PNHP

Health care is why Canadians can spend

Health care is why Canadians can spend

By Richard C. Dillihunt, M.D.
Letters, The Portland Press Herald, Sept. 21, 2011

The Press Herald’s Sept. 5 piece describing an increase in Canadian spending in Maine was good and timely economic news.

Attributing this to advertising and good bilingual skills deserves the credit received, but there is a more important factor here that needs to be emphasized because it is fundamental to our economy.

It is the matter of health care costs. Canada, with its universal health care and single-payer system, spends only about half what we do on health care. Canadians enjoy more money in their budgets for other things. Naturally, shopping and travel enter this picture.

This is another example of our need for health care reform. Unlike in Canada, our nation sits around in fear of getting sick and going bankrupt. The situation is now worse than ever as depicted by the recently released statistic by The Commonwealth Fund documenting that 44 percent of American adults were either uninsured or underinsured last year – an appalling increase.

The bottom line is that huge numbers of everyday Canadians are visiting here, having fun and spending statewide, to our delight. Meanwhile, for Americans, stifling health costs orchestrated by greedy special interests prevent our economy from turning around.

The fact that this situation is perpetuated by a Congress that seems more concerned about themselves than its people earns a 10 on the discouragement index.

All Americans are urged to address our own broken-down system and consider joining to develop one like that of Canada – where life might just be good again.

Richard C. Dillihunt, M.D., a retired general, vascular and transplant surgeon, lives in Portland, Maine.

http://www.pressherald.com/opinion/health-care-is-why-canadians-can-spend_2011-09-21.html

Corporate control of drug pricing and distribution

Walgreen battle over drug prices will limit consumer choice

By David Lazarus
Los Angeles Times, October 7, 2011

Beginning Jan. 1, Walgreens will no longer fill prescriptions for Anthem Blue Cross members, meaning that they’ll have to switch to another drugstore if they want their insurance to keep covering their meds.

In this case, though, it’s not the insurance giant calling the shots. Instead, it’s Anthem’s pharmacy benefit manager, a St. Louis company called Express Scripts Inc.

The dispute between Walgreens and Express Scripts highlights how consumers can find their healthcare choices limited by the money-minded business decisions of big corporations.

(Express Scripts) is spending about $29 billion to acquire rival Medco Health Solutions Inc. If the deal passes regulatory muster, it would give Express Scripts control over about a third of the market for pharmacy benefits. Nearly 4 billion prescriptions are dispensed in the U.S. annually.

Obviously steps should be taken to keep medical costs down. Both Express Scripts and Walgreen say that’s what they’re trying to do.

But it’s hard not to think all we’re really seeing here is two large, profit-hungry corporate behemoths fighting over as much of our healthcare dollars as they can get their hands on.

Inevitably, prices will go up for consumers and choices will be further limited.

http://www.latimes.com/business/la-fi-lazarus-20111007,0,2128189,full.column

Comment:

By Don McCanne, MD

Congress turned the Medicare prescription business over to private pharmacy benefit managers under the fiction that they would increase choices and reduce costs. What did we get? Reduced choices in drugs covered, reduced choices in pharmacies, and prices much higher than the government obtains for the Medicaid and the VA drug programs. It’s only going to get worse, unless we finally decide that we’re ready to take over the financing of health care in America by establishing our own public insurance program.

Gettysburg panel discusses pros and cons of Pa. single-payer health care

A proposed system would give coverage to all.

By JACQUELINE PALOCHKO
The Evening Sun (Hanover, Pa.), Oct. 6, 2011

A few years ago, Dr. Dwight Michael would have said he was not in favor of a universal health care system in Pennsylvania.

He believed, like many of colleagues, that a person has the right to choose their health care provider. But the Gettysburg physician said his views changed after he saw so many of his patients face the “unfairness” of the system – especially during the economic downturn when so many lost their jobs and had no health insurance.

“We’re lead to believe that we have a great system in this country,” Michael said. “But we don’t.”

Opponents and supporters of health care reform attended a public meeting Thursday night in Gettysburg to discuss a single-payer system that would give universal coverage to all in Pennsylvania. With nearly every seat taken in a lecture room at Lutheran Theological Seminary, the panel included Michael, Dave Steil, president of the group Health Care 4 All Pennsylvania and state Rep. Dan Moul, R-Conewago Township.

