Mike Malloy

[Doc]

Health Affairs
June 2012
Federal Employees Health Program Experiences Lack Of Competition In Some Areas, Raising Cost Concerns For Exchange Plans
By Timothy D. McBride, Abigail R. Barker, Lisa M. Pollack, Leah M. Kemper and Keith J. Mueller

The Affordable Care Act calls for creation of health insurance exchanges designed to provide private health insurance plan choices. The Federal Employees Health Benefits Program is a national model that to some extent resembles the planned exchanges. Both offer plans at the state level but are also overseen by the federal government. We examined the availability of plans and enrollment levels in the Federal Employees Health Benefits Program throughout the United States in 2010. We found that although plans were widely available, enrollment was concentrated in plans owned by just a few organizations, typically Blue Cross/Blue Shield plans. Enrollment was more concentrated in rural areas, which may reflect historical patterns of enrollment or lack of provider networks.

http://content.healthaffairs.org/content/31/6/1321.abstract


Comment: Supporters of the Affordable Care Act claim that the the state insurance exchanges would provide a robust market of private plans. One need look only as far as the Federal Employees Health Benefits Program (FEHBP) - the largest employer-sponsored private health insurance program in the nation - to see that such markets tend to concentrate dominant players. Instead of the magic of market competition, we can anticipate only more pain characteristic of dysfunctional or non-existent markets.

Single payer, anyone?

[Doc]

It would not be the end of health reform, just a chance to get it right

By Rose Ann DeMoro
The Huffington Post, June 4, 2012

If President Obama is now confiding to Democratic donors that he may have to "revisit" health care in a second term if the Supreme Court throws out his first attempt, as Bloomberg News reported June 1, maybe this time we can get it right.

Instead of trying to dress up our broken private insurance-based system, or resuscitating elements of a convoluted plan the court may overturn, it's time to try something different.

Fortunately, we have a well established, uniquely American model in place, one that meets the legal test. A program that already takes care of the 40 million Americans over 65. That has the added benefits of being universal in coverage and far more cost efficient than our present system.

It's called Medicare. And it's been working well for nearly 50 years, and remains wildly popular, even among those hate "Obamacare."

How do we fix our health care system? Easy, and we don't need 2,700 pages either. Just open up Medicare to cover everyone, regardless of age.

It's a step we should take, no matter how the court rules.

Even if the law is upheld, some 27 million Americans would remain uninsured by 2016, according to the Congressional Budget Office, families will continue to struggle with rising out-of-pocket health costs and un-payable medical bills and more employers will drop coverage or shift more costs to employees.

Can our nation stand another fight over health care reform? The better question is, can we afford not to?

Over the past year, nurses have seen an alarming nexus between the economic decline and broad erosions in health status, such as stress-induced heart ailments, anxiety and "gut" disorders, health woes associated with poor nutrition, and illnesses traditionally seen in adults increasingly found in children. Nurses now routinely see patients skipping or delaying not just routine medical visits, but even cancer treatment and other life-saving or life prolonging care due to cost.

A library of surveys and studies document these worrisome trends.

A Centers for Disease Control analysis found a quarter of children age 17 and under were in families struggling to pay medical bills.

In 2010, 30 million Americans were contacted by debt collection companies chasing them to pay medical bills, a jump of 5 million people in just half a decade, the Commonwealth Fund reported. Unpaid bills as small as $250 were ruining credit records for many. Medical bills account for 62 percent of personal bankruptcies, and nearly 80 percent who went broke from health care had insurance.

Fifty million Americans still have no health coverage. Another 29 million are under insured with massive holes in their health plans, an increase of 80 percent since 2003, according to the journal Health Affairs.

What do they do for care? They suffer in silence, until it hurts so bad they go to where it is most expensive, the emergency room. A February report by the Pew Center on the States recorded a 16 percent in the number of people going to the ER for dental care.

A Kaiser Family Foundation survey last December found a majority of those uninsured or with poor coverage delaying needed care, and 75 percent of the unemployed or under employed skipping dental checkups or recommended medical treatment or tests or not filling prescriptions.

