much less.  “Every carrier is moving to this,” says Ken Sperling, global health care practice leader at the benefit consulting firm Aon Hewitt.

Many employers welcome the change as a way to slow rising premium increases, but some “employees are going to get stuck shouldering a significant portion of the bill because they don’t understand how it’s done,” Sperling says.

Consumers are responsible for the difference between what the out-of-network doctor charges and what their insurer pays. But few understand the basis on which plans reimburse, let alone the widely varying prices doctors and hospitals charge. As a result, they may be blindsided by big bills, says Lynn Quincy, senior health policy analyst at Consumers Union.

Insurer networks are designed to slow rising health care costs, in part by getting doctors and hospitals who join to agree to negotiated rates, which are generally lower than their usual fees.

Because out-of-network hospitals and doctors are not held to negotiated rates, they can set their own fees and “balance bill” patients for the portion insurers don’t cover.

“One of the most expensive decisions that a customer could make is going out of network,” says Alan Muney, chief medical officer at Cigna.

Medicare strictly limits how much patients can be balance billed by doctors who don’t participate in the program.

Benefit consultants, insurers, patient advocates and actuaries say the shift to Medicare rates began after a national database tracking usual and customary charges — run by UnitedHealthcare subsidiary Ingenix — was shuttered in 2009 following an investigation by the New York Attorney General, who questioned whether the data were skewed in favor of insurers.

While the closure was touted as a consumer win, “unfortunately, it’s worse now,” says Jennifer Jaff, executive director of Advocacy for Patients with Chronic Illness, a Connecticut-based group that helps file insurance appeals for consumers. “Once New York said you can’t use those (Ingenix figures) anymore, the insurers looked at it as an opportunity to pay even less.”

http://www.kaiserhealthnews.org/Stories/2012/February/09/consumers-hit-by-higher-out-of-network-medical-costs.aspx

Comment: 

By Don McCanne, MD

The most effective cost containment tool introduced during the managed care revolution was the ability of insurers to contract for set rates with networks of health care providers, eliminating arbitrarily high rates by those providers, rates that seemed to have no end in sight. Although health plan purchasers benefited by the slowing of the rate of premium increases, the trade-off was that care obtained outside of the networks either required larger out-of-pocket costs, or was not covered at all.

A universal single payer system would apply rate controls to all health care no matter where is was obtained. The obvious advantage would be that patients would then have their choice of any and all health care providers. With the current provider networks established by the private insurers, care outside of the networks may not be available because of prohibitive out-of-pocket costs.

Networks may not include centers of excellence, specialists with greater expertise of complex problems, an adequate network of primary care physicians, care that is provided by non-network physicians called in during a hospitalization, or care that is accessible within reasonable geographic boundaries. There are many reasons, not always under the control of the patient, as to why care is obtained out of the network.

Although the insurer may not provide any coverage for out-of-network care, it is more common to provide coverage that will cost the insurer no more or even less that would be paid to in-network providers. The patient could bear the brunt of the costs when the amount of the allowed charges not covered is higher, but the greater risk is that the patient is responsible for the full amount of charges over the allowed amount since the providers’ charges are not bound by a network contract.

Those supporting the private insurance industry tout the application of insurer innovations as being one of the great advantages of market solutions. But these are not social institutions that serve the public good. These are private businesses that serve their own interests. The innovations are designed to leverage markets in their favor.

This latest innovation is particularly repulsive because it is a new deception that was designed to replace the fraudulent rate-setting perpetrated by Ingenix, a UnitedHealthcare subsidiary. Ingenix and the insurers using them were caught cheating patients by manipulating downward the usual fees charged by out-of-network providers so that they would pay less out-of-network, while the patients had to take up the slack. The insurance industry paid hundreds of millions of dollars in legal settlements and shut down the Ingenix program.

Not to be outdone, without fanfare, they replaced the phony usual fee determination for out-of-network care with an allowable fee based on a percentage of Medicare fees. In most cases, this shifts even more of the costs away from the insurers and onto the patients receiving care. So these Ingenix-driven scam artists have shifted to a worse-than-Ingenix system of manipulating prices, but one that will pass legal muster since it’s in the fine print of the insurance contract (as an example, on page 108 of the 126 page booklet of the Oxford/UnitedHealthcare plan mentioned in the article).