A bill introduced in the state’s House and Senate in July 2009, would establish a system that is publicly funded but privately administered – similar to how Medicare works. Under the proposed system, individuals would be taxed 3 percent of their income, and businesses would be taxed 10 percent of their payroll.

Steil’s group is working to support the single-payer health care bill – known as the Family and Business Health Security Act. While no state has yet passed a single-payer health care bill, 26 do have proposals like the one in Pennsylvania.

“We cannot have a system that leaves people behind,” Steil said while talking about today’s health care problems.

And the proposed health care system would not leave anyone behind, Steil said. Even those who have no income at all and cannot be taxed would still receive health care. Or say a Pennsylvania resident is attending college out of state, Steil added – that individual would still receive care in the college’s state.

Moul, on the other hand, said the proposed system would take away a person’s right to choose what health care services they want. Additionally, the lawmaker said, he won’t support anything until he knows if it would be successful. Moul suggested an unbiased group conduct a study to see how well such a system would work in Pennsylvania.

Moul stressed that he was not expert on health care, but said he believes that if a child is sneezing and the parents bring the youngster to a doctor, taxpayers shouldn’t have to pay for that appointment.

“People who truly need health care will get it,” he said.

“It’s too bad Moul still looks at it like that,” Alan Olson, of Carroll Valley, said of Moul’s view on the proposed system.

Olson, a supporter of the single-payer health care bill, said he attended Thursday’s meeting because he’s very concerned about health care.

But even though Moul was on opposite sides with Michael and Steil, all three panelists did agree on one aspect.

“Our health care system is broken,” Moul acknowledged.

http://www.eveningsun.com/ci_19059408

Corporate control of drug pricing and distribution

Walgreen battle over drug prices will limit consumer choice

By David Lazarus
Los Angeles Times, October 7, 2011

Beginning Jan. 1, Walgreens will no longer fill prescriptions for Anthem Blue Cross members, meaning that they’ll have to switch to another drugstore if they want their insurance to keep covering their meds.

In this case, though, it’s not the insurance giant calling the shots. Instead, it’s Anthem’s pharmacy benefit manager, a St. Louis company called Express Scripts Inc.

The dispute between Walgreens and Express Scripts highlights how consumers can find their healthcare choices limited by the money-minded business decisions of big corporations.

(Express Scripts) is spending about $29 billion to acquire rival Medco Health Solutions Inc. If the deal passes regulatory muster, it would give Express Scripts control over about a third of the market for pharmacy benefits. Nearly 4 billion prescriptions are dispensed in the U.S. annually.

Obviously steps should be taken to keep medical costs down. Both Express Scripts and Walgreen say that’s what they’re trying to do.

But it’s hard not to think all we’re really seeing here is two large, profit-hungry corporate behemoths fighting over as much of our healthcare dollars as they can get their hands on.

Inevitably, prices will go up for consumers and choices will be further limited.

http://www.latimes.com/business/la-fi-lazarus-20111007,0,2128189,full.column

Congress turned the Medicare prescription business over to private pharmacy benefit managers under the fiction that they would increase choices and reduce costs. What did we get? Reduced choices in drugs covered, reduced choices in pharmacies, and prices much higher than the government obtains for the Medicaid and the VA drug programs. It’s only going to get worse, unless we finally decide that we’re ready to take over the financing of health care in America by establishing our own public insurance program.

IOM's disturbing report on "essential health benefits"

Essential Health Benefits: Balancing Coverage and Cost

Institute of Medicine
October 6, 2011

Abstract

The principle intent of the Patient Protection and Affordable Care Act (ACA) is to enable previously uninsured Americans to obtain health insurance. To accomplish this, in part, subsidized plans will be offered to low- and moderate-income individuals and small employers through health insurance exchanges. Plans qualified to be offered through exchanges must at minimum include “essential health benefits” (EHB). The ACA is not very specific on the definition of EHB except that such benefits shall include at least ten enumerated general categories and that the scope of the EHB shall be equal to the scope of benefits provided under a typical employer plan. The ACA requires the Secretary of the Department of Health and Human Services to define the essential health benefits.

