PNHP

Connecticut drops insurers from Medicaid

Connecticut drops insurers from Medicaid

By Phil Galewitz, Kaiser Health News
USA Today, Dec. 29, 2011

HARTFORD, Conn. – In the past decade, most states have turned Medicaid over to private insurance plans, hoping they could control costs and improve care. Nearly half of the 60 million people in the government program for the poor are in managed-care plans run by insurance giants such as UnitedHealthcare and Aetna.

Connecticut, the “insurance capital of the world,” is bucking the trend.

Beginning Sunday, Connecticut will jettison its private health plans from Medicaid, the state-federal health insurance program. Instead of paying the companies a set monthly fee to cover the health costs of more than 400,000 children and parents, the state will assume financial responsibility.

State officials say the companies, including Hartford-based Aetna, did not fulfill their promise of lower costs and better care.

“Connecticut has a 15-year history with managed-care organizations, and there has been a diminishing confidence in the value of what they are providing,” says Mark Schaefer, the state’s Medicaid director.

Nationally, managed-care plans oversee care for 27 million people enrolled in Medicaid and control $150 billion of the $400 billion in Medicaid spending — numbers likely to increase partly because of the influx of an additional 16 million people expected to be covered by the program beginning in 2014 under the national health care law.

Connecticut’s decision stands out at a time when a growing number of states are requiring more people in Medicaid to join managed-care plans. Florida, Texas and California are among nearly two dozen states planning expansions in 2012.

Whether Connecticut’s move turns out to be a blip in the industry’s growing control of Medicaid or the beginning of a backlash, officials in other states are watching closely. In any case, the reversal of the trend in the insurance industry’s home base has given managed care critics a rare, if mostly symbolic, victory.

“There is a cadre of people who hate for-profit health care, and this is another point of ammunition for them to point to and say that if they came to this determination in the insurance capital of the world, how can it be such great shakes?” says Joel Menges, a health care consultant who has worked with the state.

Connecticut has more of its residents employed in the insurance industry than any other — 2.1%, or more than 71,000 people, according to the U.S. Census.

Now, the state is betting that its employees, working with a private, non-profit company, can ensure that Medicaid patients get better care at lower cost.

Connecticut is only the second state in a decade to drop its for-profit managed-care plan. Oklahoma moved away from private plans in 2005, and officials there say they have no regrets. “While achieving very encouraging marks in both member satisfaction and quality, the cost per member has grown at a very low average annual rate of 1.2% over the last five years,” says Mike Fogarty, Oklahoma’s Medicaid director.

The Connecticut Medicaid managed-care business was worth more than $800 million this year to Aetna, UnitedHealthcare of Minnetonka, Minn., and Community Health Network of Connecticut Inc., a non-profit.

Aetna officials defended their record, saying they held down costs while ensuring patients’ access to care. “We continue to see strong interest in managed Medicaid from states that are looking to meet the health needs of this vulnerable population without crippling their state budgets,” spokesman Matthew Wiggin says.

“We do not see this as a trend,” says Tyler Mason, a spokesman for UnitedHealthcare, which covers more than 3 million Medicaid recipients in 19 states.

Critics of managed care hope Connecticut’s reversal will spur other states to look at alternatives. New Haven Legal Assistance Association, an advocacy group for the poor, had complained for years that managed care erected barriers to care and diverted too many resources to administration and profits. It pointed to a 2009 state-commissioned report showing Connecticut was overpaying insurers by nearly $50 million a year — about 6% of total expenses.

Other state reports found the plans were spending too little on health services and published networks of doctors that were misleading because many doctors refused to accept Medicaid patients when “secret shoppers” called for appointments.

Many doctors are happy to see the state’s experiment with managed- care plans end. Many had been frustrated with having to follow different rules for different plans. They also complained about payment delays and problems referring patients to some specialists.

Elsa Stone, a North Haven pediatrician who had refused to contract with the state’s two for-profit Medicaid plans owned by UnitedHealthcare and Aetna, cheered the decision.

“I don’t think there should be a profit motive in health care,” she says. “I think all the health care dollars should go to care.”

Heather Greene, 36, of Waterbury, Conn., has been on Medicaid for seven years, along with her husband and two children. She says her Aetna plan did not make it easy for her to find a urologist or for her daughter to find an ear, nose and throat specialist. She is cautiously optimistic: “I trust the state a little more than the plans, which are looking to make a profit and cut corners wherever they can.”

http://www.usatoday.com/news/nation/story/2011-12-28/connecticut-health-care-medicare-insurance/52257962/1

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

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.

Uwe Reinhardt describes single payer, and we respond

Health Care Payers Push Back Against Costs

By Uwe E. Reinhardt
The New York Times, February 3, 2012

In a paper, “Divide et Impera: Protecting the Growth of Health Care Incomes (Costs),” published this month in the British journal Health Economics, I summarize themes touched on here and there in several earlier posts on this blog.