Another newer innovation that compounds the injustice of this scheme is that insurers are increasing the number of limited network plans – smaller networks which increase the probability that patients will be stuck with the much higher costs of out-of-network providers.

Also compounding this problem is that the high-deductible plans that flooded the individual market are now being adopted wholesale by employers. Insurers benefit because they can keep their premiums more competitive, even if still outrageous. Employers have complicity with these strategies because they want the lower premiums made possible by protecting the insurers from the costs that are shifted to the patients.

Under the Affordable Care Act, we’ll continue to see more of these abuses. Employers will continue to shift more payment responsibilities to their employees. Insurers will continue to innovate to bring them the highest return possible using this sick financing system. And the patients will be exposed to ever greater financial hardship.

Most employers would prefer not to introduce these innovations that stiff their employees, but the very high cost of private plans almost force them to do so. We should relieve employers of the obligation to sponsor their employees’ health plans. Above all, we need to eliminate the industry that uses health care payment innovations to enrich themselves at a great cost to patients.

For those who have not yet watched Lawrence O’Donnell’s video on employer-sponsored plans and single payer, do it now, and then share it with others:
http://www.msnbc.msn.com/id/45755883/vp/46320398#46321122

Local physician will lead national group

Andrew Coates chosen by organization that supports universal care

By Cathleen F. Crowley
Albany Times-Union, Thursday, February 9, 2012

ALBANY – A local physician and activist was chosen as president-elect of Physicians for a National Health Program, a national organization of 18,000 doctors who support universal health care.

Dr. Andrew Coates, 49, was selected to lead the group by PNHP’s executive committee last month. His one-year term starts in 2013.

“We still need real health reform in this country,” Coates said. “We still need health care that will provide comprehensive and necessary care for absolutely everyone.”

Coates, who often shows up at peace rallies and health care protests in a bow tie and fleece jacket, is director of medical services at Capital District Psychiatric Center, medical director at Albany County Nursing home and a member of the executive board of the Public Employees Federation.

Coates, who is board certified in internal medicine and hospice and palliative medicine, is also a Times Union blogger.

“Andy is a fabulous person who is committed to social justice and that includes health care for all and it includes adequate income and housing and food,” said Dr. Richard Propp, a retired doctor who founded the Capital District Alliance for Universal Health Care. “Basically, he is someone who is fighting on all levels for everybody.”

Coates founded the region’s chapter of PNHP about 10 years ago with Dr. Paul Sorum, a family doctor in Latham.

Sorum said, “He has a very good vision of what a just society should provide in the way of real health care access.”

The United States should model its health care system on countries like Canada, Taiwan, New Zealand and England, Coates said.

“What doesn’t work is private health insurance,” he said.

Coates was raised in Greene County and attended Hamilton College. He has a master’s degree in history from SUNY Albany and a medical degree from Columbia University College of Physicians and Surgeons. He trained at Bassett Healthcare and teaches at Albany Medical College. He lives in Delmar with his wife, Lori Coates, and their three children.

Read more: http://www.timesunion.com/business/article/Local-physician-will-lead-national-group-3213628.php#ixzz1lzY871di