The Institute of Medicine (IOM) was asked by the Secretary to make recommendations on the methods for determining and updating the essential health benefits. Notably, the request was to focus on criteria and policy foundations for the determination of the EHB, not to develop the list of benefits. The IOM formed a committee of volunteers with varied perspectives and professional backgrounds; the committee held four face-to-face meetings and numerous conference calls. Broad public input was obtained. In two open workshops, the committee heard from more than 50 witnesses, and 345 comments were received in response to questions posted on the web. The consensus report then underwent rigorous external review in accordance with procedures established by the Report Review Committee of the National Research Council.

As the committee examined its charge, it saw two main questions for the Secretary: (1) how to determine the initial EHB package and (2) how to update the EHB package.

Defining the initial EHB package. In considering how to determine the initial EHB package, the committee was struck by two compelling facts: (1) if the purpose of ACA was to provide access to health insurance coverage, that coverage had to be affordable; and (2) the more expansive the benefit package was, the more it was likely to cost and the less affordable it would be. How to balance the competing goals of comprehensiveness of coverage and affordability was key.

The committee concluded that it was best to begin simply by defining the EHB package as reflecting the scope and design of packages offered by small employers today, modified to include the ten required categories. This package would then be assessed by criteria and a defined cost target recommended by the committee. The committee considered how four policy domains – economics, ethics, population-based health, and evidence-based practice – could guide the Secretary in determining the EHB package in general. From these policy foundations, the committee recommends: criteria to guide the aggregate EHB package; criteria to guide specific EHB inclusions and exclusions; and criteria to guide methods for defining and updating the EHB.

To ensure affordability and protect the intent of the ACA, the committee concluded that costs must be considered both in the determination of the initial EHB package and in its updating. Thus, the cost of the initial EHB package resulting from the previous steps should be compared to a premium target defined by the committee as what small employers would have paid, on average, in 2014. Committee members believe that absent a premium target, there would be no capacity to acknowledge the realities of limited resources and the ongoing need for affordability of the package. The EHB package should be modified as necessary to meet this estimated premium, including using a structured public deliberative process. In addition, the committee recommends that states operating their own exchanges be able to design a variant of the EHB package if certain standards are met.

Updating the EHB package. Both medical science and our understanding of how best to design insurance products will change over time. Thus, the committee recommends creating a framework and infrastructure for collecting data and analyzing implementation of the initial EHB; a National Benefits Advisory Council is recommended to give the Secretary advice on the research plan and on updates to the EHB package. The committee believes that the EHB package should become more fully evidence-based, specific, and value-based over time. In addition, as with the initial package, costs must be taken into account such that any service added to the package should be offset by savings, through either medical management or the elimination of inappropriate or outmoded services.

Finally, the committee noted that even with the use of a premium target, the affordability of the EHB package is threatened by rising medical costs in the United States overall and recommends that the Secretary, in collaboration with others, develop a strategy to reduce health care spending growth across all sectors.

http://iom.edu/Reports/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost.aspx

And from the IOM Report Brief:

One way to think about the EHB package is to compare HHS’s task to going grocery shopping. One option is to go shopping, fill up your cart with the groceries you want, and then find out what it costs. The other option is to walk into store with a firm idea of what you can spend and to fill the cart carefully, with only enough food to fit within your budget. The committee recommends that HHS take the latter approach to developing the EHB package and to keep in mind what small employers and their employees can afford. Employers who offer insurance packages make such choices now.

http://iom.edu/~/media/Files/Report%20Files/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost/essentialhealthbenefitsreportbrief.pdf

Comment: 

By Don McCanne, MD

From the start of the reform process it was understood that defining which essential benefits should be covered by the exchange plans would be controversial. What is no surprise is that, just as the process of writing the Affordable Care Act (ACA) was guided by the private insurance industry, this recommendation for establishing a process for determining essential benefits has the private insurance industry’s fingerprints all over it.

When ACA was developed, the large group employer health plans were functioning fairly well, so it was decided to include policies that would encourage the continuation of these plans. It was the market of small group and individual plans that was not functioning well. Benefits were quite skimpy, and underwriting practices prevented many from obtaining coverage in this market. Thus it was decided to establish state health insurance exchanges in which a market of better regulated and more standardized insurance products would be available.