My argument in the paper is that what is often called overuse of health care by what are often described as excessively insured Americans — especially their use of high-cost, high-tech procedures — is at best a partial explanation for the high cost of American health care.

Yet cost-containment initiatives like high deductibles and co-insurance have taken use of health care as their chief target. These efforts will be only partly successful in controlling national health spending.

Equally important contributors to our high health spending, and probably more so, have been two other factors.

The first is the much higher administrative overhead costs loaded onto the American health system. David Cutler and Dan Ly, both of Harvard University, illuminate this proposition in their recent paper, “The (Paper) Work of Medicine: Understanding International Medical Costs,” in which they compare health spending in Canada and the United States.

Earlier, in a 2003 paper, “Costs of Health Care Administration in the United States and Canada,” Dr. Steffie Woolhandler, Terry Campbell and Dr. David Himmelstein estimated that in 1999 total administrative costs of health insurers and all other parties in health care, save patients, accounted for 31 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada.

A second major factor accounting for high health spending per capita in the United States is the significantly higher prices Americans pay for virtually all health care services and products.

My thesis on this issue — expressed in the title of my paper — is that these much higher prices are the product of a deliberate strategy, hashed out in our political bazaars between the supply side of health care and state and federal legislators, always to keep the payment side of our health system fragmented and relatively weak vis à vis the supply side of health care.

http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/

Comments (published on the NYT blog):

Don McCanne
San Juan Capistrano, CA

In his paper, “Divide et Impera,” Professor Reinhardt discusses three approaches to controlling health spending: single payer, all-payer, and rationing by prices.

The last, of course, is what we now have and is rejected by most of us who wish to see a more humane method of financing care. It is still supported by those who believe the health care consumer should use their own funds to shop for care, even though these supporters are reluctant to call it what is is – rationing by ability to pay.

In his article, single payer is dismissed based on lack of political feasibility, a view widely held in the United States.

In contrast, Dr, Reinhardt discusses an all-payer system in which prices are standardized and budgeted by associations – a great improvement over our current system (which Dr. Reinhardt discussed in a previous blog). However, he states, “Admittedly, a transition from the current to an all-payer system for all providers of health care in all states would be challenging, both analytically and politically.”

Politically challenging. Isn’t that like questioning political feasibility?

Is the political hurdle for an equitable and efficient single payer system really that much greater than the hurdle for a less efficient, less equitable and more fragmented all-payer system?

If we’re going to have to break down political barriers, why don’t we go for the best?

http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/?comments#permid=1

Nathan Punwani
Cambridge, MA

If we’re really interested in cost control, do we really need a public option? What about an all-payer system? What are the advantages and disadvantages of an all-payer system relative to a single-payer system (besides private insurers don’t like single payer)?

Nathan Punwani
MPH Candidate – Harvard School of Public Health

http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/?comments#permid=24

Uwe Reinhardt
Princeton, NJ

The advantages of a single-payer system are:

1. They are simple and easily understood by all concerned.

2. They foster egalitarian health care delivery, because they usually are financed on the ability-to-pay principle. and providers are paid the same fee regardless of the socio-economic status of the patient.

3. They are ideal platforms for the smart application of electronic health information systems.

4. They have relatively low administrative overhead costs.

5. They give the insurer (the single-payer) a financial incentive to invest in preventive care and behavioral health care, because patients have automatic life cycle insurance under these systems so that the insurer reaps the savings in acute care treatment costs over the longer run.

6. Cost control is easy with these systems.

The disadvantages are:

1. Prospective insured do not have a choice among different insurers and different benefit packages.

2. Government, which usually operates these systems, may underfund them relative to what the people actually want and would be willing to pay for, although one should think that in a properly functioning democracy that could not go on for very long.

3. Mistakes at the center in coverage or payment matters quickly diffuse to all corners of the system.

4. Some people, notably Americans, just oppose all forms of centralized power, however efficient it may be.

http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/?comments#permid=24:15

Don McCanne
San Juan Capistrano, CA

Some of the other effective tools of the single payer model, as supported by Physicians for a National Health Program, include the following:

* Administratively efficient global budgeting of hospitals, as with police and fire departments

* Negotiation of fair rates with physicians

* Bulk purchasing of pharmaceuticals, like the VA

* Reducing diversion of patient care funds by eliminating for-profit corporations and their passive investors

* Planning and separate budgeting of capital improvements to prevent wasteful excess capacity, while ensuring adequate capacity in under-served areas

* Replacing choice of restrictive, wasteful, expensive private insurers with the choice we want – choice of our health care professionals and institutions

The greatest problem with single payer systems is that conservative governments strive to privatize and underfund the programs, such as the current efforts in England and Canada, and also here with the conservative attack on our Medicare program. Such anti-egalitarian approaches tend to shift burdensome costs to patients who are already suffering from ill health.
The efficient and equitable policies of the single payer model which would provide us with much greater value in our health care purchasing are precisely what we need. It’s the politics that we need to change, something that we should be able to do with a “properly functioning democracy.”

http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/?comments#permid=24:17

New Coalition to Advocate for Universal Health Care in Oregon

'Oregon's current health care system is neither humane nor cost-effective'

Salem-News.com (Ore.), Feb. 4, 2012

PORTLAND, Ore. — Delegates from 28 unions, nonprofits and grassroots organizations gathered in Portland on Friday, January 27, to form a new coalition that will advocate for universal health care in Oregon and the U.S. Seven labor unions joined with 21 community organizations to sign the membership agreement, approve bylaws, and elect an interim executive committee.