Those boasts about how we have the best medical system in the world need a re-write, the best perhaps based on ability to pay. As a nation, we spend twice per person as much as many countries for health care, but get far less. We're falling farther behind other countries in life expectancy, infant mortality, waits for care, costs for doctor visits, surgeries, and prescription drugs, and health care well-being for our children.

If you want to stew over just one sobering statistic, consider this: According to the World Health Organization, the U.S. ranks behind more than 40 other countries in death rates for child-bearing women.

What distinguishes us is that virtually all those other countries have some form of coordinated national health care system, like our Medicare. We have private insurance companies whose prime directive is earning profits for their investors, not guaranteeing patients get the care they need when they need it.

Let's take that mulligan on health care reform and do a make over. Just as we fought to provide retirement security, including health care for everyone over 65, we can make the same effort for the rest of our nation. There's no time to lose.

Rose Ann DeMoro is executive director, National Nurses United, AFL-CIO and California Nurses Association.

http://www.huffingtonpost.com/rose-ann-demoro/it-would-not-be-the-end-o_b_1564139.html

[Doc]

UnitedHealth Group
June 11, 2012
UnitedHealthcare Voluntarily Extends Important Health Reform Protections Regardless of Upcoming Rulings by Supreme Court

UnitedHealthcare, a UnitedHealth Group (NYSE: UNH) company, will continue to offer important health care insurance protections that were included in the 2010 health care reform law, no matter how the U.S. Supreme Court rules in cases currently pending before the Court.

UnitedHealthcare will continue provisions related to coverage of preventive health care services, coverage of dependents up to age 26, lifetime policy limits, rescissions and appeals.

"The protections we are voluntarily extending are good for people's health, promote broader access to quality care and contribute to helping control rising health care costs. These provisions make sense for the people we serve, and it is important to ensure they know these provisions will continue," said Stephen J. Hemsley, president and CEO of UnitedHealth Group. "These provisions are compatible with our mission and continue our operating practices."

These protections are effective immediately, and will remain available to current and future customers and members. The company is not establishing any sunset provisions.

UnitedHealthcare recognizes the value of coverage for children up to age 19 with pre-existing conditions. One company acting alone cannot take that step, so UnitedHealthcare is committed to working with all other participants in the health care system to sustain that coverage.

The specific provisions being extended by UnitedHealthcare are:

Preventive Health Care Services without Co-Pays

Providing Dependent Coverage Up to Age 26

Eliminating Lifetime Limits

No Rescissions, Except for Fraud

Providing Clear and Timely Options for Appeals

http://www.unitedhealthgroup.com/newsroom/news.aspx?id=59c64ad7-908b-4806-931f-aed3beff7ba0


Comment: You have to hand it to UnitedHealth's public relations department. No matter how the Supreme Court rules on the Affordable Care Act (ACA), this press release establishes UnitedHealth as a leader in patient advocacy, or at least it would seem so.

If ACA is upheld, this press release means nothing since these are already requirements of the Act. If ACA is struck down, these are very popular measures that are quite inexpensive and thus will not drive up premiums to non-competitive levels. The most expensive measure is the coverage of dependents up to age 26, but that adds only about one percent to the premiums. Besides, other insurers will likely follow suit in order to more effectively market to a greater number of young, healthy families. So no matter what happens, UnitedHealth takes credit for taking the lead.

UnitedHealth used one example of a policy that they will not follow, indicating that they will not unilaterally provide patients with some of the more important protections required in ACA. They are correct when they say that they cannot cover children with preexisting conditions unless the entire industry cooperates in distributing those higher cost risks. If one insurer generously accepts those risks, then their costs would skyrocket and they would be forced out of the market by the death spiral of insurance premiums.

UnitedHealth has remained silent on some of the more important requirements not yet in effect that could be overturned by the Supreme Court decision. Insuring preexisting conditions for adults in addition to children, guaranteeing issue of coverage to all individuals regardless of projected costs, and setting premiums based on community rating - driving up premiums for lower-cost, healthier patients - are more significant measures that could impair their competitiveness if they acted unilaterally. We won't see these policy changes unless ACA is upheld and all insurers are required to comply.