Insurers shift more out-of-network costs to patients

Consumers Hit By Higher Out-of-Network Medical Costs

By Julie Appleby
Kaiser Health News, February 8, 2012
Consumers have long complained about the cost of going outside their health plan’s network, but …
Now, instead of paying a percentage of the “usual and customary” charges from physicians and other providers, insurers are basing reimbursements on a percentage of what Medicare pays, which can be much less.  “Every carrier is moving to this,” says Ken Sperling, global health care practice leader at the benefit consulting firm Aon Hewitt.
Many employers welcome the change as a way to slow rising premium increases, but some “employees are going to get stuck shouldering a significant portion of the bill because they don’t understand how it’s done,” Sperling says.
Consumers are responsible for the difference between what the out-of-network doctor charges and what their insurer pays. But few understand the basis on which plans reimburse, let alone the widely varying prices doctors and hospitals charge. As a result, they may be blindsided by big bills, says Lynn Quincy, senior health policy analyst at Consumers Union.
Insurer networks are designed to slow rising health care costs, in part by getting doctors and hospitals who join to agree to negotiated rates, which are generally lower than their usual fees.
Because out-of-network hospitals and doctors are not held to negotiated rates, they can set their own fees and “balance bill” patients for the portion insurers don’t cover.
“One of the most expensive decisions that a customer could make is going out of network,” says Alan Muney, chief medical officer at Cigna.
Medicare strictly limits how much patients can be balance billed by doctors who don’t participate in the program.
Benefit consultants, insurers, patient advocates and actuaries say the shift to Medicare rates began after a national database tracking usual and customary charges — run by UnitedHealthcare subsidiary Ingenix — was shuttered in 2009 following an investigation by the New York Attorney General, who questioned whether the data were skewed in favor of insurers.
While the closure was touted as a consumer win, “unfortunately, it’s worse now,” says Jennifer Jaff, executive director of Advocacy for Patients with Chronic Illness, a Connecticut-based group that helps file insurance appeals for consumers. “Once New York said you can’t use those (Ingenix figures) anymore, the insurers looked at it as an opportunity to pay even less.”
http://www.kaiserhealthnews.org/Stories/2012/February/09/consumers-hit-by-higher-out-of-network-medical-costs.aspx

The most effective cost containment tool introduced during the managed care revolution was the ability of insurers to contract for set rates with networks of health care providers, eliminating arbitrarily high rates by those providers, rates that seemed to have no end in sight. Although health plan purchasers benefited by the slowing of the rate of premium increases, the trade-off was that care obtained outside of the networks either required larger out-of-pocket costs, or was not covered at all.
A universal single payer system would apply rate controls to all health care no matter where is was obtained. The obvious advantage would be that patients would then have their choice of any and all health care providers. With the current provider networks established by the private insurers, care outside of the networks may not be available because of prohibitive out-of-pocket costs.
Networks may not include centers of excellence, specialists with greater expertise of complex problems, an adequate network of primary care physicians, care that is provided by non-network physicians called in during a hospitalization, or care that is accessible within reasonable geographic boundaries. There are many reasons, not always under the control of the patient, as to why care is obtained out of the network.
Although the insurer may not provide any coverage for out-of-network care, it is more common to provide coverage that will cost the insurer no more or even less that would be paid to in-network providers. The patient could bear the brunt of the costs when the amount of the allowed charges not covered is higher, but the greater risk is that the patient is responsible for the full amount of charges over the allowed amount since the providers’ charges are not bound by a network contract.
Those supporting the private insurance industry tout the application of insurer innovations as being one of the great advantages of market solutions. But these are not social institutions that serve the public good. These are private businesses that serve their own interests. The innovations are designed to leverage markets in their favor.
This latest innovation is particularly repulsive because it is a new deception that was designed to replace the fraudulent rate-setting perpetrated by Ingenix, a UnitedHealthcare subsidiary. Ingenix and the insurers using them were caught cheating patients by manipulating downward the usual fees charged by out-of-network providers so that they would pay less out-of-network, while the patients had to take up the slack. The insurance industry paid hundreds of millions of dollars in legal settlements and shut down the Ingenix program.
Not to be outdone, without fanfare, they replaced the phony usual fee determination for out-of-network care with an allowable fee based on a percentage of Medicare fees. In most cases, this shifts even more of the costs away from the insurers and onto the patients receiving care. So these Ingenix-driven scam artists have shifted to a worse-than-Ingenix system of manipulating prices, but one that will pass legal muster since it’s in the fine print of the insurance contract (as an example, on page 108 of the 126 page booklet of the Oxford/UnitedHealthcare plan mentioned in the article).
Another newer innovation that compounds the injustice of this scheme is that insurers are increasing the number of limited network plans – smaller networks which increase the probability that patients will be stuck with the much higher costs of out-of-network providers.
Also compounding this problem is that the high-deductible plans that flooded the individual market are now being adopted wholesale by employers. Insurers benefit because they can keep their premiums more competitive, even if still outrageous. Employers have complicity with these strategies because they want the lower premiums made possible by protecting the insurers from the costs that are shifted to the patients.
Under the Affordable Care Act, we’ll continue to see more of these abuses. Employers will continue to shift more payment responsibilities to their employees. Insurers will continue to innovate to bring them the highest return possible using this sick financing system. And the patients will be exposed to ever greater financial hardship.
Most employers would prefer not to introduce these innovations that stiff their employees, but the very high cost of private plans almost force them to do so. We should relieve employers of the obligation to sponsor their employees’ health plans. Above all, we need to eliminate the industry that uses health care payment innovations to enrich themselves at a great cost to patients.
For those who have not yet watched Lawrence O’Donnell’s video on employer-sponsored plans and single payer, do it now, and then share it with others:
http://www.msnbc.msn.com/id/45755883/vp/46320398#46321122

Help make Lawrence O'Donnell on SINGLE PAYER go viral!