The coalition grew out of a partnership between four organizations – Health Care for All–Oregon, Portland Jobs With Justice, Mad As Hell Doctors (MAHD) and Physicians for a National Health Program (PNHP). Two years ago these organizations formed the Oregon Single Payer Campaign (OSPC), which last year organized a conference at the First Unitarian Church in Portland attended by 500 people. OSPC also spearheaded the introduction of HB 3510 last year in the Oregon legislature by Rep. Michael Dembrow (D-HD 45). HB 3510 would create a single-payer financing system that guaranteed universal access to health care for all Oregonians, including the more than 600,000 Oregonians who do not have health insurance. Rep. Dembrow was in attendance at the founding meeting of the coalition.

The goal of OSPC was to get the issue of universal access health care on the table, since its advocates had been shut out of the federal health care reform debate,” said Michael Moore, delegate from Sisters of the Road and newly elected interim president of the coalition. “The goal of the new coalition is to engage all communities across Oregon in a conversation about what we can and should expect from our health care system. We think providing universal access, as almost all other industrialized nations do, is the only truly humane and cost-effective system available. We need a broad and diverse coalition of organizations to help us understand how to take that message to all the constituencies we need to reach.

Oregon’s current health care system is neither humane nor cost-effective. The only health care resources available to many uninsured adults are hospital emergency rooms and pay-for-service options at some clinics. Even in communities such as Scappoose, only 21 miles from Portland, the Oregon Health Sciences University clinic does not accept uninsured patients. In Oregon, it is estimated that the cost of uncompensated care for uninsured and under-insured adults and children will exceed $1.1 billion in 2012.

Rosalie Pedroza, delegate from the Rural Organizing Project, said, “In rural communities, many areas don¹t have insurance options, and facilities are limited. Current cost increases are unsustainable; we need affordable health care for all.”

The unions signing on to the coalition’s founding are: American Federation of Government Employees Local 2157, Communication Workers of America Local 7901, Laborers Local 483, National Association of Letter Carriers Branch 82, National Association of Social Workers ­ Oregon, Oregon Nurses’ Association and Service Employees International Union Local 49. The nonprofits joining them are: Alliance for Democracy, Center for Inter-cultural Organizing, Community Alliance of Tenants, Elders in Action, Fellowship of Reconciliation, Health Care for All Oregon, Health Care for All Oregon–Eugene, Jobs with Justice-Central Oregon, Jobs with Justice–Portland, Jobs with Justice–Southern Oregon, Mad as Hell Doctors, Mid-Valley Health Care Advocates, Oregon Action, Oregon Latino Health Coalition, OSPC-Florence Organizing Committee, Physicians for a National Health Program–Eugene, Mid Valley and Portland, Rural Organizing Project, Sisters of the Road. The Tree Institute, and Universal Health Care for Oregon. Six affiliated or pledged organizations were unable to attend, and ten organizations sent delegates as observers.

The coalition does not plan to introduce legislation this year. In the near term, it will focus on grassroots community organizing and outreach. It plans to meet again in six to eight weeks to elect a full board of directors, develop a strategic plan and finalize the selection of a name.

http://www.salem-news.com/articles/february042012/healthcare-oregon.php

The battle for Vermont's health

Insurance firms seeking to sow doubt about proposed single-payer system

By Wendell Potter
iWatch News, Feb. 6, 2012

MONTPELIER, Vt. — You can’t see them. They’re hidden from view and probably always will be. But the health insurance industry’s big guns are in place and pointed directly at the citizens of Vermont.

Health insurers were not able to stop the state’s drive last year toward a single-payer health care system, which insurers have spent millions to scare Americans into believing would be the worst thing ever. Despite the ceaseless spin, Vermont lawmakers last May demonstrated they could not be bought nor intimidated when they became the first in the nation to pass a bill that will probably establish a single-payer beachhead in the U.S.

When he signed Act 48 into law on May 27, surrounded by dozens of state residents who worked for many years to achieve universal coverage, Governor Peter Shumlin expressed great pride in what had been accomplished.

“We gather here today to launch the first single payer system in America, to do in Vermont what has taken too long—to have a health care (system) that is the best in the world, that treats health care as a right and not a privilege, where health care follows the individual, not the employer,” Shumlin said.