When the Institute of Medicine tried to balance the essential health benefits package (EHB) with affordability what did they choose? They decided that affordability must come first, and then benefits selected to match the affordable premiums.

Wait a minute! What is being made affordable? Health care or health plans? Skimpy benefits equate with unaffordable health care since much of health care has to be paid out-of-pocket simply because it is not part of the benefit package. By establishing the current benefits of existing small group plans as the standard essential benefits in the plans offered by the exchanges, the IOM has made a deliberate choice of making private health insurance pro
ducts affordable at the cost of making health care itself unaffordable for those purchasing their plans in the exchanges.

This is precisely what the private insurance industry wanted when it came to defining the essential health benefit packages. By making the austere small business packages the new standard, the insurers could keep their premiums low enough to ensure that they still had a market for their products. The insurers could care less what happens to patients when they actually need care, as long as their own market is protected.

It isn’t the insurers’ problem now since they have the prestigious Institute of Medicine telling the nation that we can’t have more than skimpy, spartan health care unless we are willing and able to pay for it out-of-pocket. Since most middle-income families can’t, they’ll just have to do without.

(Single payer systems do not cut benefits. They control spending through administrative efficiencies, global budgeting, price negotiations, elimination of coverage for detrimental services, and by planning and separate budgeting of capital expenditures.)

The Occupy Wall Street movement and single payer

By Katie Robbins

I am writing this on the bus to Washington, D.C., for the launch of the October 2011 movement. The past few weeks have been exhilarating to watch the growing Occupy Demonstrations gain momentum with increased solidarity from labor, faith groups, peace and justice organizations, and of course the health justice community.

Some people have been asking about how to engage with the Occupy Wall Street solidarity actions around the country, particularly around health care. I will share our experience in New York City.

The Occupy Wall Street Demo at Zuccotti Park is happening across the street from the offices of WellPoint, the largest health insurance company in the U.S. Two years ago, we held a sit-in at the offices of WellPoint to protest the obscene profits and patient abuse, while pointing to the need for single-payer health care.

Healthcare-NOW! NYC members have been petitioning, leafleting, and talking to human beings about single-payer health care regularly. The response has been excitement about our positive message and how to improve our society in a just and equitable way. People approach us to talk about our signs that say “Medicare for All” and “Health Care is a Human Right.”

Last night, a contingent of single-payer health care supporters joined 20,000 New Yorkers in a solidarity march with the Occupy Wall Street demonstration. [PNHP note: a 1-minute video showing the participation of physicians in yesterday’s action is available here, courtesy of Dr. SteveB at Daily Kos.] Some of the Wall Street demonstrators then made it to our public forum on single-payer health care at Church of the Ascension on the Upper West Side.

You don’t have to participate in civil disobedience to join the Occupy Demonstrations or sleep outside. You do have a responsibility to educate and share information about the movement for health justice and talk to people about how the health crisis affects them and their families.

You might consider bringing food, clothes, and card board for signs for those who are sustaining this peaceful occupation.

Together, we can show solidarity and create the kind of movement to meet the needs of the 99 percent, including winning a just and equitable health care system. Let me know if you’d like to talk about any other ideas to link up single-payer health care advocacy and #OccupyTogether actions. There are 503 cities participating in this movement as of right now. Find an event near you here: http://www.occupytogether.org/

Katie Robbins is national organizer for Healthcare-NOW! She can be reached at katie@healthcare-now.org.

IOM’s disturbing report on “essential health benefits”

Essential Health Benefits: Balancing Coverage and Cost

Institute of Medicine
October 6, 2011

Abstract

The principle intent of the Patient Protection and Affordable Care Act (ACA) is to enable previously uninsured Americans to obtain health insurance. To accomplish this, in part, subsidized plans will be offered to low- and moderate-income individuals and small employers through health insurance exchanges. Plans qualified to be offered through exchanges must at minimum include “essential health benefits” (EHB). The ACA is not very specific on the definition of EHB except that such benefits shall include at least ten enumerated general categories and that the scope of the EHB shall be equal to the scope of benefits provided under a typical employer plan. The ACA requires the Secretary of the Department of Health and Human Services to define the essential health benefits.