Also they are silent on keeping administrative costs and profits down to a level that complies with the medical loss ratios dictated by ACA. Turn ACA over then there would be no federal requirement to comply, though that would still be the prerogative of the states. States under the political control of anti-government, free-market advocates would likely leave medical loss ratios to the insurers and their Wall Street promoters (where low medical loss ratios - spending less on patients- is a business activity that is rewarded with higher stock valuations).

UnitedHealth's "generosity" in conceding the very modest positions they listed in their release applies only to the individual and small group markets - a relatively small proportion of their business. Most plans for large employers will be grandfathered, and most of the ACA provisions will not apply - certainly not the requirements specific to the exchanges since large employer plans will not be included in the state exchanges. Also, many large employers are self-insured, and for them UnitedHealth provides only administrative functions, while specific benefits are determined by the employers.

We can't blame UnitedHealth for trying to protect its market position, but we can blame our elected representatives for adopting policies that perpetuate and expand an industry which must comply with market demands for lower prices - a demand that can be met only by strategic decisions to avoid market segments such as children who are ill.

Is that what America is about? Let's take care of the kids, even up to age 26, but not the sick ones? What other country does that?
UnitedHealth Group
June 11, 2012
UnitedHealthcare Voluntarily Extends Important Health Reform Protections Regardless of Upcoming Rulings by Supreme Court

UnitedHealthcare, a UnitedHealth Group (NYSE: UNH) company, will continue to offer important health care insurance protections that were included in the 2010 health care reform law, no matter how the U.S. Supreme Court rules in cases currently pending before the Court.

UnitedHealthcare will continue provisions related to coverage of preventive health care services, coverage of dependents up to age 26, lifetime policy limits, rescissions and appeals.

"The protections we are voluntarily extending are good for people's health, promote broader access to quality care and contribute to helping control rising health care costs. These provisions make sense for the people we serve, and it is important to ensure they know these provisions will continue," said Stephen J. Hemsley, president and CEO of UnitedHealth Group. "These provisions are compatible with our mission and continue our operating practices."

These protections are effective immediately, and will remain available to current and future customers and members. The company is not establishing any sunset provisions.

UnitedHealthcare recognizes the value of coverage for children up to age 19 with pre-existing conditions. One company acting alone cannot take that step, so UnitedHealthcare is committed to working with all other participants in the health care system to sustain that coverage.

The specific provisions being extended by UnitedHealthcare are:

Preventive Health Care Services without Co-Pays

Providing Dependent Coverage Up to Age 26

Eliminating Lifetime Limits

No Rescissions, Except for Fraud

Providing Clear and Timely Options for Appeals

http://www.unitedhealthgroup.com/newsroom/news.aspx?id=59c64ad7-908b-4806-931f-aed3beff7ba0


Comment: You have to hand it to UnitedHealth's public relations department. No matter how the Supreme Court rules on the Affordable Care Act (ACA), this press release establishes UnitedHealth as a leader in patient advocacy, or at least it would seem so.

If ACA is upheld, this press release means nothing since these are already requirements of the Act. If ACA is struck down, these are very popular measures that are quite inexpensive and thus will not drive up premiums to non-competitive levels. The most expensive measure is the coverage of dependents up to age 26, but that adds only about one percent to the premiums. Besides, other insurers will likely follow suit in order to more effectively market to a greater number of young, healthy families. So no matter what happens, UnitedHealth takes credit for taking the lead.

UnitedHealth used one example of a policy that they will not follow, indicating that they will not unilaterally provide patients with some of the more important protections required in ACA. They are correct when they say that they cannot cover children with preexisting conditions unless the entire industry cooperates in distributing those higher cost risks. If one insurer generously accepts those risks, then their costs would skyrocket and they would be forced out of the market by the death spiral of insurance premiums.

UnitedHealth has remained silent on some of the more important requirements not yet in effect that could be overturned by the Supreme Court decision. Insuring preexisting conditions for adults in addition to children, guaranteeing issue of coverage to all individuals regardless of projected costs, and setting premiums based on community rating - driving up premiums for lower-cost, healthier patients - are more significant measures that could impair their competitiveness if they acted unilaterally. We won't see these policy changes unless ACA is upheld and all insurers are required to comply.

