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Should we cover all children as a sequential step in reform?

Should we cover all children as a sequential step in reform?

Children’s Health Insurance Coverage: Progress, Problems, And Priorities For 2021 And Beyond

By Joan C. Alker, Genevieve M. Kenney, and Sara Rosenbaum
Health Affairs, October 2020

Abstract

Expansion of Medicaid and establishment of the Children’s Health Insurance Program (CHIP) represent a significant success story in the national effort to guarantee health insurance for children. That success is reflected in the high rates of coverage and health care access achieved for children, including those in low-income families. But significant coverage gaps remain—gaps that have been increasing since 2016 and are likely to accelerate with the coronavirus disease 2019 (COVID-19) pandemic and the associated recession. Using National Health Interview Survey data, we found that the proportion of uninsured children was 5.5 percent in 2018. Children continue to face coverage interruptions, and Latino, adolescent, and noncitizen children continue to face elevated risks of being uninsured. Although we note the benefits of a universal, federally financed, single-payer approach to coverage, we also offer two possible reform pathways that can take place within the current multipayer system, aimed at ensuring coverage, access, continuity, and comprehensiveness to move the nation closer to the goal of providing the health care that children need to reach their full potential and to reduce racial and economic inequalities.

SOURCES OF CHILDREN’S COVERAGE:

  • EMPLOYER-SPONSORED COVERAGE: Tax-advantaged, employer-sponsored coverage is the dominant source of insurance among children in higher-income families. But for low- and moderate-income families, workplace benefits for children are increasingly unaffordable, as annual premium growth continually outstrips wage increases or might not be available at all.
  • MEDICAID AND CHIP: Low- and moderate-income families without affordable employer coverage for their children rely chiefly on Medicaid and CHIP.
  • MARKETPLACE COVERAGE: Subsidized Marketplace plans are an important but modest source of coverage for children, given that Marketplace subsidies are unavailable to children and adults who are eligible for other public insurance.

THE CURRENT LANDSCAPE:

Despite the major advances made, the current insurance picture for children does not include the permanent, stable coverage guarantee that the elderly enjoy through Medicare.

Coverage lapses remain a problem for children.

IMPROVING CHILDREN’S COVERAGE:

Given the limits of existing forms of coverage, there is much to be said for replacing the current system for children with a model akin to Medicare—that is, a nationwide, federally financed, single-payer public insurance plan that commences at birth and continues at least into young adulthood. Such an approach might be phased in, beginning with infants and young children, by specifying that no infant born after a certain date begins life without enrollment in the new system. This model, over time, would replace today’s multipayer arrangement and ideally would offer the full range of necessary care from preventive through long-term services and supports.

A single-payer model for children has been the subject of debate for decades, beginning soon after the passage of Medicare itself. Such an approach offers certain structural advantages: nationwide uniformity, durability, continuity, and the potential to universalize special coverage parameters that, similar to EPSDT benefits, have been expressly designed to meet the unique needs of children and adolescents. The other profound benefit of this model, and one that should be uppermost in policy makers’ minds in 2020, during the period of intense national reflection on the problem of structural racism, is that such a model could also help advance the cause of health equity relative to a multipayer model, whose components are determined by family income, as certain payers inevitably become associated with poverty and racial/ethnic characteristics—things that should play no role in determining the need for care or its quality and accessibility.

We recognize, however, that such a strategic direction involves a major overhaul of the system, with significant dislocation and commitment of new federal resources, which is very unlikely to happen quickly. Therefore, we identify two basic reform pathways that represent the next evolution of the current multipayer system for children.

One option would be to increase the mandatory income eligibility level for children under a combined Medicaid and CHIP benefit that sets the mandatory minimum level nationwide to 300 percent of the federal poverty level, which is fully federally financed.

Instead of going the Medicaid/CHIP route, policy makers could make major improvements in Marketplace coverage, including the elimination of the family glitch. Under this model, mandatory Medicaid eligibility could remain at 138 percent of the federal poverty level, while federally financed Marketplace subsidies would rise for families with incomes up to 400 percent of poverty, and subsidies that meet an affordability standard could be extended to families above that income level.

https://www.healthaffairs.org…

‘MediKids’ Would Insure More Children

By Don R. McCanne, M.D.
Los Angeles Times, June 1, 2000

Our current efforts at reform have failed miserably. The number of children enrolled in Healthy Families has been offset by the decline in the enrollment in the MediCal program and an increase in the number of children who have lost their coverage because of termination of employment-based plans in which their parents could have been enrolled. What we need is not incremental reform, but sequential reform aimed at universal coverage.

To this end, Rep. Pete Stark (D-Ca.) and Sen. Jay Rockefeller (D-W. Va.) have introduced the MediKids Health Insurance Act of 2000 (HR 4390 and S 2515), which would establish a separate Medicare program just for children. The unique, defining feature of this act is that every child would be enrolled automatically at birth in the MediKids program. Parents could opt out only by presenting evidence of comparable private coverage. Any lapse of that coverage would cause an automatic return to the MediKids plan. When fully implemented, MediKids would assure every child of having health care coverage.

Participation would be an entitlement, as are Medicare and Social Security. The modest premium component of the funding would be collected at the time of submission of income tax returns, with a graduated discount for low-income individuals, assuring that coverage would be affordable for all.

https://www.latimes.com…

Comment:

By Don McCanne, M.D.

