UnitedHealth Group Earnings: What They Suggest about Patient Access to Care, American Hospital Association, July 15, 2021, by Rick Pollack, AHA President and CEO

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Today UnitedHealth Group announced a jaw-dropping $6 billion in earnings in a single quarter. But not enough has been said about a big contributor to these profits: not paying for health care services. During the same quarter last year the company noted its $9.2 billion in profit was due in part to “broad-based deferral of care.” What that means in real-life: profit was earned off missed childhood vaccinations, reduced access to opioid misuse treatment and avoided emergency care for cardiac arrest. But even this isn’t the full story.

Throughout the course of the pandemic, United pursued a number of changes to its policies to further restrict patients’ coverage. United didn’t just profit from avoided care, it actively sought to scale back what care it would pay for at the same time.

• Specialty Pharmacy Services: In many parts of the country, United has been rolling out coverage restrictions that no longer permit patients to access specialty pharmacy therapies in a hospital outpatient department even if that is where their doctors practice.
• Surgeries: United will no longer cover a large number of surgical procedures performed in hospital outpatient departments.
• Lab and Radiology Services: United has announced plans to restrict coverage for many lab and radiology services provided by hospitals and outpatient departments.
• Primary Care and Specialty Services:  United, the nation’s largest employer of physicians, says it will begin restricting coverage for most physician evaluation and management services provided in hospital outpatient departments, including provider-based clinics.

United routinely rolls out these coverage restrictions throughout the year, meaning that enrollees purchase their health plans under one set of rules only to later learn that their providers and cost-sharing responsibilities have changed.

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Our top private health insurer is rolling in cash. And it’s reducing coverage, Los Angeles Times, July 20, 2021, by David Lazarus, Business Correspondent

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UnitedHealth Group, parent of UnitedHealthcare, the country’s largest private health insurer, earned $15.4 billion in profit last year. It took in more than $9 billion in profit during the first half of this year.

So what does a well-heeled insurer do amid such a windfall? It seeks to reduce people’s coverage, of course. …

The insurer won’t cover nonemergency treatment at non-network facilities outside a policyholder’s service area, which is defined as your state of residence and adjoining states.

This change mainly affects UnitedHealthcare members who want to travel to residential treatment facilities, rehabilitation clinics and other nonhospital healthcare providers.

Which is to say, if you’re a UnitedHealthcare member and you need rehab for any reason, you’d better stay in network and you’d better stick close to home. Otherwise, you’ll be footing the bill yourself. …

Coverage networks might save insurers a few bucks, but they’re not in the best interest of patients, who should be free to seek the best possible care from the best-qualified doctor or hospital.

Nor, for that matter, should people’s coverage be tethered to their jobs. Lose your job, lose your health insurance — what the hell kind of system is that?

We know from the experience of other developed countries that [insurance risk management] is done most effectively by creating a single risk pool comprising the entire population, and then having a single government program handle all claims consistently, fairly and transparently.

Studies have shown that the taxes paid into such a single-payer system — Medicare for all, say — would be less than the premiums, copays and deductibles that now constitute most out-of-pocket medical expenses for Americans.

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Comment:

By Don McCanne, M.D.

UnitedHealth Group has demonstrated that it has mastered its ability to increase profits by not paying for health care services. They are serving their corporate shareholders at a cost to their customers, aka patients.

Contrast this private insurer function to what the role of a publicly financed and publicly administered insurer would be. Passive insurer shareholders and profits would play no role. The goal would be to pay for necessary health care services, not avoid them.

Even David Lazarus – the Business Correspondent for the LA Times – sees what UnitedHealth Group does and in response sings the praises of single payer.

Based on Rick Pollack’s comments, the American Hospital Association should be a valuable team member in our efforts to achieve health care justice for all.

http://healthjusticemonitor.org…

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Hospital Prices Must Now Be Transparent. For Many Consumers, They’re Still Anyone’s Guess, KHN, July 2, 2021, by Julie Appleby

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The Health 202: Biden Says He’ll Enforce Trump-era Rules Requiring Hospitals to Post their Prices, Washington Post, July 12, 2021, by Alexandra Ellerback with Paige Winfield Cunningham

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“Ultimately, the unanswered question is whether price transparency will lead to overall lower prices.” – Appleby

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Comment:

By Hannah Leibson and Allison K. Hoffman, J.D.

Efforts to increase price transparency in health care have become a policy obsession of academics and policymakers alike, despite little evidence it provides any benefit to patients.

On January 1, 2021, the Trump Administration finalized the Transparency in Coverage final rule and drank the Kool-Aid. This rule requires hospitals to disclose publicly what they charge uninsured patients for items and services as well as the rates they negotiate with insurers. The Administration hoped that the rule would force insurers to compete with each for lower priced items and services, driving down the overall cost of health care.