Also they are silent on keeping administrative costs and profits down to a level that complies with the medical loss ratios dictated by ACA. Turn ACA over then there would be no federal requirement to comply, though that would still be the prerogative of the states. States under the political control of anti-government, free-market advocates would likely leave medical loss ratios to the insurers and their Wall Street promoters (where low medical loss ratios - spending less on patients- is a business activity that is rewarded with higher stock valuations).

UnitedHealth's "generosity" in conceding the very modest positions they listed in their release applies only to the individual and small group markets - a relatively small proportion of their business. Most plans for large employers will be grandfathered, and most of the ACA provisions will not apply - certainly not the requirements specific to the exchanges since large employer plans will not be included in the state exchanges. Also, many large employers are self-insured, and for them UnitedHealth provides only administrative functions, while specific benefits are determined by the employers.

We can't blame UnitedHealth for trying to protect its market position, but we can blame our elected representatives for adopting policies that perpetuate and expand an industry which must comply with market demands for lower prices - a demand that can be met only by strategic decisions to avoid market segments such as children who are ill.

Is that what America is about? Let's take care of the kids, even up to age 26, but not the sick ones? What other country does that?

[Doc]

Center for American Progress
June 2012
Paper Cut - Reducing Health Care Administrative Costs
By Elizabeth Wikler, Peter Basch, and David Cutler

This paper outlines the nature of administrative costs affecting both health care payers and providers, and considers ways to contain these costs. Many such efforts are underway, including the ongoing implementation of the Health Insurance Portability and Accountability Act alongside several different elements of the Affordable Care Act. Continued progress in these areas is thus a central step to lower administrative spending.

Even still, many additional actions will be needed. In the pages that follow, we outline a three-pronged strategy for addressing administrative costs:

* Integration: embedding administrative simplification rules and systems into existing reform efforts

* Coordination: bringing together similar administrative processes by different health care participants to maximize efficiency

* Leadership: creating a new federal office dedicated to simplifying health care administrative plans

Tackling wasteful administrative costs in our health care system in these three ways would result in savings we estimate at $40 billion per year.

These savings are eminently achievable. By integrating new performance standards to promote adoption of electronic transactions such as requiring that electronic health records include utilization metrics for electronic billing and other administrative transactions, we can achieve roughly $26.1 billion in annual savings. By coordinating similar processes by different health care participants—such as physician credentialing and enrollment, quality and safety reporting, and enrollment and retention systems for public programs—we can save $7.7 billion each year. And by ensuring leadership at the federal government level through a new senior-level office dedicated to ensuring that administrative simplification plans are carried through and that innovative results are achieved, we can save potentially much more.

Tackling excessive administrative costs offers a promising opportunity for reducing health care costs while improving the quality of care for all Americans.

report
http://www.americanprogress.org/issues/2012/06/pdf/papercuts_final.pdf

column
http://www.americanprogress.org/issues/2012/06/healthcare_admincost.html

About the Center for American Progress

The Center for American Progress is an independent nonpartisan educational institute dedicated to improving the lives of Americans through progressive ideas and action.

We develop new policy ideas, critique the policy that stems from conservative values, challenge the media to cover the issues that truly matter, and shape the national debate.

Founded in 2003 by John Podesta to provide long-term leadership and support to the progressive movement, CAP is headed by Neera Tanden and based in Washington, D.C.

http://www.americanprogress.org/aboutus


Comment: The Center for American Progress is dedicated to "improving the lives of Americans through progressive ideas and action." Yet they were involved in bringing us the Affordable Care Act (ACA) while working with others to keep single payer off the table. They understand that one of the more important features of single payer is administrative efficiency. Let's see how they would address that under ACA.

Basically, they have three proposals. They would move administrative functions such as billing into the patients' electronic medical records; they would coordinate processes such as physician credentialing and patient enrollment through information technology systems, and they would add a new governmental bureaucratic agency to provide oversight of these additional administrative functions.

They contend that this would save about $40 billion annually, though $34 billion of that is already projected through the provisions of ACA and HITECH implementation. They contend that their proposal would add another $6.21 billion to the savings.