The Institute of Medicine (IOM) was asked by the Secretary to make recommendations on the methods for determining and updating the essential health benefits. Notably, the request was to focus on criteria and policy foundations for the determination of the EHB, not to develop the list of benefits. The IOM formed a committee of volunteers with varied perspectives and professional backgrounds; the committee held four face-to-face meetings and numerous conference calls. Broad public input was obtained. In two open workshops, the committee heard from more than 50 witnesses, and 345 comments were received in response to questions posted on the web. The consensus report then underwent rigorous external review in accordance with procedures established by the Report Review Committee of the National Research Council.

As the committee examined its charge, it saw two main questions for the Secretary: (1) how to determine the initial EHB package and (2) how to update the EHB package.

Defining the initial EHB package. In considering how to determine the initial EHB package, the committee was struck by two compelling facts: (1) if the purpose of ACA was to provide access to health insurance coverage, that coverage had to be affordable; and (2) the more expansive the benefit package was, the more it was likely to cost and the less affordable it would be. How to balance the competing goals of comprehensiveness of coverage and affordability was key.

The committee concluded that it was best to begin simply by defining the EHB package as reflecting the scope and design of packages offered by small employers today, modified to include the ten required categories. This package would then be assessed by criteria and a defined cost target recommended by the committee. The committee considered how four policy domains – economics, ethics, population-based health, and evidence-based practice – could guide the Secretary in determining the EHB package in general. From these policy foundations, the committee recommends: criteria to guide the aggregate EHB package; criteria to guide specific EHB inclusions and exclusions; and criteria to guide methods for defining and updating the EHB.

To ensure affordability and protect the intent of the ACA, the committee concluded that costs must be considered both in the determination of the initial EHB package and in its updating. Thus, the cost of the initial EHB package resulting from the previous steps should be compared to a premium target defined by the committee as what small employers would have paid, on average, in 2014. Committee members believe that absent a premium target, there would be no capacity to acknowledge the realities of limited resources and the ongoing need for affordability of the package. The EHB package should be modified as necessary to meet this estimated premium, including using a structured public deliberative process. In addition, the committee recommends that states operating their own exchanges be able to design a variant of the EHB package if certain standards are met.

Updating the EHB package. Both medical science and our understanding of how best to design insurance products will change over time. Thus, the committee recommends creating a framework and infrastructure for collecting data and analyzing implementation of the initial EHB; a National Benefits Advisory Council is recommended to give the Secretary advice on the research plan and on updates to the EHB package. The committee believes that the EHB package should become more fully evidence-based, specific, and value-based over time. In addition, as with the initial package, costs must be taken into account such that any service added to the package should be offset by savings, through either medical management or the elimination of inappropriate or outmoded services.

Finally, the committee noted that even with the use of a premium target, the affordability of the EHB package is threatened by rising medical costs in the United States overall and recommends that the Secretary, in collaboration with others, develop a strategy to reduce health care spending growth across all sectors.

http://iom.edu/Reports/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost.aspx

And from the IOM Report Brief:

One way to think about the EHB package is to compare HHS’s task to going grocery shopping. One option is to go shopping, fill up your cart with the groceries you want, and then find out what it costs. The other option is to walk into store with a firm idea of what you can spend and to fill the cart carefully, with only enough food to fit within your budget. The committee recommends that HHS take the latter approach to developing the EHB package and to keep in mind what small employers and their employees can afford. Employers who offer insurance packages make such choices now.

http://iom.edu/~/media/Files/Report%20Files/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost/essentialhealthbenefitsreportbrief.pdf

From the start of the reform process it was understood that defining which essential benefits should be covered by the exchange plans would be controversial. What is no surprise is that, just as the process of writing the Affordable Care Act (ACA) was guided by the private insurance industry, this recommendation for establishing a process for determining essential benefits has the private insurance industry’s fingerprints all over it.

When ACA was developed, the large group employer health plans were functioning fairly well, so it was decided to include policies that would encourage the continuation of these plans. It was the market of small group and individual plans that was not functioning well. Benefits were quite skimpy, and underwriting practices prevented many from obtaining coverage in this market. Thus it was decided to establish state health insurance exchanges in which a market of better regulated and more standardized insurance products would be available.