The rule’s roll out has not gone as anticipated. Up to 83 percent of hospitals are not fully complying with the rule. For hospitals that have disclosed prices, they are often hidden deep on their websites – shielded from patients’ view. This week, the Biden Administration urged the Department of Health and Human Services to boost their enforcement of the rule.

But as Appleby and Ellerback have highlighted, the rule overlooks a key reality. Even when consumers have greater access to information, they generally do not use it to shop medical care as policymakers imagine. Empirical research has shown that consumers are unwilling to price compare, and even when they do, it does not drive their choices.

Instead, the role of referring physicians plays a far greater role in patient choice and decisionmaking. This is unsurprising. Price data says little about quality, which is just as or more important to people, and assessing quality and making price/quality tradeoffs is a herculean task for most of us. Various studies have shown that giving people price information, even in a fairly digestible form and even with regard to reasonably fungible services, does little. Consider just two:

One study examined the consumer choices of people with easy access to price shopping for lower-leg MRIs, where quality does not vary wildly. The researchers concluded that only 14 percent of consumers went to the lowest-cost MRI provider within thirty minutes of their home, often bypassing six lower-priced providers between their home and location of their chosen scan. They went to the location their doctor suggested.

Another recent study assessed whether consumers changed their behavior after a transparency tool was introduced in the California Public Employees’ Retirement System (CalPERS). The interface showed consumers the prices for lab tests, office visits, and imaging services. The researchers found that only 12 percent of people used the interface in the first fifteen months after it was introduced, and most did not choose a lower-priced service after use.

Given this reality, it is likely that the Transparency in Coverage final rule will have a trivial effect on lowering the overall cost of health care through consumer-driven behavior. Regulations like the Transparency in Coverage rule are rooted in a fallacy that when we make the market work better, patients can navigate in the front seat. And they perpetuate that fallacy.

More direct price regulation or central budgeting, like what occurs under the Medicare program, is the only way to rein in escalating prices going forward. Without such measures, we will continue to face rapidly rising health care costs.

http://healthjusticemonitor.org…

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When Is Tinkering with Safety Net Programs Harmful to Beneficiaries?, National Bureau of Economic Research, July 2021, by Jeffrey Clemens & Michael J. Wither

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Abstract

Interactions between redistributive policies can confront low-income households with complicated choices. We study one such interaction, namely the relationship between Medicaid eligibility thresholds and the minimum wage. A minimum wage increase reduces the number of hours a low-skilled individual can work while retaining Medicaid eligibility. We show that the empirical and welfare implications of this interaction can depend crucially on the relevance of labor market frictions. Absent frictions, affected workers may maintain Medicaid eligibility through small reductions in hours of work. With frictions, affected workers may lose Medicaid eligibility unless they leave their initial job. Empirically, we find that workers facing this scenario became less likely to participate in Medicaid, less likely to work, and more likely to spend time looking for new jobs, including search while employed. The observed outcomes suggest that low-skilled workers face substantial labor market frictions. Because adjustment is costly, tinkering with safety net program parameters that determine the location of program eligibility notches can be harmful to beneficiaries.

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Comment:

By Don McCanne. M.D.

Who should be deprived of health care? Likely most would agree that nobody should, and, ideally, everyone should agree.

With our dysfunctional, fragmented system of financing health care, a special funding program must exist to cover those who do not have the resources to pay for health care, thus we established Medicaid. But what threshold do we establish for eligibility? Is it all-or-none financing? Does minor tinkering invoke all-or-none decisions?

In the real-world example presented, an increase in minimum wage reduced the number of hours that a low-skilled worker could work and still maintain eligibility for Medicaid. The result was both less employment and less Medicaid. Such all-or-none decisions could be disastrous for the health care or income of an affected low-wage worker. Last year, evidence from Arkansas showed that a work requirement decreased Medicaid enrollment without increasing work.

Suppose we had a single payer Medicare for All system. Everyone would automatically have financial barriers removed from medical care. There would be no need to establish a special medical welfare program such as Medicaid. Controlling costs for the indigent would be accomplished by funding the entire system though progressive taxes. That way, everyone could have health care in a system that is affordable for each of us. The complexity and injustices of segregating patients into a Medicaid program would no longer be necessary.

http://healthjusticemonitor.org…

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Democrats Have An Historic Opportunity To Advance FDR’s Vision For Universal, Guaranteed Health Care, Common Dreams, July 14, 2021, by Nancy Altman

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FDR, his Labor Secretary Frances Perkins, and their allies had a much broader definition of Social Security than the one we use today. They understood the term as a synonym for economic security. They knew that to ensure economic security, all of us need the assurance that if faced with an illness, we or our loved ones will receive high-quality treatment as a guaranteed right.