The problem for Shumlin and his allies is this: it will take five years before Vermont can fully implement its new system, partly because the federal health care reform law prohibits states from undertaking more far-reaching reforms until 2017 unless granted waivers from the feds to do so. And though Vermont’s Congressional delegation is on board to pursue a waiver that would let the state set up a single payer system two years from now, the insurance industry’s friends in Washington are not keen to let that happen. That’s because they want to use those five years to persuade Vermonters that they really don’t want to go the single payer route after all.

During my 20 years as a health insurance PR executive, I was involved in numerous efforts to make the very term “single payer” toxic to most Americans. We even spent hundreds of thousands of premium dollars in 2007 to help finance the operation of a front group, called Health Care America, for the sole purpose of trashing a movie — Michael Moore’s “Sicko” — that put single payer systems abroad in a favorable light. You can rest assured that the industry will spend much, much more to make sure that Vermont does not succeed.

I have observed in Vermont over the past several days just how the invisible hand of the insurance industry is working. Insurers know their efforts will be more effective if they can get others — third party advocates, they call them — to carry out them out. I recognized the campaign because the tactics are the same as those used in previous attempts to kill reforms insurers don’t like.

Part of the strategy is to get key groups of individuals to begin raising doubts, to get Vermonters to second-guess themselves. Among the first groups the insurers have targeted are those most easily spooked — certain business owners and physicians, especially specialists who thrive in the current system.

Last Wednesday, legislators got a sampling of what they’re in for. At a hearing on creation of the state’s health care exchange, or marketplace — mandated by the federal reform law — employers worried about losing the ability to choose from numerous competing insurers. And they worried too about not being able to shift their employees into benefit plans with high deductibles. Insurers and employers have been collaborating for the past several years in a mutually beneficial effort to shift more of us into high-deductible policies. The higher the deductible, the less insurers and employers have to pay for our care. This collaboration has been so successful that increasing numbers of American families filing for bankruptcy are, at least theoretically, insured.

At a hearing a few days earlier in Rutland, this one for health care providers, several physicians were, wittingly or not, using some of the same industry talking points I used to write for insurers’ allies.

Dermatologist Dan McCauliffe was one of several doctors there who suggested that patients needed to pay more — not less — out of their own pocket for care. Ironically, this skin doctor joined other physician specialists in arguing that health care costs would never stabilize until patients had “more skin in the game,” a term my former colleagues used frequently as we tried to spin the “advantages” of high-deductible plans. According to statistics from the American Medical Association, dermatologists are among the highest paid specialists, making on average more than $230,000. 

So why do insurers care so much about Vermont? Even though Vermont is a small state where most for-profit insurers have little business, the insurers don’t want a single state to go single payer. Just last week, single payer advocates in California fell just a few votes short of getting a bill to the floor of the Senate for a vote. If Vermont succeeds, California lawmakers might actually get the votes they need. 

Health insurers make enormous amounts of money off of us, something they cannot do so effectively in other countries, especially Canada. The four largest insurers, United, WellPoint, Aetna and CIGNA, reported earning a combined $11 billion on nearly $220 billion in revenues last year. For years insurers have been successful in persuading Americans to believe something that is at best debatable — that they play a useful role in the U.S. health care system. They are nervous that if Vermont proves to the rest of the country that health insurers are about as useful as teats on a boar, they might have to figure out another way to make a few billion bucks.

Former CIGNA executive-turned-whistleblower Wendell Potter writes about the health care industry and the ongoing battle for health reform. Potter is the author of “Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans.”

http://www.iwatchnews.org/2012/02/06/8094/analysis-battle-vermonts-health

The battle for Vermont’s health

Insurance firms seeking to sow doubt about proposed single-payer system

By Wendell Potter
iWatch News, Feb. 6, 2012

MONTPELIER, Vt. — You can’t see them. They’re hidden from view and probably always will be. But the health insurance industry’s big guns are in place and pointed directly at the citizens of Vermont.

Health insurers were not able to stop the state’s drive last year toward a single-payer health care system, which insurers have spent millions to scare Americans into believing would be the worst thing ever. Despite the ceaseless spin, Vermont lawmakers last May demonstrated they could not be bought nor intimidated when they became the first in the nation to pass a bill that will probably establish a single-payer beachhead in the U.S.

When he signed Act 48 into law on May 27, surrounded by dozens of state residents who worked for many years to achieve universal coverage, Governor Peter Shumlin expressed great pride in what had been accomplished.

“We gather here today to launch the first single payer system in America, to do in Vermont what has taken too long—to have a health care (system) that is the best in the world, that treats health care as a right and not a privilege, where health care follows the individual, not the employer,” Shumlin said.

The problem for Shumlin and his allies is this: it will take five years before Vermont can fully implement its new system, partly because the federal health care reform law prohibits states from undertaking more far-reaching reforms until 2017 unless granted waivers from the feds to do so. And though Vermont’s Congressional delegation is on board to pursue a waiver that would let the state set up a single payer system two years from now, the insurance industry’s friends in Washington are not keen to let that happen. That’s because they want to use those five years to persuade Vermonters that they really don’t want to go the single payer route after all.