How America got into birth control mess

The Last Word with Lawrence O’Donnell
MSNBC, February 8, 2012

In this seven minute video, Lawrence O’Donnell uses the current controversy over coverage of contraception as a platform to launch his message on why single payer is the imperative.

http://www.msnbc.msn.com/id/45755883/vp/46320398#46321122

We often ask what we can do to advance the single payer cause. Besides the “be there and do it” rule, a very simple, immediate step is to help this video go viral by sharing it with your friends, colleagues, social websites, email lists, and anywhere else that people may want to hear the message that there is real HOPE for the future of health care in America.

And…

It is important to understand that the rationale of the single payer model is not only in the purview of progressives like Lawrence O’Donnell. Here is a statement from Michael Brendan Dougherty of Business Insider and The American Conservative (Democracy Now!, Feb. 8, 2012):

Michael Brendan Dougherty:  And most of the people who want to enforce this rule (employer-sponsored coverage of contraception) would prefer a single-payer system of healthcare anyway, where you’re not actually forcing employers to violate their conscience in buying this.

Amy Goodman:  So you’re saying a single-payer system would solve the problem.

Michael Brendan Dougherty:  Well, I’m saying it would solve this particular problem of conscience, as it has in Europe.

http://www.democracynow.org/2012/2/8/as_contraceptives_rule_enters_gop_race

Comment:

By Don McCanne, MD

CALL FOR ACTION:  Share the O’Donnell video NOW! GO VIRAL!

Help make Lawrence O’Donnell on SINGLE PAYER go viral!

How America got into birth control mess

The Last Word with Lawrence O’Donnell
MSNBC, February 8, 2012

In this seven minute video, Lawrence O’Donnell uses the current controversy over coverage of contraception as a platform to launch his message on why single payer is the imperative.

http://www.msnbc.msn.com/id/45755883/vp/46320398#46321122

We often ask what we can do to advance the single payer cause. Besides the “be there and do it” rule, a very simple, immediate step is to help this video go viral by sharing it with your friends, colleagues, social websites, email lists, and anywhere else that people may want to hear the message that there is real HOPE for the future of health care in America.

And…

It is important to understand that the rationale of the single payer model is not only in the purview of progressives like Lawrence O’Donnell. Here is a statement from Michael Brendan Dougherty of Business Insider and The American Conservative (Democracy Now!, Feb. 8, 2012):

Michael Brendan Dougherty:  And most of the people who want to enforce this rule (employer-sponsored coverage of contraception) would prefer a single-payer system of healthcare anyway, where you’re not actually forcing employers to violate their conscience in buying this.

Amy Goodman:  So you’re saying a single-payer system would solve the problem.

Michael Brendan Dougherty:  Well, I’m saying it would solve this particular problem of conscience, as it has in Europe.

http://www.democracynow.org/2012/2/8/as_contraceptives_rule_enters_gop_race

Comment:

By Don McCanne, MD

CALL FOR ACTION:  Share the O’Donnell video NOW! GO VIRAL!

Help make Lawrence O'Donnell on SINGLE PAYER go viral!

How America got into birth control mess

The Last Word with Lawrence O’Donnell
MSNBC, February 8, 2012
In this seven minute video, Lawrence O’Donnell uses the current controversy over coverage of contraception as a platform to launch his message on why single payer is the imperative.
http://www.msnbc.msn.com/id/45755883/vp/46320398#46321122
We often ask what we can do to advance the single payer cause. Besides the “be there and do it” rule, a very simple, immediate step is to help this video go viral by sharing it with your friends, colleagues, social websites, email lists, and anywhere else that people may want to hear the message that there is real HOPE for the future of health care in America.