When the Institute of Medicine tried to balance the essential health benefits package (EHB) with affordability what did they choose? They decided that affordability must come first, and then benefits selected to match the affordable premiums.

Wait a minute! What is being made affordable? Health care or health plans? Skimpy benefits equate with unaffordable health care since much of health care has to be paid out-of-pocket simply because it is not part of the benefit package. By establishing the current benefits of existing small group plans as the standard essential benefits in the plans offered by the exchanges, the IOM has made a deliberate choice of making private health insurance products affordable at the cost of making health care itself unaffordable for those purchasing their plans in the exchanges.

This is precisely what the private insurance industry wanted when it came to defining the essential health benefit packages. By making the austere small business packages the new standard, the insurers could keep their premiums low enough to ensure that they still had a market for their products. The insurers could care less what happens to patients when they actually need care, as long as their own market is protected.

It isn’t the insurers’ problem now since they have the prestigious Institute of Medicine telling the nation that we can’t have more than skimpy, spartan health care unless we are willing and able to pay for it out-of-pocket. Since most middle-income families can’t, they’ll just have to do without.

(Single payer systems do not cut benefits. They control spending through administrative efficiencies, global budgeting, price negotiations, elimination of coverage for detrimental services, and by planning and separate budgeting of capital expenditures.)

Undocumented immigrants under the Affordable Care Act

Undocumented Immigrants, Left Out Of Health Reform, Likely To Continue To Grow As Share Of The Uninsured

By Stephen Zuckerman, Timothy A. Waidmann and Emily Lawton
Health Affairs, October 2011

The increase in undocumented immigration between 1999 and 2007 contributed to an increase in the number of uninsured people in the United States. During this period, the number of undocumented immigrants increased from an estimated 8.5 million to 11.8 million, leading to an estimated additional 1.8 million uninsured. These uninsured and undocumented immigrants were estimated to represent 27 percent of the overall increase of 6.9 million uninsured people during this period. Undocumented immigrants accounted for one in seven of the uninsured in 2007, up from one in eight in 1999. These undocumented immigrants will not be eligible for public insurance or any type of private coverage obtained through exchanges under the Affordable Care Act of 2010. As a result, members of this group will eventually constitute a larger percentage of the uninsured population, unless other policy actions are taken to provide for their coverage, or their immigration status is changed.

http://content.healthaffairs.org/content/30/10/1997.abstract

Comment:

By Don McCanne, MD

Under a properly designed single payer national health program, the financing of the health care system and the delivery of care are totally separated. Everyone contributes funds to the system based on ability to pay, including undocumented immigrants. Everyone who needs health care receives health care, including undocumented immigrants.

During the national dialogue on health care reform, a vociferous component of our society opposed including health insurance coverage for undocumented immigrants, and Congress complied with their wishes. The reason often given was that they were “illegals” (an unfortunate pejorative term). They committed the crime of coming to this country illegally, so they shouldn’t receive the benefit of health care, so the argument goes.

But is denying health care to those who commit crimes really our national policy? Hardly. Individuals who commit crimes severe enough to result in imprisonment are automatically granted health care. Anyone who shows up at an emergency room in need of urgent care is given that care, regardless of immigration status.

From a practical standpoint, in a microsimulation study that we did as part of the California Health Care Options Project, we showed that, under a single payer model, providing comprehensive care for absolutely everyone, including undocumented immigrants, would actually reduce our total health care spending. All immigrants, documented or not, would participate like everyone else – paying into the system and receiving care when needed.

Regardless of all this, what should be the overriding principle is the concept of social justice, specifically health care justice. No person in the community should be singled out for any reason whatsoever to be excluded from gaining access to the practitioners of the healing arts. A just society would guarantee that access for everyone, regardless of ability to pay or immigration status.

Meet the Bay State’s Uninsured

The national media pass on an important story

By Trudy Lieberman
Columbia Journalism Review, Campaign Desk, Sept. 26, 2011

Last week the Census Bureau released new numbers showing that 5.6 percent of the population in Massachusetts remained without health insurance coverage. That’s a 42 percent drop in the number of the state’s uninsured since the law took effect in 2006. A new study by the Cambridge Health Alliance, one of the state’s safety net providers, showed who was left out, putting a human face on those without insurance. The findings are illuminating given that the Bay State’s health law is the model for the national law, which takes full effect in 2014, and the Romney-Perry feud often flares up around the topic of health reform in the state.

