Lack Of Access Due To Costs Remains A Problem For Some In Massachusetts Despite The State’s Health Reforms

By Cheryl R. Clark, Jane Soukup, Usha Govindarajulu, Heather E. Riden, Dora A. Tovar and Paula A. Johnson
Health Affairs
February 2011

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer.

http://content.healthaffairs.org/content/30/2/247#aff-6

And…

More get waivers of health insurance

By Kay Lazar
The Boston Globe
February 7, 2011

Massachusetts regulators granted more exemptions last year to residents who said they could not afford the health insurance required by the state, waiving the tax penalty for more than half of those who appealed, according to state data.

That is prompting regulators to take a fresh look at how Massachusetts defines affordable when it comes to mandatory health insurance.

Massachusetts residents with the lowest family incomes, less than $33,075 for a family of four, make up the largest share — 43 percent — of the uninsured, according to state data.

“We may want to let them in [to government subsidized health insurance], but it would cost money, and we would have to decide if the state wants to spend money that way,” said committee member Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology.

http://www.boston.com/news/local/massachusetts/articles/2011/02/07/more_get_waivers_of_health_insurance/?page=full

Does an individual mandate to purchase private insurance with cost-sharing requirements ensure that citizens will have health care access and be able to afford it? It hasn’t in Massachusetts, and it will not throughout the United States because it is an irreparably flawed mechanism of financing health care.

The literature is replete with policies that would nudge us a little bit closer to the goals of affordability and expanded coverage, but, as Jonathan Gruber, an advocate of the private insurance mandate model, says, “we would have to decide if the state wants to spend money that way.”

But it’s the model, stupid! Dump it and replace it with an improved Medicare for all and then health care will be affordable for everyone. Why does Gruber and the others insist on separating state money from personal money, as if state money is sacred and personal money isn’t? It all belongs to us anyway.

Well here we are. Super Bowl weekend! Hurrah! What could be more American than this? Billions of dollars and the nation’s full attention directed to a couple dozen men playing a game. And this is no sandlot game. No. This is our nation at its finest – honoring in unparalleled splendor those great Americans who prevail and are declared winners of this historic rough-and-tumble fracas. And what more could our nation be than about winners?

Let me digress for a moment. I have a little story to tell.

I was still in practice during the Clinton effort to reform health care. Although practicing in an affluent community, I was experiencing great frustrations in trying to obtain specialized health care services for not only our indigent patients, but also for our insured patients who were facing increasing managed-care barriers to care.

Previously, in 1989, a life-changing event had occurred for me. It was simply that I read an article in The New England Journal of Medicine titled “A National Health Program for the United States,” written by a team led by David Himmelstein and Steffie Woolhandler, representing a group called Physicians for a National Health Program. I was stoked! I joined PNHP.

Then Bill Clinton was elected, and the nation was ready for a national health program. As masters of health policy science, PNHP was there and ready to help guide the process. But President Clinton decided that they would follow the path of political expediency and build reform based on the existing private insurers/managed care entities. Thus, in a political maneuver, to be repeated years later, PNHP was denied a seat at the table.

I watched the process closely. I listened as the opposition proposed a model almost identical to that of the Patient Protection and Affordable Care Act. I saw the effort go down in flames. I decided that we couldn’t just walk away.

I felt then that a pure single payer program, as much as I wanted it, could never pass. But I thought that there was enough agreement on fundamental principles that almost everyone would be able to support some model of social insurance, if we just had the right one. So I crafted a model. It was brilliant – just the right balance to achieve our goals while pleasing everyone.

I sent it in to PNHP. The task of reviewing it was handed to PNHP’s new president, Claudia Fegan. It required more postage to return it to me, because it was newly laden with red ink.

My lesson? I was passionate about reforming our system so that everyone would have the health care that they need, but I knew nothing about health policy science. I am forever indebted to Claudia for showing me the light, and resetting my course in my advocacy for reform. The principle she taught me is that you change policy recommendations only when policy science has demonstrated that there are better policies available. You do not ever change policy recommendations simply to conform to politics.

Claudia has continued to be a great inspiration to me. And that brings us to a crystal stair. On this glittering Super Bowl weekend, we should take a look at that crystal stair. You will understand what I mean when you read the Claudia’s remarks that she delivered to the Louisville, Kentucky Urban League on January 15, 2011. After reading her comments maybe we can think about what it really takes to make winners in America.

Cladia Fegan’s remarks to the Louisville Urban League:
http://www.spiritualprogressives.org/article.php/2011020212215961

By Benjamin D. Sommers and Sara Rosenbaum
Health Affairs
February 2011

The Affordable Care Act will extend health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges. But by definition, eligibility for these programs is sensitive to income and can change over time with fluctuating income and changes in family composition. The law specifies no minimum enrollment period, and subsidy levels will also change as income rises and falls. Using national survey data, we estimate that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will.