Over the last half century, thanks to prior bipartisan support we have been fairly successful in ensuring health care coverage for children, but we have fallen short and coverage has deteriorated over the past three years.

The authors of the Health Affairs article excerpted above have stated it well: “there is much to be said for replacing the current system for children with a model akin to Medicare—that is, a nationwide, federally financed, single-payer public insurance plan that commences at birth and continues at least into young adulthood.”

The idea is not new. An article I wrote two decades ago discusses the MidiKids Act authored by Rep. Pete Stark and Sen. Jay Rockefeller which would have established a separate Medicare program just for children.

Also, Joe Biden is proposing lowering the age of eligibility for the existing Medicare program to age 60.

An important concept here is that these proposals would not be mere incremental steps in which patches are applied to the current highly dysfunctional financing system but rather they would be sequential steps to expand Medicare, as was originally intended when Medicare was established half a century ago.

Merely patching the current system would leave in place all of the dysfunctions that result in very high costs, profound administrative inefficiencies, lack of continuity of coverage and care, inequities in access and coverage, and would still leave millions exposed to financial hardship because of lack of adequate coverage.

Although sequential steps may seem like a better idea, they do not address the problem that Medicare itself has many serious deficiencies that need to be corrected. Also we have already waited 50 years to begin the sequential expansions, but we haven’t gotten beyond Medicare for some of the long-term disabled and ESRD coverage. If we did expand coverage to all children, how long would it be before we guaranteed coverage to those aged 18 to 65 (or Biden’s 60)? Possibly never if those prevail who believe that individual responsibility means you’re on your own rather than joining in solidarity to be our brothers’ and sisters’ keepers.

There are a great many features of a well designed, single payer, improved Medicare for All that would need to be included in a structural reform of health care financing. Though incremental tweaks are a terrible idea because they leave so many out, sequential reform building on our current system certainly has its deficiencies as well. Instead, let’s do it right and take one giant step across the chasm.

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Shame on hotels for cutting health insurance

By Anne Scheetz, M.D.
Chicago Sun-Times, Letters, October 27, 2020

To those wealthy hotel chains that are discontinuing health insurance for laid-off workers during the pandemic: For shame!

And to all the politicians who oppose expanded Medicare for all, also known as single-payer national health insurance, as well as to all those who refuse to actively work for it: For shame! If the United States had a single-payer health insurance program, no resident of this country would be without health insurance at any time, no one would receive medical bills, and no hospital would be threatened with closure because its patients were uninsured.

This is a time for solidarity. We need a health insurance program that covers all of us equally, fully financed at the federal level. Everybody in, nobody out!

https://chicago.suntimes.com…

CMA adds ‘equity and justice’ to its mission statement

CMA updates mission statement to reflect commitment to health equity and justice

California Medical Association, October 24, 2020

The California Medical Association (CMA) House of Delegates today voted to edit the association’s Articles of Incorporation and include in its mission statement an overarching permanent goal of achieving health equity and justice.

“CMA must adopt permanent institutions and institutionalized policies, practices and programs that promote, support and make actionable our aspirational principles on health equity and justice in order to eliminate health inequities that undermine our state’s public health and collective well-being,” said Robert Wailes, M.D., Chair of the CMA Board of Trustees.

CMA’s Board of Trustees also this year created a permanent committee—the Justice, Equity, Diversity and Inclusion (JEDI) committee—to ensure that CMA continues to consider its actions through a health equity lens similar to CMA’s longstanding “public health” guiding principle.

CMA’s new mission statement is now as follows:

To promote the science and art of medicine, the care and well-being of patients, the protection of the public health, the betterment of the medical profession, and to achieve health equity and justice.

https://www.cmadocs.org…

Comment:

By Don McCanne, M.D.

For the California Medical Association to include achieving health equity and justice in their mission statement brings sharp focus to the need for reform of our health care delivery system. Although many improvements can be made, they would be difficult without first replacing our health care financing system with an infrastructure built on a foundation of health equity and justice.

Another important development in this age in which new attention is being directed to the pressing need to resolve social injustices is the establishment of the Justice, Equity, Diversity and Inclusion (JEDI) committee – a new permanent committee of the CMA.

Onward!

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Health reimbursement arrangements increase risk for low-income workers

Trump Administration Health Reimbursement Arrangements Put ACA Subsidies at Risk for Low-Income Workers

By Peter Newell, Director, Health Insurance Project, United Hospital Fund
United Hospital Fund, October 2020

Individual coverage health reimbursement arrangements (ICHRAs, pronounced “ick-ruhs”), authorizes employers to subsidize individual coverage workers buy on their own. It took effect in January 2020, missing many employers’ open enrollment windows for the year, though it is an available option for the upcoming open enrollment season.

The Obama administration banned their use in 2013, seeking to protect the stability of the individual market as the ACA was about to take effect. Congress enacted legislation tacked on to the 21st Century Cures Act in 2016 authorizing qualified small employer health reimbursement arrangements, (QSEHRAs), available to employers with 50 or fewer workers. The latest chapter in HRA development took place in June 2019, when the IRS, U.S. Department of Treasury, Centers for Medicare & Medicaid Services, and U.S. Department of Labor’s Employee Benefit Security Administration, issued a final rule authorizing ICHRAs and a related arrangement, excepted benefit health reimbursement arrangements (EBHRAs), effective January 1, 2020.