They understood that to be economically secure, all of us must have universal, guaranteed health care as our birthright. Today’s Democrats appropriately proclaim that health care should be a right, not a privilege. Now is the moment to walk the walk, to add action to the rhetoric. …

Democrats have the opportunity to pass a package that takes the next big step in that direction. The following Medicare and Medicaid improvements are being debated as you read these words:

1. Creating an out-of-pocket cap in Medicare, because no one should go bankrupt trying to pay for health care.
2. Adding the essential benefits of vision, hearing, and dental care to Medicare.
3. Lowering the Medicare eligibility age to 60, as Medicare’s architects anticipated and as President Biden promised in his campaign.
4. Empowering Medicare to negotiate lower prescription drug prices not just for seniors and people with disabilities but for everyone in America.
5. Allowing people to remain in their homes, rather than forced into institutions, by funding home and community-based long-term care.

Each of these steps would make Americans more economically secure, and enormously improve our lives. It exemplifies the promise to build back better.

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Comment:

By Eagan Kemp

Nancy Altman, the President of Social Security Works–a staunch ally in the fight for Medicare for All–highlights how crucially important it is for Congress to improve and expand Medicare, while also lowering the cost of prescription drugs and improving access to home and community based long-term care in the next reconciliation package.

While these steps are important on their own, they also help us think about how we move from the fragmented health care system we have now to the health care system we truly need, Medicare for All.

The reality is that most people are fed up with the health care system and are ready for things to change. The question is then how do we change it.

Given the limitations of the current Congress and President Biden’s opposition to Medicare for All, how do we make progress on health care without making the situation worse?

Taking steps to reduce corporate power in health care while strengthening public programs is a good place to start. While these reforms aren’t perfect, they help us push back on the corporate onslaughts on Medicare and, if crafted correctly, will also take a bite out of prescription drugmakers’ power.

Getting these reforms over the finish line will mean relief for millions of Americans but will still take a lot of work, as corporate lobbyists fight to water them down.

But make no mistake, the fight for Medicare for All must continue, regardless of whether these interim measures pass. It will take the largest grassroots mobilization in decades to finally guarantee health care for everyone in the U.S.

Luckily, those fighting for Medicare for All haven’t lost focus. Over 20 municipalities passed Medicare for All Resolutions in recent months and many more are working to do so soon. Additionally, the Medicare for All bill in the House just added its 118th cosponsor, highlighting the progress that we continue to make in Congress. And with hearings on Medicare for All forthcoming in both the House and Senate, the support within Congress will continue to deepen.

http://healthjusticemonitor.org…

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When It Comes to People Like My Daughter, One Size Does Not Fit All, New York Times, July 4, 2021, by David Axelrod

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I am profoundly grateful for the disability rights movement that has waged a decades-long battle to shutter such institutions, many of which were run by the states, and to win for people with intellectual disabilities the right to live in small apartments and homes with services in residential neighborhoods.

But now the ideal has hardened into dogma: All larger communities are bad. All small, neighborhood-based group homes are good.

Of course, neither of these things is true, and the rigidity of that thinking denies the simple truths that there are good and bad places, large and small, and people with disabilities are not all the same. Like anyone else, they have different personalities, capacities and preferences.”

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Comment:

By Allison K. Hoffman, J.D.

I was touched by this op-ed by David Axelrod and his ability to illustrate pointedly why we need various options to meet the range of possible care needs of people with disabilities of all ages, through a telling of his own struggles to find the right support for his daughter, Lauren, who has suffered from debilitating and disabling seizures for decades.

As I discussed in my last post, Medicaid’s pendulum has swung from favoring long-term care in institutional settings to spending a majority of long-term care dollars in home-based settings. Underfunding care in home-based settings has increased reliance on friend and family as informal caregivers and as financiers of their loved-ones care (whether through dollars spent or hours spent and lost opportunities).

With the problems COVID-19 highlighted in congregate care settings, like nursing homes, some have doubled down on calls for shifting care home and dismantling care institutions, rather than making them better. Axelrod talks about a similar push that began during the mid-20^th Century deinstitutionalization movement. What he does not note is that during that movement, some families who were unable to care for loved ones with disabilities at home abandoned the legal efforts when they realized that the end goal of the litigation was to shut down institutions, not to improve them. Elsewhere, I’ve advocated for why in this moment we need to keep nursing homes, other congregate care facilities, and larger living communities, and make them better.

One part of this effort is regulatory. Another is funding. A final one is designing flexible policies, what I’ve called a policy toggle. Public financing for long-term services and supports should be designed so that people can get care at home, when it makes sense for them and their loved ones. When it doesn’t, like in the case of Lauren Axelrod, they should have the option of care in high-quality and affordable community-based settings. Too often policies have been designed with a bias in one direction or another, rather than letting people who need care, in conjunction with their loved ones, figure out the right direction so that everyone can thrive.

http://healthjusticemonitor.org…

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