Income fluctuation raises issues for all subsidy-eligible individuals or families up to 400 percent of the federal poverty level, which includes those whose incomes place them squarely within the exchange system. For those purchasing coverage with subsidies through exchanges, income changes may trigger the obligation to repay some or all subsidies received; the amounts subject to repayment were significantly increased recently by Congress. But income fluctuations pose a particular challenge for individuals and families who cross the Medicaid-exchange divide, because this change may trigger a shift between plans and provider networks. In short, for this group, income fluctuation carries both financial and health care consequences.

Our multivariate analyses show that income fluctuations were common even among adults initially with incomes below the poverty level. This is particularly troubling because many of these people will often have incomes low enough to exempt them from the federal insurance mandate, which means that fatigue with frequent coverage changes may lead them to simply stop signing up for insurance over time. This is a problem on two fronts. First, it is uninsured low-income adults who have the most to gain from health reform. Second, this group includes millions of healthy adults whose participation in the exchanges is crucial to robust risk pools. We found that income changes were more common among adults who were younger, more educated, and white—characteristics that correlate with a lower burden of illness. Indeed, these results are consistent with previous findings on changes in Medicaid coverage among adults.

http://content.healthaffairs.org/content/30/2/228.abstract

Comment: 

By Don McCanne, MD

We have previously made the point that fluctuations in eligibility for Medicaid and for the income-related subsidies in the exchange plans create instability in coverage. Impaired outcomes occur because of gaps in coverage, and disruptions in provider networks. This new study puts a number on the degree of instability. Within one year, over 50 percent of adults with a family income under 200 percent of the federal poverty level (FPL) will experience a shift in eligibility from Medicaid to an insurance exchange, or vice versa.

The article discusses some of the implications of this, including problems with shifting eligibility levels for exchange subsidies for those with incomes over 200 percent of the FPL. Though eligible for one program or another, many individuals will have incomes that exempt them from the mandate to purchase insurance, and, assuredly, the healthier ones who are needed to round out the risk pools will go without coverage as a result of fatigue over multiple ejections by one program or another.

The authors offer policy options that might reduce this instability in coverage, but these options can never eliminate it. Our fragmented financing system of various private and public programs will never ensure that everyone is covered at all times, and it will continue to waste funds on administrative excesses such as trying to keep up with eligibility shifts due to income fluctuations.

A policy option that would work, not mentioned by the authors, would be to dump our dysfunctional multi-payer system and enact an improved Medicare that includes everyone. The problem of fluctuating incomes is greatly simplified because it impacts only the contribution through the tax system, without moving the individual in or out of Medicare.

Issues In Health Reform: How Changes In Eligibility May Move Millions Back And Forth Between Medicaid And Insurance Exchanges

By Benjamin D. Sommers and Sara Rosenbaum
Health Affairs
February 2011

The Affordable Care Act will extend health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges. But by definition, eligibility for these programs is sensitive to income and can change over time with fluctuating income and changes in family composition. The law specifies no minimum enrollment period, and subsidy levels will also change as income rises and falls. Using national survey data, we estimate that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will.

Income fluctuation raises issues for all subsidy-eligible individuals or families up to 400 percent of the federal poverty level, which includes those whose incomes place them squarely within the exchange system. For those purchasing coverage with subsidies through exchanges, income changes may trigger the obligation to repay some or all subsidies received; the amounts subject to repayment were significantly increased recently by Congress. But income fluctuations pose a particular challenge for individuals and families who cross the Medicaid-exchange divide, because this change may trigger a shift between plans and provider networks. In short, for this group, income fluctuation carries both financial and health care consequences.

Our multivariate analyses show that income fluctuations were common even among adults initially with incomes below the poverty level. This is particularly troubling because many of these people will often have incomes low enough to exempt them from the federal insurance mandate, which means that fatigue with frequent coverage changes may lead them to simply stop signing up for insurance over time. This is a problem on two fronts. First, it is uninsured low-income adults who have the most to gain from health reform. Second, this group includes millions of healthy adults whose participation in the exchanges is crucial to robust risk pools. We found that income changes were more common among adults who were younger, more educated, and white—characteristics that correlate with a lower burden of illness. Indeed, these results are consistent with previous findings on changes in Medicaid coverage among adults.

http://content.healthaffairs.org/content/30/2/228.abstract

We have previously made the point that fluctuations in eligibility for Medicaid and for the income-related subsidies in the exchange plans create instability in coverage. Impaired outcomes occur because of gaps in coverage, and disruptions in provider networks. This new study puts a number on the degree of instability. Within one year, over 50 percent of adults with a family income under 200 percent of the federal poverty level (FPL) will experience a shift in eligibility from Medicaid to an insurance exchange, or vice versa.