And…

It is important to understand that the rationale of the single payer model is not only in the purview of progressives like Lawrence O’Donnell. Here is a statement from Michael Brendan Dougherty of Business Insider and The American Conservative (Democracy Now!, Feb. 8, 2012):
Michael Brendan Dougherty:  And most of the people who want to enforce this rule (employer-sponsored coverage of contraception) would prefer a single-payer system of healthcare anyway, where you’re not actually forcing employers to violate their conscience in buying this.
Amy Goodman:  So you’re saying a single-payer system would solve the problem.
Michael Brendan Dougherty:  Well, I’m saying it would solve this particular problem of conscience, as it has in Europe.
http://www.democracynow.org/2012/2/8/as_contraceptives_rule_enters_gop_race

CALL FOR ACTION:  Share the O’Donnell video NOW! GO VIRAL!

Circuit Court: Individuals cannot disclaim entitlement to Medicare Part A

United States Court of Appeals
For the District of Columbia Circuit
Decided February 7, 2012

BRIAN HALL, ET AL., APPELLANTS
v.
KATHLEEN SEBELIUS, SECRETARY OF THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, AND MARK J. ASTRUE, COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, APPELLEES

KAVANAUGH, Circuit Judge: This is not your typical lawsuit against the Government. Plaintiffs here have sued because they don’t want government benefits. They seek to disclaim their legal entitlement to Medicare Part A benefits for hospitalization costs. Plaintiffs want to disclaim their legal entitlement to Medicare Part A benefits because their private insurers limit coverage for patients who are entitled to Medicare Part A benefits. And plaintiffs would prefer to receive coverage from their private insurers rather than from the Government.

Plaintiffs’ lawsuit faces an insurmountable problem: Citizens who receive Social Security benefits and are 65 or older are automatically entitled under federal law to Medicare Part A benefits. To be sure, no one has to take the Medicare Part A benefits. But the benefits are available if you want them. There is no statutory avenue for those who are 65 or older and receiving Social Security benefits to disclaim their legal entitlement to Medicare Part A benefits. For that reason, the District Court granted summary judgment for the Government. We understand plaintiffs’ frustration with their insurance situation and appreciate their desire for better private insurance coverage. But based on the law, we affirm the judgment of the District Court.

http://www.cadc.uscourts.gov/internet/opinions.nsf/0/890596479218E0818525799D00548389/$file/11-5076-1356903.pdf

Comment: 

By Don McCanne, MD

Although the government requirement that an individual be required to purchase an unwanted private health plan is being challenged before the Supreme Court, it is reassuring that Medicare is so well established within our laws that an individual over 65 who is receiving Social Security cannot disclaim their legal entitlement to Medicare Part A benefits, even though they can refuse to receive those benefits.

It is unfortunate that Congress chose a model of reform that depends on an unpopular and possibly illegal mandate to purchase private health insurance, with a financial penalty for those who fail to comply. Medicare, one of the nation’s most popular programs and one for which there is no legitimate legal challenge, should have been selected instead.

An improved Medicare for all would have been much more effective and less expensive, and would not have had to face legal challenges. All of us can have Medicare, if we, as the people, demand it.

Circuit Court: Individuals cannot disclaim entitlement to Medicare Part A

United States Court of Appeals
For the District of Columbia Circuit
Decided February 7, 2012
BRIAN HALL, ET AL., APPELLANTS
v.
KATHLEEN SEBELIUS, SECRETARY OF THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, AND MARK J. ASTRUE, COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, APPELLEES
KAVANAUGH, Circuit Judge: This is not your typical lawsuit against the Government. Plaintiffs here have sued because they don’t want government benefits. They seek to disclaim their legal entitlement to Medicare Part A benefits for hospitalization costs. Plaintiffs want to disclaim their legal entitlement to Medicare Part A benefits because their private insurers limit coverage for patients who are entitled to Medicare Part A benefits. And plaintiffs would prefer to receive coverage from their private insurers rather than from the Government.
Plaintiffs’ lawsuit faces an insurmountable problem: Citizens who receive Social Security benefits and are 65 or older are automatically entitled under federal law to Medicare Part A benefits. To be sure, no one has to take the Medicare Part A benefits. But the benefits are available if you want them. There is no statutory avenue for those who are 65 or older and receiving Social Security benefits to disclaim their legal entitlement to Medicare Part A benefits. For that reason, the District Court granted summary judgment for the Government. We understand plaintiffs’ frustration with their insurance situation and appreciate their desire for better private insurance coverage. But based on the law, we affirm the judgment of the District Court.
http://www.cadc.uscourts.gov/internet/opinions.nsf/0/890596479218E0818525799D00548389/$file/11-5076-1356903.pdf