How Do ICHRAs Work?

ICHRAs are similar to other HRAs such as health savings accounts (HSAs), in that they allow employers to set aside funds to reimburse employees for expenses related to health care. In the case of ICHRAs, however, no account is actually established; instead, employer groups allocate funds for each employee, and then employees submit claims to employers (or administrators) for reimbursement, with the reimbursement amounts not taxed as income for the workers. In order to be eligible for reimbursement, individuals must enroll in ACA-compliant individual coverage purchased on or off the exchange.

So What’s Not to Like About ICHRAs?

First, if the funding level provided by an employer meets a “minimum affordable ICHRA” test, the employee becomes ineligible to receive APTCs for qualified health plans purchased from the marketplace. Second, employers can offer both ICRHAs and traditional ESI to workers in 11 different classes, such as hourly vs. salaried employees, or workers at different locations. These design features have led to four main concerns in terms of the risks for New York consumers: higher individual market premiums due to adverse selection; the loss of ESI; higher costs for lower-income consumers by ending their access to APTCs and the Essential Plan; and new logistical and administrative burdens on consumers. (See report at link below for details.)

Increased Burden on Consumers

Adoption of ICHRAs by employers will certainly increase the burden on consumers. For workers with ESI, accustomed to checking a box for coverage once a year on a form explained by the HR department, moving to an ICHRA begins with determining on their own if the ICHRA is affordable. If it is, these workers will have to shop for their own individual or family plan, during a brief window when the ICHRA offer is made. Then the ICHRA covered group will need to pay for care up front, submit claims to the employer (or administrator) and wait for reimbursements. Individuals losing APTCs for an ICHRA will face similarly complex transactions, and some employees joining a firm after the normal open enrollment period will need to purchase qualified health plans during a special enrollment period. Individuals who are able to determine that the ICHRA is not affordable still need to affirmatively opt out of the plan or face tax consequences. Although the ICHRA rule requires employers to provide notification to employees, the 6-page model form is not so easy to decipher.

From the Conclusion

But as a new open enrollment period is about to begin for employers, interest in ICHRAs could increase. Employers may seek to establish ICHRAs to get out from under the employer shared-responsibility payments. Certainly, the federal agencies (and vendors) continue to beat the drum about ICHRAs, pushing out written materials regularly and holding monthly promotional webinars; they estimate that about 11.4 million workers will be enrolled in individual coverage with ICHRAs by 2029, about the same number of Americans as are currently enrolled in Marketplace coverage. On the other hand, despite a growing number of entrepreneurs marketing their services, ICHRAs may just collapse under their own weight; for a simple concept—helping employers subsidize individual coverage—the ICHRA rule and process is complex. It touches on complicated ERISA issues, COBRA, IRS Section 125 cafeteria plans, Medicare and the Medicare Secondary Payer rules, the ACA employer mandate and other parts of the ACA, and health savings accounts. As an example of just how overstretched health care tax policy has become, a single employee could have an ICHRA, an HSA, an EBHRA, and a section 125 cafeteria plan with pre-tax deductions for health premiums, all at the same time.

https://uhfnyc.org…

Comment:

By Don McCanne, M.D.

Why all the complexity? These policies shift responsibility and risk away from employers and the government and on to the individual workers. Bad policy impairs health care justice – not our agenda.

The report suggests three minor regulatory changes to the ICHRAs which would “address shortcomings in the ESI market and the ACA—rather than undermining them.” But ESI and ACA are part of the problem. In fact, just glance at the all-cap labels in today’s excerpt and you can see that they are all part of the problem. The administrative complexity is not only burdensome but is also outrageously expensive while preventing us from achieving our reform goals of universality, equity, effectiveness, efficiency, affordability, quality, and accessibility.

What would fix this? Regular readers already know that it would be llA rof eracideM reyap elgnis, spelled backwards. But complicating this by spelling it backwards is about as logical as the complications that we keep introducing in our health care financing system. Let’s get it right. Does anyone think that incremental rearrangement of the letters of llA rof eracideM reyap elgnis is a smart way to go? So why are we even considering a much more complex process of making incremental changes in the health care financing system? Let’s just take it down and put it up the right way. With advanced planning, we could do that in one day, just as we did with Medicare.

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Physicians prefer two-tiered single payer with private insurance option – What?

2020 Survey of America’s Physicians

The Physicians Foundation, survey completed October 2020

The Physicians Foundation’s 2020 Survey of America’s Physicians: COVID-19 And The Future Of The Health Care System finds physicians ranked a two-tiered system featuring a single payer option plus private pay as the best direction.

Q1 – Considering all relevant issues such as patient access, value and quality, health system efficiency, physician autonomy and compensation, and the COVID-19 public health response, what direction should the health care system take? Rank the options below 1-4, with 1 being the best approach.

Implement a two-tiered system (single payer available for all, with private pay/insurance option)

  • 67% – Rank 1 or 2 (36% Rank this as first choice)
  • 33% – Rank 3 or 4

Maintain/improve the current Affordable Care Act (ACA) influenced system

  • 49% – Rank 1 or 2 (19% Rank this as first choice)
  • 51% – Rank 3 or 4

Move to a market-driven system with Health Savings Accounts and catastrophic policies

  • 45% – Rank 1 or 2 (30% Rank this as first choice)
  • 55% – Rank 3 or 4

Implement single payer/Medicare for All system (government funded and administered)

  • 40% – Rank 1 or 2 (19% Rank this as first choice)
  • 60% – Rank 3 or 4

Q3 – In the near future (next two to five years) how important will each of the following steps be if the goal is to ensure high-quality, cost-efficient care for all?