The article discusses some of the implications of this, including problems with shifting eligibility levels for exchange subsidies for those with incomes over 200 percent of the FPL. Though eligible for one program or another, many individuals will have incomes that exempt them from the mandate to purchase insurance, and, assuredly, the healthier ones who are needed to round out the risk pools will go without coverage as a result of fatigue over multiple ejections by one program or another.

The authors offer policy options that might reduce this instability in coverage, but these options can never eliminate it. Our fragmented financing system of various private and public programs will never ensure that everyone is covered at all times, and it will continue to waste funds on administrative excesses such as trying to keep up with eligibility shifts due to income fluctuations.

A policy option that would work, not mentioned by the authors, would be to dump our dysfunctional multi-payer system and enact an improved Medicare that includes everyone. The problem of fluctuating incomes is greatly simplified because it impacts only the contribution through the tax system, without moving the individual in or out of Medicare.

By John Wilkerson
Inside Health Reform
February 3, 2011

CMS Administrator Donald Berwick indicated on Feb. 1 that CMS still plans to use a demonstration to let accountable care organizations include Medicare beneficiaries and patients with private insurance. Specifically, he said the CMS innovation center will make room for the “vanguards” of accountable care organizations so CMS can test ACO models that go beyond what is called for under the ACO program.

Sources say CMS had been planning to announce a demonstration program late last year to assign Medicare and possibly Medicaid beneficiaries to existing clinically integrated entities in the private insurance market. That announcement was delayed, they said, leaving them to wonder whether CMS had backed off the plan – but Berwick seemed to say at a Brookings Institution conference that the plan is still in the works.

CMS is talking to private payers about public-private partnerships and about how clinically integrated organizations can align what they are doing for patients with private insurance with the goals of ACOs, Berwick told reporters after his presentation. (The Federal Trade Commission has warned that broad-based ACOs involving private payers could raise antitrust concerns, but the FTC has been working out those matters with CMS.)

Berwick said the proposed rule on the ACO program should be published soon, but when asked by Inside Health Policy whether a demonstration would be announced before the proposed rule, Berwick said only that the innovation center would move “quickly” on ACO demonstrations. The health reform law created an ACO program, which is permanent and separate from the temporary demonstrations that the innovation center approves. However, CMS could approve ACO demonstrations that would later be wrapped into the ACO program, sources say.

http://www.ahiphiwire.org/FocusMed/News/Default.aspx?doc_id=749955

Brookings Institution Conference: ACHIEVING BETTER CARE AT LOWER COSTS
THROUGH ACCOUNTABLE CARE ORGANIZATIONS (transcript – 110 pages):
http://www.brookings.edu/~/media/Files/events/2011/0201_accountable_care/20110201_accountable_care.pdf

Comment: 

By Don McCanne, MD

This Brookings Institute conference on accountable care organizations (ACOs) provides important insights as to what we might be facing. These experts, including Donald Berwick, Elliott Fisher and Mark McClellan, provide abstractions as to policies that might achieve the quality and cost-containment goals of the ACOs that are mandated by the Patient Protection and Affordable Care Act (PPACA).

The Medicare Shared Savings Program will begin on January 1, 2012, less than one year from now. At that time, “groups of providers of services and suppliers meeting criteria specified by the Secretary may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization” (PPACA). Details as to the requirements can be found in Sec. 3022 and Sec. 10307 of PPACA.

If you read the transcript of the Brookings presentations of the experts and the panel discussions following, you should be concerned – very concerned. Within months, these somewhat nebulous abstractions are to be transformed into real life organizations of health professionals and facilities that supposedly will deliver higher quality care at a lower cost, while splitting the savings with the government.

Obviously, these ACOs will not spring up de novo; there isn’t enough time. We already know that the early demonstration projects are using existing entities that can best be categorized as managed care organizations. According to the report from Inside Health Reform, “CMS is talking to private payers about public-private partnerships and about how clinically integrated organizations can align what they are doing for patients with private insurance with the goals of ACOs, Berwick told reporters after his presentation.”

As recorded in the transcript of the Brookings conference, CMS Administrator Donald Berwick stated, “Now, I’m in a little bit of an awkward moment, aren’t I? The Notice of Proposed Rulemaking isn’t out yet. It will be out very soon, but I can’t tell you what’s in it yet because I guess I’m not supposed to, but you’ll see it soon. And then there’ll be a comment period, which I hope you’ll all take seriously.”

Be ready. When the Notice of Proposed Rulemaking is released for public comment, peruse it to determine if Medicare is going to be turned over to private insurer/managed care organizations in the name of higher quality and lower costs through accountable care organizations. We need to find out if this is merely new rhetoric that will mask the further privatization of Medicare, intended or not. If so, we cannot let it stand.