During my 20 years as a health insurance PR executive, I was involved in numerous efforts to make the very term “single payer” toxic to most Americans. We even spent hundreds of thousands of premium dollars in 2007 to help finance the operation of a front group, called Health Care America, for the sole purpose of trashing a movie — Michael Moore’s “Sicko” — that put single payer systems abroad in a favorable light. You can rest assured that the industry will spend much, much more to make sure that Vermont does not succeed.

I have observed in Vermont over the past several days just how the invisible hand of the insurance industry is working. Insurers know their efforts will be more effective if they can get others — third party advocates, they call them — to carry out them out. I recognized the campaign because the tactics are the same as those used in previous attempts to kill reforms insurers don’t like.

Part of the strategy is to get key groups of individuals to begin raising doubts, to get Vermonters to second-guess themselves. Among the first groups the insurers have targeted are those most easily spooked — certain business owners and physicians, especially specialists who thrive in the current system.

Last Wednesday, legislators got a sampling of what they’re in for. At a hearing on creation of the state’s health care exchange, or marketplace — mandated by the federal reform law — employers worried about losing the ability to choose from numerous competing insurers. And they worried too about not being able to shift their employees into benefit plans with high deductibles. Insurers and employers have been collaborating for the past several years in a mutually beneficial effort to shift more of us into high-deductible policies. The higher the deductible, the less insurers and employers have to pay for our care. This collaboration has been so successful that increasing numbers of American families filing for bankruptcy are, at least theoretically, insured.

At a hearing a few days earlier in Rutland, this one for health care providers, several physicians were, wittingly or not, using some of the same industry talking points I used to write for insurers’ allies.

Dermatologist Dan McCauliffe was one of several doctors there who suggested that patients needed to pay more — not less — out of their own pocket for care. Ironically, this skin doctor joined other physician specialists in arguing that health care costs would never stabilize until patients had “more skin in the game,” a term my former colleagues used frequently as we tried to spin the “advantages” of high-deductible plans. According to statistics from the American Medical Association, dermatologists are among the highest paid specialists, making on average more than $230,000. 

So why do insurers care so much about Vermont? Even though Vermont is a small state where most for-profit insurers have little business, the insurers don’t want a single state to go single payer. Just last week, single payer advocates in California fell just a few votes short of getting a bill to the floor of the Senate for a vote. If Vermont succeeds, California lawmakers might actually get the votes they need. 

Health insurers make enormous amounts of money off of us, something they cannot do so effectively in other countries, especially Canada. The four largest insurers, United, WellPoint, Aetna and CIGNA, reported earning a combined $11 billion on nearly $220 billion in revenues last year. For years insurers have been successful in persuading Americans to believe something that is at best debatable — that they play a useful role in the U.S. health care system. They are nervous that if Vermont proves to the rest of the country that health insurers are about as useful as teats on a boar, they might have to figure out another way to make a few billion bucks.

Former CIGNA executive-turned-whistleblower Wendell Potter writes about the health care industry and the ongoing battle for health reform. Potter is the author of “Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans.”

http://www.iwatchnews.org/2012/02/06/8094/analysis-battle-vermonts-health

Uwe Reinhardt describes single payer, and we respond

Health Care Payers Push Back Against Costs

By Uwe E. Reinhardt
The New York Times, February 3, 2012
In a paper, “Divide et Impera: Protecting the Growth of Health Care Incomes (Costs),” published this month in the British journal Health Economics, I summarize themes touched on here and there in several earlier posts on this blog.
My argument in the paper is that what is often called overuse of health care by what are often described as excessively insured Americans — especially their use of high-cost, high-tech procedures — is at best a partial explanation for the high cost of American health care.
Yet cost-containment initiatives like high deductibles and co-insurance have taken use of health care as their chief target. These efforts will be only partly successful in controlling national health spending.
Equally important contributors to our high health spending, and probably more so, have been two other factors.
The first is the much higher administrative overhead costs loaded onto the American health system. David Cutler and Dan Ly, both of Harvard University, illuminate this proposition in their recent paper, “The (Paper) Work of Medicine: Understanding International Medical Costs,” in which they compare health spending in Canada and the United States.
Earlier, in a 2003 paper, “Costs of Health Care Administration in the United States and Canada,” Dr. Steffie Woolhandler, Terry Campbell and Dr. David Himmelstein estimated that in 1999 total administrative costs of health insurers and all other parties in health care, save patients, accounted for 31 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada.
A second major factor accounting for high health spending per capita in the United States is the significantly higher prices Americans pay for virtually all health care services and products.
My thesis on this issue — expressed in the title of my paper — is that these much higher prices are the product of a deliberate strategy, hashed out in our political bazaars between the supply side of health care and state and federal legislators, always to keep the payment side of our health system fragmented and relatively weak vis à vis the supply side of health care.
http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/