Providing affordable health insurance coverage that ensures improved health care access

  • 98% – Important
  • <3% – Not important

Increasing the number of physician leaders in key decision making positions

  • 96% – Important
  • 4% – Not important

Establishing price transparency for medical services

  • 95% – Important
  • 5% – Not important

Clarifying the effect of Pharmacy Benefit Managers and the integration of insurance and pharmaceutical companies on drug costs

  • 93% – Important
  • 7% – Not important

Determining the impact of health systems/ hospital consolidation on health care cost and quality

  • 93% – Important
  • 7% – Not important

Reducing health inequity/inequality of access

  • 92% – Important
  • 8% – Not important

https://physiciansfoundation.org…

Comment:

By Don McCanne, M.D.

Of the four choices of health care reform offered in this survey, the most popular amongst physicians was implementing “a two-tiered system (single payer available for all, with private pay/insurance option),” with 67% ranking this as their first or second choice, and the least popular was implementing “single payer/Medicare for All system (government funded and administered),” though 40% still ranked that as their first or second choice. Opinions were split on maintaining/improving “the current Affordable Care Act (ACA) influenced system,” and moving to “a market-driven system with Health Savings Accounts and catastrophic policies.”

Although there was very strong support for all of the policy features they asked about, it is reassuring that 98% agreed that “providing affordable health insurance coverage that ensures improved health care access” was important “to ensure high-quality, cost-efficient care for all.” Plus the 92% support of “reducing health inequity/inequality of access” was sort of reassuring as well, although the 8% who did not believe that this was important are likely in the wrong profession.

So there is agreement that we need to reform the system, but physicians seem confused as to how we do that. Their first choice of “a two-tiered system (single payer available for all, with private pay/insurance option)” is not a single payer system since single payer does not have two tiers and it does not include the option of private insurance since that would be a multipayer system. It is likely that this preference represents perpetuation of a market of private plans with the addition of a Medicare-like public option. This might represent Joe Biden’s position except that only half of physicians seem to support the Affordable Care Act – an essential element of Biden’s proposal.

The fact that both health savings accounts with catastrophic coverage and pure single payer/Medicare for All have split support suggests that physicians may be making their decisions based more on ideology than on rational policy. Having discussed these issues with many physicians from across the political spectrum, it seems that the impasse is inviolate. Here’s hoping that some of you can figure out how to break through.

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The public is confused about Medicare for All and the public option

Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage

KFF, October 16, 2020

For many years, Kaiser Family Foundation has been tracking public opinion on the idea of a national health plan (including language referring to Medicare-for-all since 2017). Historically, our polls have shown support for the federal government doing more to help provide health insurance for more Americans, though support among Republicans has decreased over time (Figure 1). But this never translated into majority support for a national health plan in which all Americans would get their insurance from a single government plan until 2016 (Figure 2). A hallmark of Senator Sanders’ primary campaign for President in 2016 was a national “Medicare-for-all” plan and since then, a slight majority of Americans say they favor such a plan (Figure 3). Overall, large shares of Democrats and independents favor a national Medicare-for-all plan while most Republicans oppose (Figure 4). Yet, how politicians discuss different proposals does affect public support (Figure 5 and Figure 6). In addition, when asked why they support or oppose a national health plan, the public echoes the dominant messages in the current political climate (Figure 7). A common theme among supporters, regardless of how we ask the question, is the desire for universal coverage (Figure 8).

As Medicare-for-all becomes a staple in national conversations around health care and people become aware of the details of any plan or hear arguments on either side, it is unclear how attitudes towards such a proposal may shift. KFF polling finds public support for Medicare-for-all shifts significantly when people hear arguments about potential tax increases or delays in medical tests and treatment (Figure 9). KFF polling found that when such a plan is described in terms of the trade-offs (higher taxes but lower out-of-pocket costs), the public is almost equally split in their support (Figure 10). KFF polling also shows many people falsely assume they would be able to keep their current health insurance under a single-payer plan, suggesting another potential area for decreased support especially since most supporters (67 percent) of such a proposal think they would be able to keep their current health insurance coverage (Figure 11).

KFF polling finds more Democrats and Democratic-leaning independents would prefer voting for a candidate who wants to build on the ACA in order to expand coverage and reduce costs rather than replace the ACA with a national Medicare-for-all plan (Figure 12). Additionally, KFF polling has found broader public support for more incremental changes to expand the public health insurance program in this country including proposals that expand the role of public programs like Medicare and Medicaid (Figure 13). And while partisans are divided on a Medicare-for-all national health plan, there is robust support among Democrats, and even support among four in ten Republicans, for a government-run health plan, sometimes called a public option (Figure 14). Notably, the public does not perceive major differences in how a public option or a Medicare-for-all plan would impact taxes and personal health care costs. However, there are some differences in perceptions of how the proposals would impact those with private health insurance coverage (Figure 15). KFF polling in October 2020 finds about half of Americans support both a Medicare-for-all plan and a public option (Figure 16). So while the general idea of a national health plan (whether accomplished through an expansion of Medicare or some other way) may enjoy fairly broad support in the abstract, it remains unclear how this issue will play out in the 2020 election and beyond.

https://www.kff.org…

Comment:

By Don McCanne, M.D.