Can you imagine the expense of these complex computer systems and the nightmare of trying to coordinate and integrate the various systems amongst aggressive competitors, each of whom would attempt to position themselves in a effort to dominate the market? And obsolescence? That's built in, both through efforts to perpetuate revenue flows to this industry, and through disruptive innovation designed to capture competitors' markets. This won't save costs. Costs will dramatically increase.

And adding another governmental administrative bureaucracy to our dysfunctional system is going to reduce administrative costs? In their effort to continue to suppress single payer they seem to have rejected the obvious concept that they need to REPLACE our current fragmented system of private plans and programs that wastes so much in administration. Instead, they would pile more onto the system.

It's not as if they didn't understand. They even cited a paper by David Himmelstein and Steffie Woolhandler, well known in the policy community as authors of landmark papers on administrative excesses in health care. But they didn't include one of the obligatory Woolhandler/Himmelstein papers that showed that the United States could recover hundreds of billions of dollars in administrative waste by switching to a single payer system. Instead, they pushed their own proposal purportedly showing a highly dubious savings of a mere $6 billion, even though it is much more likely that their proposal would increase costs instead.

Neera Tanden, president of the Center for American Progress has been deeply involved with the current administration in formulating and advocating for the Affordable Care Act. This article seems to be a dishonest vehicle for continuing to dismiss single payer, with the excuse that they are taking care of the administrative inefficiencies, and supposedly saving us money in so doing.

This article coincides with the pending release of the Supreme Court decision on the constitutionality of the Affordable Care Act. It seems to be a preemptive maneuver in anticipation of the imminent surge in demand for a single payer national health program when the decision is announced. They may think that, with this paper as a distraction, they're ready for us, but we've got their number. Let's lead the surge.

[Doc]

Health Affairs
June 2012
National Health Expenditure Projections: Modest Annual Growth Until Coverage Expands And Economic Growth Accelerates
By Sean P. Keehan, Gigi A. Cuckler, Andrea M. Sisko, Andrew J. Madison, Sheila D. Smith, Joseph M. Lizonitz, John A. Poisal and Christian J. Wolfe

2012

$2,809.0 billion - NHE (National Health Expenditures)

$8,952.8 - NHE per capita

17.9% - NHE as percent of GDP

$37.5 billion - Government administration (Note d)

$162.6 billion - Net cost of health insurance (Note e)

d Includes all administrative costs (federal, state, and local employees’ salaries; contracted employees, including fiscal intermediaries; rent and building costs; computer systems and programs; other materials and supplies; and other miscellaneous expenses) associated with insuring individuals enrolled in the following public health insurance programs: Medicare, Medicaid, Children’s Health Insurance Program, Department of Defense, Department of Veterans Affairs, Indian Health Service, workers’ compensation, maternal and child health, vocational rehabilitation, Substance Abuse and Mental Health Services Administration, and other federal programs.

e Net cost of health insurance is calculated as the difference between calendar year premiums earned and benefits paid for private health insurance. This includes administrative costs and, in some cases, additions to reserves; rate credits and dividends; premium taxes; and plan profits or losses. Also included in this category is the difference between premiums earned and benefits paid for the private health insurance companies that insure the enrollees of the following public programs: Medicare, Medicaid, Children’s Health Insurance Program, and workers’ compensation (health portion only).

Conclusion

For 2011 through 2013, the lingering effects of the economic recession and modest recovery, mostly in the form of limited growth in incomes, are expected to continue to constrain health spending growth. In 2014 the coverage expansions laid out in the Affordable Care Act for Medicaid and for private health insurance are expected to increase the growth rate for health spending to 7.4 percent, with notable increases expected in spending on physician services and prescription drugs for newly insured patients. By the end of the projection period, higher income growth and the continuing shift of baby boomers into Medicare are expected to cause health spending to grow roughly two percentage points faster than overall economic growth, which is about the same differential experienced over the past thirty years.

http://content.healthaffairs.org/content/early/2012/06/11/hlthaff.2012.0404.abstract


Comment: This is the annual report that is used most often as a resource for our health care spending.

The numbers to remember for 2012:

National Health Expenditures: about $2.8 trillion
Health spending per capita: about $9000
Spending as a percent of GDP: about 18%

After the transitions of the next decade, health care spending is expected to continue to grow two percentage points faster than overall economic growth - the same differential experienced over the past thirty years. It makes you wonder when Herbert Stein's principle will kick in (essentially, if it can't go on, it won't).