The local press, primarily the Boston Globe and WBUR, covered the story; the national media whiffed on its implications for federal reform. If reform in Massachusetts cut the number of uninsured roughly in half, the same is likely to happen nationally, according to government data. The latest Census Bureau numbers show that nearly fifty million people have no health coverage; the Congressional Budget Office estimates about twenty-three million will be still be uninsured later in the decade. It was as if the national media has forgotten that Massachusetts is a harbinger of what will happen nationally. Or perhaps it’s easier for the national media to cover the he said/he said back and forth between Perry and Romney.

Writing on WBUR’s CommonHealth blog, Carey Goldberg started with an intriguing lead that showed she could sniff out a story — and showed why others should, too: “You figure that when a press release comes in from Physicians for a National Health Program, it has an agenda. But that doesn’t negate the value of the research it highlights—which, in this case, was a paper from Harvard Medical School researchers just out in the Journal of General Internal Medicine.”

Researchers surveyed 431 patients who sought care in the emergency department of the Cambridge Health Alliance and conducted in-person interviews with 189 who were uninsured. Their results show that fragmentation still exists in a system built on employer-sponsored coverage. Gobs of paperwork also still exist, and private insurance remains unaffordable for many — even with government tax subsidies. The key points from the study are these:

• Finding affordable coverage is hard. One-third of the respondents said they were uninsured because they could not buy affordable coverage. Half the sample said that the mandate to buy coverage prompted them to look for insurance, but they couldn’t find any they could afford.

• Two-thirds of the uninsured were working, but only one-quarter of them had employer coverage.

• Some declined employer coverage because of its cost. The state requires an employer to cover only 20 percent of the annual family premium and 33 percent of an individual premium. The authors suggest that if the trend continues that requires employees to pay more out-of-pocket, even fewer employees will take their employers’ coverage.

• One-third of the respondents said they were uninsured because they lost their coverage. People receiving subsidized coverage must re-enroll every year. If they don’t get the paperwork sent in within ten days, they lose coverage.

• Eighty-five percent of the uninsured qualified for state-subsidized insurance, but still one-third were without coverage, suggesting, the authors say, “that for some working poor, even heavily subsidized insurance premiums may be unaffordable.”

• Only about six percent said they were uninsured because they didn’t think they needed coverage; in other words, there were few “free riders.” That’s an important point to remember next time the candidates declare that people like to take risks by being uninsured.

Several months ago, a group called PHI, which works to improve conditions for workers who provide long-term care, released a study that meshes with the Cambridge Health Alliance findings. PHI found that while many employers offered coverage, workers were not taking it. About half of the workers surveyed were not eligible for employer coverage because they worked part time or had to satisfy a waiting period for coverage. About one-third of employers raised the level of cost-sharing for their workers. The media showed little interest in this study as well.

“If you don’t find out what the old polices have done, it’s a prescription for bad policy going forward,” says Steffie Woolhandler, one of the Cambridge study authors. Woolhandler and her colleagues offered suggestions for improvement like increasing employer incentives to cover a greater portion of premium costs, reducing cost-sharing for low-wage workers, and making the enrollment process easier. William Woo, who was the editor of the St. Louis Post Dispatch, once told me there’s a master narrative the press follows. Examining the shortcomings of Massachusetts health reform doesn’t fit the master narrative—at least so far.

http://www.cjr.org/campaign_desk/meet_the_bay_states_uninsured.php

Undocumented immigrants under the Affordable Care Act

Undocumented Immigrants, Left Out Of Health Reform, Likely To Continue To Grow As Share Of The Uninsured

By Stephen Zuckerman, Timothy A. Waidmann and Emily Lawton
Health Affairs, October 2011

The increase in undocumented immigration between 1999 and 2007 contributed to an increase in the number of uninsured people in the United States. During this period, the number of undocumented immigrants increased from an estimated 8.5 million to 11.8 million, leading to an estimated additional 1.8 million uninsured. These uninsured and undocumented immigrants were estimated to represent 27 percent of the overall increase of 6.9 million uninsured people during this period. Undocumented immigrants accounted for one in seven of the uninsured in 2007, up from one in eight in 1999. These undocumented immigrants will not be eligible for public insurance or any type of private coverage obtained through exchanges under the Affordable Care Act of 2010. As a result, members of this group will eventually constitute a larger percentage of the uninsured population, unless other policy actions are taken to provide for their coverage, or their immigration status is changed.