All comments originally published on the NYT blog
Don McCanne
San Juan Capistrano, CA
In his paper, “Divide et Impera,” Professor Reinhardt discusses three approaches to controlling health spending: single payer, all-payer, and rationing by prices.
The last, of course, is what we now have and is rejected by most of us who wish to see a more humane method of financing care. It is still supported by those who believe the health care consumer should use their own funds to shop for care, even though these supporters are reluctant to call it what is is – rationing by ability to pay.
In his article, single payer is dismissed based on lack of political feasibility, a view widely held in the United States.
In contrast, Dr, Reinhardt discusses an all-payer system in which prices are standardized and budgeted by associations – a great improvement over our current system (which Dr. Reinhardt discussed in a previous blog). However, he states, “Admittedly, a transition from the current to an all-payer system for all providers of health care in all states would be challenging, both analytically and politically.”
Politically challenging. Isn’t that like questioning political feasibility?
Is the political hurdle for an equitable and efficient single payer system really that much greater than the hurdle for a less efficient, less equitable and more fragmented all-payer system?
If we’re going to have to break down political barriers, why don’t we go for the best?
http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/?comments#permid=1

Nathan Punwani
Cambridge, MA
If we’re really interested in cost control, do we really need a public option? What about an all-payer system? What are the advantages and disadvantages of an all-payer system relative to a single-payer system (besides private insurers don’t like single payer)?
Nathan Punwani
MPH Candidate – Harvard School of Public Health
http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/?comments#permid=24

And…

Uwe Reinhardt
Princeton, NJ
The advantages of a single-payer system are:
1. They are simple and easily understood by all concerned.
2. They foster egalitarian health care delivery, because they usually are financed on the ability-to-pay principle. and providers are paid the same fee regardless of the socio-economic status of the patient.
3. They are ideal platforms for the smart application of electronic health information systems.
4. They have relatively low administrative overhead costs.
5. They give the insurer (the single-payer) a financial incentive to invest in preventive care and behavioral health care, because patients have automatic life cycle insurance under these systems so that the insurer reaps the savings in acute care treatment costs over the longer run.
6. Cost control is easy with these systems.
The disadvantages are:
1. Prospective insured do not have a choice among different insurers and different benefit packages.
2. Government, which usually operates these systems, may underfund them relative to what the people actually want and would be willing to pay for, although one should think that in a properly functioning democracy that could not go on for very long.
3. Mistakes at the center in coverage or payment matters quickly diffuse to all corners of the system.
4. Some people, notably Americans, just oppose all forms of centralized power, however efficient it may be.
http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/?comments#permid=24:15

Don McCanne
San Juan Capistrano, CA
Some of the other effective tools of the single payer model, as supported by Physicians for a National Health Program, include the following:
* Administratively efficient global budgeting of hospitals, as with police and fire departments
* Negotiation of fair rates with physicians
* Bulk purchasing of pharmaceuticals, like the VA
* Reducing diversion of patient care funds by eliminating for-profit corporations and their passive investors
* Planning and separate budgeting of capital improvements to prevent wasteful excess capacity, while ensuring adequate capacity in under-served areas
* Replacing choice of restrictive, wasteful, expensive private insurers with the choice we want – choice of our health care professionals and institutions
The greatest problem with single payer systems is that conservative governments strive to privatize and underfund the programs, such as the current efforts in England and Canada, and also here with the conservative attack on our Medicare program. Such anti-egalitarian approaches tend to shift burdensome costs to patients who are already suffering from ill health.
The efficient and equitable policies of the single payer model which would provide us with much greater value in our health care purchasing are precisely what we need. It’s the politics that we need to change, something that we should be able to do with a “properly functioning democracy.”
http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/?comments#permid=24:17

A word about the Susan G. Komen Foundation

A Painful Betrayal

Editorial
The New York Times, February 2, 2012

With its roster of corporate sponsors and the pink ribbons that lend a halo to almost any kind of product you can think of, the Susan G. Komen for the Cure foundation has a longstanding reputation as a staunch protector of women’s health. That reputation suffered a grievous, perhaps mortal, wound this week from the news that Komen, the world’s largest breast cancer organization, decided to betray that mission. It threw itself into the middle of one of America’s nastiest political battles, on the side of hard-right forces working to demonize Planned Parenthood and undermine women’s health and freedom.