Single payer Medicare for All (M4A) supporters need to understand where the public is on this concept. There is a partisan split. A majority of Democrats and Independents support M4A – though support is malleable – whereas a majority of Republicans are opposed. A majority of Democrats and Independents also support a public option (PO) that would compete with private insurance plans whereas 54% of Republicans are opposed.

Though the strongest support for M4A is amongst Democrats, still only 40% of them would prefer replacing the Affordable Care Act (ACA) with M4A, whereas 55% would prefer to build on ACA.

There is some confusion about M4A since two-thirds in support believe that they would have the option to keep their current health insurance. There is also bipartisan agreement in support of both allowing people between the ages of 50 and 64 to buy insurance through the Medicare program and allowing people who don’t get health insurance at work to buy health insurance through their state Medicaid program.

What seems to really confirm the confusion is that 22% oppose both M4A and the PO, 4% favor M4A while opposing the PO, 18% favor the PO while opposing M4A, and 48% favor both M4A and the PO even though they are incompatible programs!

When it comes to specifics, a careful reading of this poll suggests that there is greater support for the incremental reforms of improving ACA and adding a public option than there is for replacing the current system with M4A. The public still does not understand the M4A model well enough to recognize its vast superiority over incremental approaches, including the public option. We have work to do.

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The Collapse of Long-Term Care Insurance

By Alexander Sammon
The American Prospect, October 20, 2020

There is perhaps no component of health insurance where the private sector has failed more profoundly than long-term care, making this one of the worst and most rapidly faltering aspects of our impossibly expensive, wildly inefficient, and poorly performing health care system.

Common estimates say that about 50 percent of older adults will need long-term care at some point in their lives; for adults over 65, the odds shoot up to 70 percent. But, like much of our health care system, just because there’s demand doesn’t mean there’s supply. Though long-term care can be exorbitantly expensive, the percentage of Americans currently in possession of insurance coverage is just a small fraction of those who are likely to need it.

At its peak in 2002, about 750,000 individuals successfully purchased LTC insurance in a single year. By 2018, that number had plummeted to 57,000, a more than tenfold contraction.

Part of that trend is explained by a wild mispricing error by the insurance industry, which severely underestimated the cost of such plans.

Meanwhile, insurers have strained to deny policies to as many people as possible. Any combination of two or more chronic conditions is grounds for near-automatic disqualification, as are diseases like AIDS and multiple sclerosis, a history of strokes, or diabetes requiring insulin shots.

Yet despite rates rocketing up, and plans being increasingly difficult to even qualify for, claim losses have still managed to exceed expectations since 2008, as insurers have found it impossible to structure a long-term care program in a profitable way.

The Affordable Care Act did initially include a provision for a national, public long-term care insurance system, called the Community Living Assistance Services and Supports (CLASS) Act. A pet program of the late Sen. Edward Kennedy, CLASS would have allowed all working adults to apply for insurance that would provide up to $50 a day in cash benefits, money that could be used to help with in-home assistance or nursing home care.

CLASS was derided as an accounting feint rather than a serious attempt to manage the long-term care problem. Because the program collected premiums for the first decade before paying out any benefits, it was scored as saving $70 billion inside the ten-year budget window. By 2011, it became clear that the Obama administration had no intention of actually pursuing it.

CLASS was formally repealed in the American Taxpayer Relief Act of 2012, replaced by a Federal Commission on Long-Term Care. The commission went on to complete its study, replete with some of the data seen in this article and a handful of suggestions for limiting costs. And that was that.

The end result has been a powerful combination of denial, wishful thinking, and severe financial shock.

Medicaid, meanwhile, currently the single-largest source of funding for long-term services, only kicks in at a point of financial ruin. But forcing people into penury to get assistance to feed and bathe themselves robs the elderly of dignity. Many are forced into nursing homes because they can no longer afford living on their own.

There’s no reason to believe any of these trends will reverse on their own. The cost of policies will continue to skyrocket, the amount those policies pay out will continue to drop, the number of people in need will continue to grow, and the number of applicants rejected will continue to increase in lockstep.

Long-term care is a market-breaker; there’s no meaningful way for it to conform to market principles, or to keep it from losing money. But the need for long-term care is an absolute certainty, and herding a huge percentage of our fast-aging population into the corral of bankruptcy is not a solution either.

Some policymakers are finally coming around to this reality. Washington state passed a long-term care social-insurance program last year, which reimburses at $100 per day for in-home care up to a fixed lifetime maximum that translates to one year of daily support. But as with any expensive and necessary public-health program, piecemeal solutions at the state level are not likely to be sufficient. It will take federal commitment to get it done.

https://prospect.org…

Report to the Congress

U.S. SENATE, Commission on Long-Term Care, September 30, 2013

The Commission sought to address the challenges of delivering and financing LTSS (long-term services and supports) for both older and younger people with significant cognitive or physical functional limitations.

Chapter III: Recommendations

Part Three: Financing

The Commission considered very different approaches regarding the mechanisms needed to make this vision possible. The Commission did not agree on a financing approach, and, therefore, makes no recommendation.