Since we are seeing an increase in the political rhetoric divided over whether the government or markets should be the dominant force in health care financing, it is worthwhile looking at the total administrative costs of these two approaches to financing health care. Although government spending accounts for about half of all health care spending, we are paying private insurers more than four times as much in administrative costs and profits as we are spending on government administration of health insurance programs.

It is true that the net cost of private health insurance includes the administrative costs of private Medicare Advantage plans and private Medicaid and CHIP managed care plans, but this does not begin to account for the four fold differences in total administrative costs between public and private insurance.

Keep this in mind during the national debate over the Affordable Care Act this political season, which will continue to take place regardless of the Supreme Court decision. One side will argue that we need to encourage free markets of private plans plus private options for Medicare. The other side will argue that we need exchanges to provide choices of private plans, while continuing to offer private Medicare Advantage plans. The one side will talk about private markets while condemning the government, whereas the other side simply will avoid rhetoric referencing the government while touting the virtues of nominal ACA reforms of the private insurers. Both sides are wrong!

We need to get rid of the private insurers and switch to a publicly administered single payer national health program. Besides, then we can address more effectively our health care costs that continue to increase at a rate two percent above the growth in our economy - a rate that is intolerable when compounded fear after year.

[Doc]

The New York Times
June 12, 2012
Navigating the Health Care Maze
By Abby Goodnough

Even if the Supreme Court strikes down the federal mandate, many people believe that some form of exchanges could still be crucial to expanding coverage in a number of states. In Massachusetts, insurers bid to participate in the Connector — offering plans that include some level of hospitalization, prescription drugs, maternity care and other services deemed essential by the state — and the Connector uses its market leverage and unique guidelines to promote innovation and competition among them.

"It can — and it has — helped people find more affordable options than they otherwise knew existed," said Glen Shor, executive director of the Connector.

A vast majority of the people who have gotten insurance through the Connector since the economic downturn began have not had to worry about deductibles because they qualify for subsidized coverage. In that program, the big challenge has been keeping costs down as enrollment has steadily climbed.

One strategy has been to reward the lowest-cost insurers in Commonwealth Care, the subsidized program, by driving customers to them. (For example, people who pay no premium because of their income can choose between the two lowest-cost insurers.) Some insurers have responded by limiting which doctors and hospitals customers can use.

Such limitations are controversial, but Mr. Shor said limited-network plans are just the kind of cost-saving innovation that exchanges are well-positioned to bring about by promoting competition in the market.

http://www.nytimes.com/2012/06/13/us/navigating-the-health-care-maze.html?pagewanted=2&hpw&pagewanted=all


Comment: One of the greatest strategic errors in this entire health care reform process has been to fixate on the promotion of competition in the health care market. An example of how deviant this has been is the push to expand limited-network plans.

Think about it. What we want is our choice of hospitals and our health care professionals. What the insurance industry has done is to package their own selection of hospitals and professionals into limited networks, and then prohibit our access to out-of-network care unless we pay prohibitive financial penalties. For this, collectively we are paying even more in wasteful administrative costs. It is totally illogical to pay for extra administrative services designed to artificially take away our choices in the health care market.

Think of what it would be like if we did that with housing. Imagine the government mandating us to select a residential benefits plan. Suppose when we were ready to rent or purchase a residence the third party administrative agency told us that we could have access to only residential buildings within their limited network, though we would have our choice of bronze, silver, gold or platinum houses or apartments. Adding to the insult, collectively we would have to pay extra to this administrative agency that artificially takes away our choices.

What if third parties in the private market were able to corner the food industry and contract with them to create artificial limited-network food plans, with a government mandate that we had to select one of the plans? Within the segregated food market you could shop bronze, silver, gold or platinum selections based on the food insurance premium paid. You could shop outside of the segregated markets, but only by paying large financial penalties. Again, collectively we would be paying extra to meet the costs of this intrusive third party administrator that would be taking away our choices.