Although the government requirement that an individual be required to purchase an unwanted private health plan is being challenged before the Supreme Court, it is reassuring that Medicare is so well established within our laws that an individual over 65 who is receiving Social Security cannot disclaim their legal entitlement to Medicare Part A benefits, even though they can refuse to receive those benefits.
It is unfortunate that Congress chose a model of reform that depends on an unpopular and possibly illegal mandate to purchase private health insurance, with a financial penalty for those who fail to comply. Medicare, one of the nation’s most popular programs and one for which there is no legitimate legal challenge, should have been selected instead.
An improved Medicare for all would have been much more effective and less expensive, and would not have had to face legal challenges. All of us can have Medicare, if we, as the people, demand it.

California's health insurance lessons for the U.S.

The State of Health Insurance in California: Findings from the 2009 California Health Interview Survey

By Shana Alex Lavarreda, PhD, MPP, Livier Cabezas, MPAff, Ken Jacobs, Dylan H. Roby, PhD, Nadereh Pourat, PhD, Gerald F. Kominski, PhD
UCLA Center for Health Policy Research, February 2012

Excerpts (These paragraphs are not contiguous in the report.)

Medi-Cal, Healthy Families, and Medicare provided insurance coverage to 9.3 million people in California for all or part of 2009. Despite the presence of these state and federally run public programs, there are still many low-income, uninsured Californians who do not qualify for coverage. Additionally, there are children and their parents, people with disabilities or medical needs, and elderly Californians who are eligible for public insurance programs but who are not enrolled.

Only three-fourths of uninsured Latinos will be able to gain coverage under ACA. A slightly higher percentage (43.1%) will be eligible for the Medi-Cal expansion, but far fewer will participate in the Exchange, either with subsidies (21%) or without (9.2%). The rest will be ineligible to participate in the coverage expansions due to their citizenship status (26.8%).

The exclusions embedded in ACA will likely increase the health insurance disparities between U.S. citizens and non-citizens over time. If these issues remain unaddressed, California runs the risk of increasing racial/ethnic inequities in health care access and outcomes.

Medicare beneficiaries without Medi-Cal or a supplemental source of coverage were more likely to report delays in obtaining medical care or necessary prescription drugs.

Not all types of health insurance are equal in their impact on access. Significant variations in premiums, cost sharing, and benefits exist between employment-based and individually purchased insurance, further complicated by the high-deductible plans that exist in both markets. Medi-Cal and Healthy Families coverage have very low or no premiums and cost sharing, but funding shortfalls often threaten eligibility, benefits, and provider participation in these programs.

The uninsured were also more likely than the insured to forgo or delay needed medical care due to costs or lack of insurance; 5.7% of those with employment-based insurance reported such barriers, compared to 19.5% of the uninsured.

The existing racial and ethnic disparities in health insurance coverage and resulting access to the health care system will be exacerbated as health care reform is implemented, with the very serious possibility that more than one million California residents (including non-citizen children) will be left to rely on safety net providers who may not receive enough money to care for the residual uninsured.

According to the 2009 California Health Interview Survey, approximately 92.7% of all children who were eligible for Medi-Cal actually signed up in 2009, and a lower percentage of adults ages 19 to 64 who were eligible actually enrolled (85.0%). That represents more than 215,000 children who could have had health insurance through a low-cost, public program but who did not enroll. In addition, another 331,000 adults were estimated to be eligible for Medi-Cal but remained uninsured. Although Healthy Families does not enroll adults, a smaller number of uninsured children are eligible for the program. Approximately 189,000 of uninsured children are estimated to be eligible for Healthy Families but are not enrolled – 22.2% of the eligible population.

Variations in health care use, as well as reports of forgoing needed care or delaying it due to costs and presence of medical debt by type of insurance, are likely due to differences in deductible levels and cost sharing and benefits. These variations indicate that health insurance does not fully address the financial barriers to access. Among the publicly insured, the presence of access barriers and financial debt illustrate the challenges the Medi-Cal and Healthy Families programs have to overcome despite the perennial funding shortfalls that threaten eligibility, benefits, and provider participation in these programs.