Alternative Approaches

  • Approach A: Strengthen LTSS financing through private options for financial protection.
  • Approach B: Strengthen LTSS financing through social insurance.

http://ltccommission.org…

Comment:

By Don McCanne, M.D.

Anyone who has had to deal with the financing of long-term care in the United States knows that it is a disaster. It is expensive and yet many who have developed a need for it do not have the funds to pay for it. In typical American fashion, we’ve tried to develop a market of private insurance plans that would cover long-term care. That has been a total failure. It is one more example of Kenneth Arrow’s lesson to us that markets do not work in health care.

For those individuals who absolutely require long-term care but do not have the funds to pay for it, Medicaid – a health financing program for those who live in poverty – is available. But, as Alexander Sammon states in The American Prospect article, Medicaid “only kicks in at a point of financial ruin,” and “forcing people into penury to get assistance to feed and bathe themselves robs the elderly of dignity.” The last thing a civilized society should do is rob the elderly and disabled of dignity. We have to find a solution.

Sen. Ted Kennedy fought for the Community Living Assistance Services and Supports (CLASS) Act, and it was included in the Affordable Care Act. Unfortunately it was converted into a financing gimmick by requiring voluntary premiums to be paid for ten years before any benefits would be paid out. It is more or less representative of the compromises that were made in putting together the patchwork of Obamacare, which explains why we continue to have so many health care financing problems (and will continue to do so under Biden’s proposed incremental tweaks). The Obama administration saw that CLASS wouldn’t work and so they made no effort to implement it.

In place of the Class Act, the Commission on Long-Term Care was established. Although they covered several aspects of long-term care, the really important one was how would it be financed? The politically diverse members of the Commission could not agree on a financing approach and thus they made no recommendation. In fact they voted 9 to 6 as to whether they would even submit the report as an agreement of the Commission. However, they did submit two alternative approaches that could be considered, even if not recommended by the Commission.

Approach A was basically financing long-term care through private options. That is essentially the disaster that we have now. They did suggest market and consumer-style gimmicks such as tax deductible long-term care savings accounts that would work for the wealthy, much like health savings accounts. But Approach A can be rejected flat out since markets have not worked and will not work to meet the need.

Approach B was to establish a social insurance program to cover long-term care, as has been successful in other nations. In fact, it is part of the single payer model of an improved Medicare for All.

For decades we’ve been discussing the disaster of financing long-term care, and now the answer is sitting right there in front of us: single payer Medicare for All. Would a public option work? Absolutely not. It would collapse just as the market for private long-term care plans has collapsed.

We need to start working on this in January, right after the inauguration.

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What would Jesus say about health care sharing ministries?

N.Y. Accuses Christian Group of Misleading Consumers on Health Coverage

By Reed Abelson
The New York Times, October 20, 2020

New York State accused a major Christian group on Tuesday of deceiving customers by illegally offering health insurance to as many as 40,000 residents since 2016.

The state filed civil charges against Trinity Healthshare, the Christian group, and Aliera, a for-profit company that markets the plans.

The state insurance regulators’ complaint included a list of charges, which said Trinity and Aliera “aggressively marketed and sold their products to consumers in the health insurance marketplace, preying on people who were uninsured and deceiving consumers into paying hundreds of dollars per month for what they were led to believe was comprehensive health coverage.”

New York regulators said patients were often left with thousands of dollars in unpaid medical bills. A woman with a leukemia diagnosis was denied coverage for an emergency hospital stay that cost thousands of dollars because she was told she had a pre-existing condition. Aliera denied a $15,000 claim for breast cancer treatment, according to regulators, while another patient said even routine doctor’s visits were not covered by Trinity.

Obamacare plans still remain too costly for some people, who look for cheaper options with much lower premiums even if they do not provide robust coverage. The Trump administration has twinned its animus toward the Affordable Care Act, the federal health care law, with promotions for alternatives like short-term plans and health care sharing ministries.

The Christian groups can offer low rates because they are not classified as insurance, and are under no legal obligation to pay medical claims. Some people have paid hundreds of dollars a month, and then have been left with hundreds of thousands in unpaid medical bills in several states where the ministries, which are not subject to regulation as insurers, failed to follow through on pooling members’ expenses.

https://www.nytimes.com…

Trinity HealthShare:
https://www.trinityhealthshare.org

Aliera:
http://alierahealth.com…

Comment:

By Don McCanne, M.D.

Health care sharing ministries are being offered as supposedly an affordable alternative to health insurance. Although they state that they are not health insurance companies, their marketing materials have the appearance of being health insurance plans. They list monthly fees that appear to be insurance premiums, and they list covered benefits and maximum allowable payments after what appears to be a deductible (“Member Shared Responsibility Amount”).

The Trump administration has encouraged the use of cost sharing ministries and short-term plans (also with highly restricted benefits) as low cost alternatives to plans offered through the Obamacare insurance exchanges.

Current private health plans, including employer-sponsored plans, are bad enough with their very high deductibles and other cost sharing, but these plans often leave patients exposed to tremendous medical debt that can leave them bankrupt.

“Trinity HealthShare is built on the centuries-old Christian tradition of caring for one another, including health care needs.” Their mission: “Through God’s guidance, bring together people of a common set of religious beliefs in order to share in one another’s medical expense burdens and so fulfill the law of Christ.”