The Associated Press reported on Tuesday that the foundation is cutting off its financing of breast cancer screening and education programs run by Planned Parenthood affiliates. That means nearly $700,000 less for Planned Parenthood, which performed 750,000 such screenings last year, many thousands of them with money from the Komen foundation.

http://www.nytimes.com/2012/02/03/opinion/a-painful-betrayal.html

And…

Consolidated Statements of Functional Expenses

The Susan G. Komen Breast Cancer Foundation, Inc.
Year Ended March 31, 2011

Public support and revenue – $471,750,158

Program services
Research – $75,301,537
Public health education – $181,092,283
Health Screening Services – $54,089,036
Treatment services – $23,251,563
Total program services – $333,734,419

http://ww5.komen.org/uploadedFiles/Content/AboutUs/Financial/2011%20Komen%20Financial%20Statements%20FINAL(3).pdf

Comment: 

By Don McCanne, MD

Nothing further needs to be said about how unwise it was for the Susan G. Komen Foundation to cut off funds for breast cancer services at Planned Parenthood facilities. Having made an error so grievous that some suggest could result in the demise of this public service organization dedicated to fighting breast cancer, we should ask if we can afford to lose their contributions to this effort.

We need to take a look at their program services.

The $75 million that they spend on research could easily be incorporated into the budget of the National Institutes of Health, the world’s largest medical research institute.

The $181 million spent on public education has reached all of us through their pink ribbon campaign. Although it certainly is important for the public to know about screening mammography, isn’t it likely that this will still be common knowledge, even without the pink ribbons?

The $54 million for screening and the $23 million for treatment actually are already being paid for by taxpayers. If you consider that the marginal tax rate for Komen donors likely averages about 30 percent, then tax subsidies for the $471 million in public support amount to about $141 million, far more than the $77 million being spent on screening and treatment. In fact, the balance of our tax subsidies would pay for most of the research that they fund.

A more fundamental question is why aren’t all women guaranteed appropriate screening and necessary treatment for breast cancer? They would be if we had a single payer national health program – an improved Medicare for all. If so, the loss of the Komen Foundation would not be all that tragic, though it is still painful to say that.

A word about the Susan G. Komen Foundation

A Painful Betrayal

Editorial
The New York Times, February 2, 2012
With its roster of corporate sponsors and the pink ribbons that lend a halo to almost any kind of product you can think of, the Susan G. Komen for the Cure foundation has a longstanding reputation as a staunch protector of women’s health. That reputation suffered a grievous, perhaps mortal, wound this week from the news that Komen, the world’s largest breast cancer organization, decided to betray that mission. It threw itself into the middle of one of America’s nastiest political battles, on the side of hard-right forces working to demonize Planned Parenthood and undermine women’s health and freedom.
The Associated Press reported on Tuesday that the foundation is cutting off its financing of breast cancer screening and education programs run by Planned Parenthood affiliates. That means nearly $700,000 less for Planned Parenthood, which performed 750,000 such screenings last year, many thousands of them with money from the Komen foundation.
http://www.nytimes.com/2012/02/03/opinion/a-painful-betrayal.html

And…

Consolidated Statements of Functional Expenses

The Susan G. Komen Breast Cancer Foundation, Inc.
Year Ended March 31, 2011
Public support and revenue – $471,750,158
Program services
Research – $75,301,537
Public health education – $181,092,283
Health Screening Services – $54,089,036
Treatment services – $23,251,563
Total program services – $333,734,419
http://ww5.komen.org/uploadedFiles/Content/AboutUs/Financial/2011%20Komen%20Financial%20Statements%20FINAL(3).pdf

Nothing further needs to be said about how unwise it was for the Susan G. Komen Foundation to cut off funds for breast cancer services at Planned Parenthood facilities. Having made an error so grievous that some suggest could result in the demise of this public service organization dedicated to fighting breast cancer, we should ask if we can afford to lose their contributions to this effort.
We need to take a look at their program services.
The $75 million that they spend on research could easily be incorporated into the budget of the National Institutes of Health, the world’s largest medical research institute.
The $181 million spent on public education has reached all of us through their pink ribbon campaign. Although it certainly is important for the public to know about screening mammography, isn’t it likely that this will still be common knowledge, even without the pink ribbons?
The $54 million for screening and the $23 million for treatment actually are already being paid for by taxpayers. If you consider that the marginal tax rate for Komen donors likely averages about 30 percent, then tax subsidies for the $471 million in public support amount to about $141 million, far more than the $77 million being spent on screening and treatment. In fact, the balance of our tax subsidies would pay for most of the research that they fund.
A more fundamental question is why aren’t all women guaranteed appropriate screening and necessary treatment for breast cancer? They would be if we had a single payer national health program – an improved Medicare for all. If so, the loss of the Komen Foundation would not be all that tragic, though it is still painful to say that.

More bad news about "essential health benefits"

HHS Essential Benefits 'Bulletin' Draws Tide Of Comments

Kaiser Health News
February 2, 2012

As the official window of time allowed for groups to react to the Department of Health and Human Services essential benefits proposal closed, a variety of objections, concerns and common themes became clear.

CQ HealthBeat: State ‘Flexibility’ For Essential Benefits Gets Cool Reception

A tide of objections and worries rolled in just before Tuesday’s deadline for health groups to react to a Department of Health and Human Services proposal on essential health benefits. Input from health interests and consumers on the benefits “bulletin” is not being made public by the Obama administration, which asked that comments be sent to an email address rather than posted on a government website as would be the practice with a proposed regulation (Norman, 2/1).