The continuing increase in premiums is likely to increase the number of high-deductible plans not accompanied by savings accounts, increase cost sharing and lead to more medical debt, increase the ranks of those who forgo or delay needed medical care, and potentially reduce timely doctor visits and increase emergency room visits.

In October 2010, California became the first state in the nation to pass legislation establishing the California Health Benefit Exchange, a fundamental component of the infrastructure of ACA. The Board faces numerous challenges over the next two years, including how to coordinate eligibility determination and enrollment processes with state and county agencies, whether to standardize co-payments and deductibles within each of the four tiers of health plans to be offered in the Exchange as a means of facilitating comparison shopping by consumers, and providing seamless transitions for individuals between Medi-Cal and the Exchange resulting from changing income, to name just a few.

Based on considerable evidence from previous expansion of public programs, including experience with individual mandates and penalties for remaining uninsured in Massachusetts, ACA will not result in 100% enrollment rates among those who are eligible for Medi-Cal or Exchange subsidies. Furthermore, we estimate that as of 2009, 1.2 million California residents will not be eligible under ACA due to their citizenship status. As a result, despite the significant reductions in the number of uninsured that are anticipated in 2014, those who remain uninsured are likely to strain the capacity of safety net providers in certain areas of the state. Our findings suggest that ACA could have a devastating effect on counties such as Los Angeles, where 20.7% of the currently uninsured, or nearly 450,000 individuals, will not be eligible for insurance under ACA. The net effect of ACA of reducing subsidies to hospitals for uncompensated care, reducing the number of uninsured, and increasing subsidies for community health centers could leave counties such as Los Angeles more vulnerable than they are now in meeting the demand for indigent care. This geographic disparity in the distribution of uninsured Californians may temper some of the considerable overall benefits anticipated under ACA.

The State of Health Insurance in California (114 pages): http://www.healthpolicy.ucla.edu/pubs/files/shic2009report.pdf

Comment: 

By Don McCanne, MD

This highly informative UCLA policy report on the status of health insurance in California confirms that coverage and access have grown more dire, made even worse by the recession. Although the report explains how some of the benefits of the Affordable Care Act will provide limited improvements, it is also clear that we will fall far short of meeting all of our health care needs.

Although the report is silent on the wisdom of the financing infrastructure of the Affordable Care Act, we already know that the model is irreparably defective. The multitude of corrective patches that might be proposed would still leave us with unaffordable underinsurance as the new standard in America, along with a chronically underfunded public program for the poor. We need to replace the ACA model with a program that works – a single payer national health program.

California’s health insurance lessons for the U.S.

The State of Health Insurance in California: Findings from the 2009 California Health Interview Survey

By Shana Alex Lavarreda, PhD, MPP, Livier Cabezas, MPAff, Ken Jacobs, Dylan H. Roby, PhD, Nadereh Pourat, PhD, Gerald F. Kominski, PhD
UCLA Center for Health Policy Research, February 2012

Excerpts (These paragraphs are not contiguous in the report.)

Medi-Cal, Healthy Families, and Medicare provided insurance coverage to 9.3 million people in California for all or part of 2009. Despite the presence of these state and federally run public programs, there are still many low-income, uninsured Californians who do not qualify for coverage. Additionally, there are children and their parents, people with disabilities or medical needs, and elderly Californians who are eligible for public insurance programs but who are not enrolled.

Only three-fourths of uninsured Latinos will be able to gain coverage under ACA. A slightly higher percentage (43.1%) will be eligible for the Medi-Cal expansion, but far fewer will participate in the Exchange, either with subsidies (21%) or without (9.2%). The rest will be ineligible to participate in the coverage expansions due to their citizenship status (26.8%).

The exclusions embedded in ACA will likely increase the health insurance disparities between U.S. citizens and non-citizens over time. If these issues remain unaddressed, California runs the risk of increasing racial/ethnic inequities in health care access and outcomes.

Medicare beneficiaries without Medi-Cal or a supplemental source of coverage were more likely to report delays in obtaining medical care or necessary prescription drugs.