http://content.healthaffairs.org/content/30/10/1997.abstract

Under a properly designed single payer national health program, the financing of the health care system and the delivery of care are totally separated. Everyone contributes funds to the system based on ability to pay, including undocumented immigrants. Everyone who needs health care receives health care, including undocumented immigrants.

During the national dialogue on health care reform, a vociferous component of our society opposed including health insurance coverage for undocumented immigrants, and Congress complied with their wishes. The reason often given was that they were “illegals” (an unfortunate pejorative term). They committed the crime of coming to this country illegally, so they shouldn’t receive the benefit of health care, so the argument goes.

But is denying health care to those who commit crimes really our national policy? Hardly. Individuals who commit crimes severe enough to result in imprisonment are automatically granted health care. Anyone who shows up at an emergency room in need of urgent care is given that care, regardless of immigration status.

From a practical standpoint, in a microsimulation study that we did as part of the California Health Care Options Project, we showed that, under a single payer model, providing comprehensive care for absolutely everyone, including undocumented immigrants, would actually reduce our total health care spending. All immigrants, documented or not, would participate like everyone else – paying into the system and receiving care when needed.

Regardless of all this, what should be the overriding principle is the concept of social justice, specifically health care justice. No person in the community should be singled out for any reason whatsoever to be excluded from gaining access to the practitioners of the healing arts. A just society would guarantee that access for everyone, regardless of ability to pay or immigration status.

Most large health plans fall short on quality

New rankings make choosing health insurance easier

By Steven Findlay
Consumer Reports Health.org, October 4, 2011

When it comes to health insurance, a familiar name and lots of members don’t guarantee quality or customer satisfaction, according to new rankings of health-insurance plans from the National Committee for Quality Assurance that we published today.

Our analysis of the NCQA rankings found that the five largest national insurers—Aetna, Cigna, Humana, Kaiser Permanente, and United Healthcare, plus the mostly state-based Blue Cross Blue Shield plans—account for about 75 percent of the 390 ranked private plans, but only 36 percent of the top 50.

Biggest isn’t best. United is the nation’s largest health-insurance company, but none of its private plans rank among the top 100, and most occupy the bottom half.

http://news.consumerreports.org/health/2011/10/new-rankings-make-choosing-health-insurance-easier.html

NCQA Health Plan Report Card
http://reportcard.ncqa.org/plan/external/plansearch.aspx

Comment: 

By Don McCanne, MD

The big health insurers that are dominating most of the markets fall short on NCQA quality standards, except for Kaiser Permanente. No surprise. What is surprising is that we continue to tolerate this mediocrity merely because an improved Medicare for all is not politically feasible. How about changing the politics?

Most large health plans fall short on quality

New rankings make choosing health insurance easier

By Steven Findlay
Consumer Reports Health.org, October 4, 2011

When it comes to health insurance, a familiar name and lots of members don’t guarantee quality or customer satisfaction, according to new rankings of health-insurance plans from the National Committee for Quality Assurance that we published today.

Our analysis of the NCQA rankings found that the five largest national insurers—Aetna, Cigna, Humana, Kaiser Permanente, and United Healthcare, plus the mostly state-based Blue Cross Blue Shield plans—account for about 75 percent of the 390 ranked private plans, but only 36 percent of the top 50.

Biggest isn’t best. United is the nation’s largest health-insurance company, but none of its private plans rank among the top 100, and most occupy the bottom half.

http://news.consumerreports.org/health/2011/10/new-rankings-make-choosing-health-insurance-easier.html

NCQA Health Plan Report Card
http://reportcard.ncqa.org/plan/external/plansearch.aspx

The big health insurers that are dominating most of the markets fall short on NCQA quality standards, except for Kaiser Permanente. No surprise. What is surprising is that we continue to tolerate this mediocrity merely because an improved Medicare for all is not politically feasible. How about changing the politics?