Shifting competition in food markets from producers and retailers to an artificial third party administrator, or shifting competition in housing from the builders or landlords to an artificial third party administrator is about as logical as shifting competition in health care from the hospitals and professionals to an artificial third party administrator, all of which would charge us extra for taking away our choices. We wouldn't tolerate that in food or housing. Why should we continue to tolerate it in health care?

Another word about our obsession with competition. The policy community recognizes that much of the dysfunction in health care is related to fragmentation of our system - both in financing and in health care delivery. Efforts are being made to integrate health services to provide an efficient, coordinated flow of health care. These efforts require cooperation between the various sectors of the health care delivery system. Competition is a divisive, destructive, evil force when it occurs within a system that should be joining together in cooperation for the public good.

Private insurers compete. Public administrators cooperate. In health care, we need more cooperation. 'Nuff said?

[Doc]

Small Business Majority
June 14, 2012
Small Business Owners’ Views on Implementing the Affordable Care Act

Executive Summary

The rising cost of health insurance has been and continues to be one of the biggest problems facing American small business owners. To help relieve them of that financial burden, the Affordable Care Act was signed into law on March 23, 2010—a piece of legislation that is already reining in Americans’ health coverage costs. More than two years later, the law’s fate rests in the hands of nine Supreme Court justices who are expected to issue their decision this month in the case against the law. According to scientific opinion polling, only one-third of small business owners would like to see them overturn it. On the other hand, half would like to see it upheld with, at most, only minor changes. This support grows after learning more details about its key provisions.

The poll, conducted in eight states with diverse political profiles—Florida, Illinois, Louisiana, Michigan, Missouri, New York, Texas and Virginia—found that once small business owners hear more about the healthcare law, their support for keeping it intact—either as is or with minor changes—rises to a 56% majority, while the desire for repeal falls to 28%—a 2:1 margin. Moreover, entrepreneurs strongly support many of its key provisions affecting small business owners.

One of the law’s crucial components, which has tremendous small business support, is the health insurance exchange—an online marketplace where small business owners will be able to pool their buying power when they purchase coverage. By a striking 8:1 ratio, owners say they would use their state exchange or at least consider using it, compared to those who say they would not consider using it when they provide benefits. The majority of entrepreneurs find possible features of the exchange very appealing, and, by a 2:1 ratio, they support their state applying for federal funds to set one up.

Furthermore, half of entrepreneurs report they’d be more likely to purchase insurance through the exchange beginning in 2014 when the small business tax credit will be available only to those using the exchange. That’s more than three times the number (14%) who say they’d be less likely to purchase from the exchange. Of respondents who fall into the basic qualification parameters for the tax credit, more than half are already taking advantage of it. Of eligible employers who aren’t claiming it, nearly half say it’s because they are not aware it exists. And nearly half of entrepreneurs say that if their company qualified for the credit, they would be more likely to provide or continue providing healthcare to their employees.

Significant majorities of small business owners also support nearly all the other provisions we asked them about: medical loss ratio, rate review, pre-existing condition exclusion bans, eliminating annual dollar limits on insurance benefits, preventing rating based on health status or sex and more.

Finally the poll revealed a strong interest (67%) in workplace wellness programs, if these programs would help lower coverage costs.

http://www.smallbusinessmajority.org/small-business-research/downloads/Small_Business_Owners_Views_on_ACA.pdf


Comment: Rather than asking about a broad spectrum of health reform policies, this poll was limited to questions about policies contained in the Affordable Care Act. From this poll no conclusions can be drawn about opinions of policies specific to single payer, but we can conclude that small business owners clearly do want reform that serves them and their employees better than the status quo in health care.

It remains our task to inform them that the policies of the single payer model will serve them far better than the meager policies of the Affordable Care Act. The majority of small business owners would support an improved Medicare for all if they had a clear understanding of the policies behind it, since it's far better for them than ACA.

Let's get to work and let them know the possibilities.

[Doc]

The Supreme Court Should Rule with the People

By Margaret Flowers and Kevin Zeese
Dissident Voice, June 13, 2012

Six years after Massachusetts enacted the state version of Obama’s health law, the people of Massachusetts are not happy. According to a June 11th poll in Massachusetts, 78% of patients say the cost of care in Massachusetts is a serious problem and 63% say it has gotten worse in the last five years. Patients report longer waits, higher premiums, higher co-pays and are less satisfied with health care. The number of bankruptcies due to medical illnessand costs has continued to increase in Massachusetts too.