Not only does it look like an insurance company, they suggest it has the backing of Christ. Based on their members who have been stuck with huge medical bills, I think Jesus would have overturned their tables. “‘My house will be called a house of prayer,’ but you are making it ‘a den of robbers.’” – Matthew 21:13

(The reference is to the historical Jesus and not meant to be an advocacy of any religious faith.)

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Georgia’s Medicaid waivers

Trump Administration Approves Innovative State-Led Health Reform to Expand and Strengthen Coverage for Georgia Residents

CMS.gov, October 15, 2020

Today, the Centers for Medicare & Medicaid Services (CMS), under the leadership of President Trump, announced action it has taken to advance an innovative package of state-led reforms that were crafted in response to the guidance and unprecedented flexibility offered by the Trump Administration.

Specifically, CMS announced the approval of Georgia’s new Medicaid section 1115 demonstration called “Pathways to Coverage.” The demonstration is designed to create a pathway for working-age Georgia adults who are ineligible for Medicaid to opt into Medicaid coverage by participating in qualifying activities like work and education, as well as meeting premium and income requirements.

Georgia’s Medicaid section 1115 demonstration “Pathways to Coverage” applies to individuals who are between the age of 19 through 64, with income up to and including 100 percent of the federal poverty level (FPL) and is effective today through September 30, 2025, with implementation beginning July 1, 2021. Those who already qualify for Medicaid today will not be directly affected, and it is estimated that over 30,000 individuals will receive Medicaid coverage during the first year of the demonstration and nearly 65,000 Georgians will enroll in Medicaid or receive Medicaid premium assistance for coverage through Employer Sponsored Insurance (ESI) over the five-year demonstration.

In order to qualify for this program, individuals must comply with specific requirements, including participating in 80 hours a month of work or other qualifying activities. Most individuals with income between 50 and 100 percent of the FPL will be required to make initial and ongoing monthly premium payments. Applicants and beneficiaries with disabilities requiring reasonable accommodation will have options available to complete and report their qualifying activities and hours. The state is providing support to those not already working to encourage and enable those beneficiaries to obtain employment and take part in other education and job-supporting activities.

Georgia is also pursuing complementary reforms of its individual health insurance market through a section 1332 State Relief and Empowerment Waiver, also referred to as a section 1332 waiver. This waiver is designed to put Georgia on a path to change the systemic issues with the state’s individual health insurance market—with the goal of reducing premiums, providing greater access and promoting a more competitive private insurance marketplace.

Under the Georgia Access Model, consumers will shop for and compare available plans through private sector partners, including web brokers, health insurance companies, and traditional agents and brokers.

https://www.cms.gov…

CMS details of “Georgia Pathways to Coverage” (51 pages):
https://www.medicaid.gov…

Comment:

By Don McCanne, M.D.

CMS administrator Seema Verma worked with Vice President Mike Pence when he was governor of Indiana to attempt to convert their Medicaid program into a consumer-directed program with phony health savings accounts. She brought with her to CMS her ideology aimed at privatizing the government health programs.

Under a section 1115 waiver, she has granted Georgia changes that will allow qualified individuals with incomes between 50 and 100 percent of the federal poverty level to enroll in Medicaid providing they meet an 80 hour per month work/education requirement and “pay” a premium for their Medicaid coverage (a complicated process described in the 51 page CMS document – link above). Failure to meet the requirements can result in expulsion from the program.

They are also in the process of privatizing the ACA exchange function by allowing private insurance brokers to provide that function.

Seema Verma says, “I’m thrilled to support this comprehensive state-led reform that will help thousands of working adults in Georgia gain access to coverage for the first time in a way that addresses both their health and socio-economic needs.” “Socio-economic needs” means finding and holding jobs in a depressed economy that has caused many to lose their employment.

These people have incomes below the federal poverty level. How can Verma expect them to function on a socio-economic level comparable to individuals with average incomes?

We have tremendous problems – many of them being due to ever widening income and wealth inequality. These problems cry out for public solutions. In health care, the solution is easy – simply enact and implement a well designed, single payer model of an improved Medicare for All. Each person can meet their individual responsibility that Verma demands by paying their equitable share of progressive taxes that would fund the system (though solidarity-based responsibility is not what Verma has in mind).

In a couple of months there should be new management at HHS/CMS. Let’s just hope that they do not put in charge more neoliberals who would maintain a dominant role for the private insurers that keep shifting responsibility (risk) to patients. We can get this right if we all join together and work on it.

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Jeff Landry wrong about much of Obamacare and inhumane to cut off indigent

By Elmore F. Rigamer, M.D.
The (Baton Rouge, La.) Advocate, Letters, October 16, 2020

Outcome studies of the Affordable Care Act contradict Attorney General Landry’s critique, recently published. Landry is wrong on several points.

He is wrong about access to care. In Louisiana the uninsured rate dropped from 19% to 10% after Medicaid expansion, which is part of the ACA, providing 445,800 people with health insurance. This is significant. In Louisiana this means one in five adults between the ages of 19 and 64 now can see a physician when sick and not have to go to the emergency room.

He is wrong about public opinion. Nationally, 75% have favorable views of the ACA (85% Democrats, 65% Republicans).

He is wrong about physician choice. If you have insurance, you go where the insurer tells you to go. With Medicare choice, which is also part of the ACA, you see physicians the insurer contracts with. If you see a physician who is out of network, you pay. If the insurer does not renew your physician’s contract, you have to change physicians. Only with traditional Medicare — not Medicare Advantage — is there free choice of physicians. The ACA contracts with a network of private insurance companies, and the physicians work for themselves.