Not all types of health insurance are equal in their impact on access. Significant variations in premiums, cost sharing, and benefits exist between employment-based and individually purchased insurance, further complicated by the high-deductible plans that exist in both markets. Medi-Cal and Healthy Families coverage have very low or no premiums and cost sharing, but funding shortfalls often threaten eligibility, benefits, and provider participation in these programs.

The uninsured were also more likely than the insured to forgo or delay needed medical care due to costs or lack of insurance; 5.7% of those with employment-based insurance reported such barriers, compared to 19.5% of the uninsured.

The existing racial and ethnic disparities in health insurance coverage and resulting access to the health care system will be exacerbated as health care reform is implemented, with the very serious possibility that more than one million California residents (including non-citizen children) will be left to rely on safety net providers who may not receive enough money to care for the residual uninsured.

According to the 2009 California Health Interview Survey, approximately 92.7% of all children who were eligible for Medi-Cal actually signed up in 2009, and a lower percentage of adults ages 19 to 64 who were eligible actually enrolled (85.0%). That represents more than 215,000 children who could have had health insurance through a low-cost, public program but who did not enroll. In addition, another 331,000 adults were estimated to be eligible for Medi-Cal but remained uninsured. Although Healthy Families does not enroll adults, a smaller number of uninsured children are eligible for the program. Approximately 189,000 of uninsured children are estimated to be eligible for Healthy Families but are not enrolled – 22.2% of the eligible population.

Variations in health care use, as well as reports of forgoing needed care or delaying it due to costs and presence of medical debt by type of insurance, are likely due to differences in deductible levels and cost sharing and benefits. These variations indicate that health insurance does not fully address the financial barriers to access. Among the publicly insured, the presence of access barriers and financial debt illustrate the challenges the Medi-Cal and Healthy Families programs have to overcome despite the perennial funding shortfalls that threaten eligibility, benefits, and provider participation in these programs.

The continuing increase in premiums is likely to increase the number of high-deductible plans not accompanied by savings accounts, increase cost sharing and lead to more medical debt, increase the ranks of those who forgo or delay needed medical care, and potentially reduce timely doctor visits and increase emergency room visits.

In October 2010, California became the first state in the nation to pass legislation establishing the California Health Benefit Exchange, a fundamental component of the infrastructure of ACA. The Board faces numerous challenges over the next two years, including how to coordinate eligibility determination and enrollment processes with state and county agencies, whether to standardize co-payments and deductibles within each of the four tiers of health plans to be offered in the Exchange as a means of facilitating comparison shopping by consumers, and providing seamless transitions for individuals between Medi-Cal and the Exchange resulting from changing income, to name just a few.

Based on considerable evidence from previous expansion of public programs, including experience with individual mandates and penalties for remaining uninsured in Massachusetts, ACA will not result in 100% enrollment rates among those who are eligible for Medi-Cal or Exchange subsidies. Furthermore, we estimate that as of 2009, 1.2 million California residents will not be eligible under ACA due to their citizenship status. As a result, despite the significant reductions in the number of uninsured that are anticipated in 2014, those who remain uninsured are likely to strain the capacity of safety net providers in certain areas of the state. Our findings suggest that ACA could have a devastating effect on counties such as Los Angeles, where 20.7% of the currently uninsured, or nearly 450,000 individuals, will not be eligible for insurance under ACA. The net effect of ACA of reducing subsidies to hospitals for uncompensated care, reducing the number of uninsured, and increasing subsidies for community health centers could leave counties such as Los Angeles more vulnerable than they are now in meeting the demand for indigent care. This geographic disparity in the distribution of uninsured Californians may temper some of the considerable overall benefits anticipated under ACA.

The State of Health Insurance in California (114 pages): http://www.healthpolicy.ucla.edu/pubs/files/shic2009report.pdf

Comment: 

By Don McCanne, MD

This highly informative UCLA policy report on the status of health insurance in California confirms that coverage and access have grown more dire, made even worse by the recession. Although the report explains how some of the benefits of the Affordable Care Act will provide limited improvements, it is also clear that we will fall far short of meeting all of our health care needs.

Although the report is silent on the wisdom of the financing infrastructure of the Affordable Care Act, we already know that the model is irreparably defective. The multitude of corrective patches that might be proposed would still leave us with unaffordable underinsurance as the new standard in America, along with a chronically underfunded public program for the poor. We need to replace the ACA model with a program that works – a single payer national health program.