Politico Pro: EHB Comments Show Some Common Themes

Believe it or not, businesses, insurers and consumers do see eye to eye on essential health benefits — well, on some parts, anyway. They’re at odds on some of the bigger issues, which doesn’t exactly come as a surprise. The comments submitted to HHS on its essential health benefits approach shows a wide divide between consumers … and businesses and insurers, who don’t see enough safeguards to keep the essential health benefits package affordable (Millman, 2/2).

http://www.kaiserhealthnews.org/Daily-Reports/2012/February/02/essential-benefits.aspx

Comment:

By Don McCanne, MD

Yesterday we reported that some of the most politically powerful organizations in the nation have joined together in a coalition to try to weaken the package of “essential health benefits” that will be required of health plans under the Affordable Care Act.  Excerpts from two new articles covered in the Kaiser Daily Health Policy Report should have us even more concerned.

In Politico Pro, it is reported that businesses and insurers “don’t see enough safeguards to keep the essential health benefits package affordable.” The proposal already has reduced the required benefits down to the relatively austere level of small group plans offered in the various states. These plans leave patients facing financial hardship when they must access health care.

Yet the powerful businesses and insurers want an even lower standard of benefits in order to keep the health benefits package affordable. The insurers want to protect their markets by keeping the insurance premiums affordable, and businesses also want the lowest premiums they can negotiate. Low premiums equate with higher out-of-pocket expenses for those with medical needs. In trying to make the health insurance plans more affordable, actual health care for the patients will be even less affordable.

As we have seen, the process has always been about powerful interests, with only a passive concern for patients.

In CQ HealthBeat, we see that comments on the proposal are being “sent to an email address rather than posted on a government website as would be the practice with a proposed regulation,” and are “not being made public by the Obama administration.”

The White House gave these special interests carte blanche with secretive access during the reform process. Secrecy continues. Should we be surprised when the final rule on “essential health benefits” pleases business and insurance interests, at a cost of exposing those with health care needs to greater financial hardship? No, not surprised. Outraged is more like it!

More bad news about “essential health benefits”

HHS Essential Benefits ‘Bulletin’ Draws Tide Of Comments

Kaiser Health News
February 2, 2012

As the official window of time allowed for groups to react to the Department of Health and Human Services essential benefits proposal closed, a variety of objections, concerns and common themes became clear.

CQ HealthBeat: State ‘Flexibility’ For Essential Benefits Gets Cool Reception

A tide of objections and worries rolled in just before Tuesday’s deadline for health groups to react to a Department of Health and Human Services proposal on essential health benefits. Input from health interests and consumers on the benefits “bulletin” is not being made public by the Obama administration, which asked that comments be sent to an email address rather than posted on a government website as would be the practice with a proposed regulation (Norman, 2/1).

Politico Pro: EHB Comments Show Some Common Themes

Believe it or not, businesses, insurers and consumers do see eye to eye on essential health benefits — well, on some parts, anyway. They’re at odds on some of the bigger issues, which doesn’t exactly come as a surprise. The comments submitted to HHS on its essential health benefits approach shows a wide divide between consumers … and businesses and insurers, who don’t see enough safeguards to keep the essential health benefits package affordable (Millman, 2/2).

http://www.kaiserhealthnews.org/Daily-Reports/2012/February/02/essential-benefits.aspx

Comment:

By Don McCanne, MD

Yesterday we reported that some of the most politically powerful organizations in the nation have joined together in a coalition to try to weaken the package of “essential health benefits” that will be required of health plans under the Affordable Care Act.  Excerpts from two new articles covered in the Kaiser Daily Health Policy Report should have us even more concerned.

In Politico Pro, it is reported that businesses and insurers “don’t see enough safeguards to keep the essential health benefits package affordable.” The proposal already has reduced the required benefits down to the relatively austere level of small group plans offered in the various states. These plans leave patients facing financial hardship when they must access health care.

Yet the powerful businesses and insurers want an even lower standard of benefits in order to keep the health benefits package affordable. The insurers want to protect their markets by keeping the insurance premiums affordable, and businesses also want the lowest premiums they can negotiate. Low premiums equate with higher out-of-pocket expenses for those with medical needs. In trying to make the health insurance plans more affordable, actual health care for the patients will be even less affordable.

As we have seen, the process has always been about powerful interests, with only a passive concern for patients.

In CQ HealthBeat, we see that comments on the proposal are being “sent to an email address rather than posted on a government website as would be the practice with a proposed regulation,” and are “not being made public by the Obama administration.”

The White House gave these special interests carte blanche with secretive access during the reform process. Secrecy continues. Should we be surprised when the final rule on “essential health benefits” pleases business and insurance interests, at a cost of exposing those with health care needs to greater financial hardship? No, not surprised. Outraged is more like it!