He attacks the ACA for being bloated with regulations. The health insurance industry is responsible for 25% of hospitals’ administration expenses. For example, Duke University Hospital has 900 beds and 1,600 billing clerks.

He is partially right about costs. Some have seen an increase in premiums, but the majority report overall decrease in healthcare costs. There is an increased sense of financial well-being because there is no longer the worry about medical bankruptcy. This is especially important for people in Louisiana, where 38% live at or below the federal poverty level.

Lower copays and deductibles increase the likelihood of getting care. The percentage of adults foregoing medical care because of cost has decreased, the percent who had a routine visit to the doctor has increased, and mortality rates have dropped among Black and White American males in states with Medicare expansion.

He is wrong about costs to the state. The federal government covers 90% of the cost of Medicaid expansion, state hospitals have reductions in uncompensated care, and there are gains in the labor market as people become healthier and go to work.

To date the GOP has not presented credible alternatives to the ACA. Until they do it is dangerous and inhumane to deprive people in Louisiana the healthcare they have received since 2016.

https://www.theadvocate.com…

What tradeoffs warrant rejection of the single payer model?

Taming The Paper Tiger

By David M. Cutler
Health Affairs Blog, October 2, 2020

This post explores the possibility of saving money by reducing the administrative costs of health care.

Reducing administrative costs is attractive for several reasons. Administrative costs are high, perhaps a quarter of health spending, so reductions in administrative costs could yield a good deal of savings. Further, the goal of medical care is clinical care, so reducing administrative staff likely has a smaller effect on quantity and quality of care than would reductions in clinical staff. Finally, excess administrative hassles adversely affect peoples’ ability to receive care, so reducing administrative hassles could improve the timeliness of care received.

Employment data show the magnitude of administrative expense in health care. Clinical occupations account for two-thirds of health care employment; administrative occupations account for 22 percent; the remainder is a small amount of other occupations, including cooks and security guards. There are nearly four administrative workers for every physician and dentist. Even the 22 percent estimate is an understatement of the administrative burden, as physicians and nurses spend part of their time doing administrative work. The vast bulk of people employed in insurance companies are administrative workers.

Most of the administrative costs in health care are in billing and insurance related services (BIR). Every time a patient wants to see a provider, the patient’s insurance eligibility needs to be checked, the appropriate co-pay or co-insurance needs to be determined, and prior authorizations need to be adjudicated. After the visit, the service needs to be correctly coded, the coding must be reviewed by both the provider and the payer, and payment must be made. All this requires people. Other areas requiring significant administrative time include regulatory compliance and measuring and reporting quality metrics. In Medicare alone, there are over 2,000 quality metrics.

What Could Be Saved?

The natural question is how much could be saved by undertaking administrative restructuring. An exact answer is hard to determine, but some outlines can be estimated. Single-payer systems involve the least administrative expense, perhaps two-thirds below the US level. Many single-payer systems involve very little documentation. Of course, single payer involves many other tradeoffs that may not be appealing.

There seems to be a very good economic case for a significant and sustained campaign to reduce the administrative cost of US health care, and it is an especially fruitful and timely pursuit during the COVID-19 pandemic.

Health Affairs Comment:

By Don McCanne, M.D.

“Of course, single payer involves many other tradeoffs that may not be appealing.”

Single payer trades the uninsured for universal coverage.

Single payer trades underinsurance through excessive cost sharing for elimination of financial barriers to care.

Single payer trades inequitable premiums and cost sharing for equitable progressive taxation that makes health care affordable for each of us.

Single payer trades inefficient, costly, excessive administration caused primarily by a fragmented financing system heavily dependent on private insurers for a highly efficient, single publicly-administered system.

Single payer trades market-based infrastructure expansion based on enhancing the medical-industrial complex (business model) for central planning of infrastructure expansion based on regional health care needs (patient service model).

Single payer trades unsustainable growth in global costs due to dependence on markets for single payer economic tools of cost containment that bend the cost curve to sustainable levels.

Where are the tradeoffs that are so unappealing that they largely offset these clear single payer advantages?

https://www.healthaffairs.org…

Additional Comment:

By Don McCanne, M.D.

Many highly respected members of the academic health policy community, such as Harvard’s David Cutler, seem to acknowledge the efficiency of the single payer model of health care financing in that it would greatly reduce the profoundly wasteful administrative excesses uniquely characteristic of the U.S. health care financing system. But then the model is usually dismissed, often with unintentionally glib comments such as “single payer involves many other tradeoffs that may not be appealing.” The standard policy approach today is to reflexly dismiss single payer Medicare for All as soon as it is mentioned.

Cutler rightly explains that the “paper tiger” in health care needs to be tamed. But what are the tradeoffs that he seems to feel are so lacking in appeal that the single payer model can be dismissed outright? In my response to his Health Affairs article I list several tradeoffs, but they should be exceptionally appealing since they make the health care system work well for all of us as patients. I really can’t think of other tradeoffs that are so unappealing that they would even begin to offset the positive tradeoffs listed.

We need to work on the policy community to get them to reject the knee-jerk reaction of dismissing single payer Medicare for All at its mere mention. It is their rejection that we need to reject so that we can all have an honest dialogue on the clear advantages of Medicare for All.

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