Despite what the corporate media report, Romney-Care, on which Obama-Care is modeled, is not working.

Americans want the Supreme Court to find the Obama law unconstitutional. More than two-thirds of Americans hope the Supreme Court will overturn some or all of the 2010 health care law, according to a June 7th New York Times-CBS poll. A mere 24% said they hoped the court “would keep the entire health care law in place.” Forty-one percent of those surveyed said the court should strike down the entire law, and another 27% said the justices should overturn only the individual mandate, the requirement that people purchase private insurance if they are not insured or pay a fine.

Overturning the entire law may have less of an impact now that three of the nation’s largest insurers, UnitedHealth, Aetna and Humana, say they will continue popular provisions such as allowing young adults under 26 to gain coverage under their parents’ plans and covering preventive care.

And overturning the law may provide an opportunity to push for a real solution to the ongoing health care crisis, to finally create a national universal and publicly-financed health insurance such as improved Medicare for All.

Perhaps this time around the nation could have a real debate about proven solutions to the fundamental problems causing the health care crisis. Private for-profit insurance and medical corporations are at the heart of that crisis. It was these corporations that heavily influenced and in some cases wrote the Obama health legislation so that it enhanced their profit margins.

For example, emails and other documents recently released by congressional investigative committees find that the Obama administration worked closely with the Pharmaceutical industry, agreeing to a back-room deal that protected their profits by opposing the re-importation of prescription medicines at lower prices. Re-importation was something President Obama supported in his 2008 campaign when he criticized the Republicans’ behind-closed-doors deals with Big Pharma.

Further the White House coordinated their $150 million advertising campaign with major pharmaceutical companies. And nearly $70 million was spent through two Super PACs — political action committees — organized by White House officials. Advocacy groups like Families USA and the unions coordinated their advertising with the White House and Big Pharma too.

The Obama law will not control costs, provide universal coverage or improve the quality of health care. More and more commentators are recognizing thatthere is a constitutional way to do so – remove two words “over 65” from the Medicare law. This would cover every American and be a major step toward improving health outcomes in the United States.

In an amicus curae brief, we joined 50 doctors to make the case that Congress has already demonstrated it can regulate health care markets effectively by implementing single payer systems such as Medicare or the Veterans Health Administration.

We argued that the mandate was obviously unconstitutional, otherwise Congress could “reform” any failing private industry – whether it be automobiles, coal, pharmaceuticals or any other – by enacting legislation requiring that every American purchase the industry’s goods or services in exchange for some perceived public good the industry provides. As some of the justices noted in oral argument, this would change the relationship between citizen and government. Indeed, forcing the purchase of products is crony capitalism on steroids.

The brief demonstrates the superior efficiencies of single-payer systems. Only 2% of Medicare’s dollars go to administration and overhead, compared to private insurance which spends 16.7%. Under a single payer system, overall administrative costs would fall from the current 33% of health care spending to less than 5%, saving hundreds of billions of dollars. In fact, studies conducted by the nonpartisan General Accounting Office and the nonpartisan Congressional Budget Office have consistently concluded that if a national single payer system were implemented in the United States, administrative cost-savings alone would be enough to guarantee universal coverage without increasing overall health care spending

The brief shows that the cost of Medicare has increased more slowly than the cost of health care generally and more slowly than the cost of private insurance. And Medicare is rated highly by senior citizens, who are its primary beneficiaries. 51% of seniors give their health insurance an “excellent” rating.

Single payer has been supported by super majorities of the American people for more than a decade. This silenced majority of Americans who wanted real universal health care under a national health plan may get another opportunity to push for what they want if the Supreme Court rules with the people and against crony capitalist health care.

Medicare for all saves lives and saves money. Say ‘No’ to Romney/Obama health care and ‘Yes’ to Medicare for all now.

[Doc]

Harvard School of Public Health/WBUR/Blue Cross Blue Shield of Massachusetts Foundation/Robert Wood Johnson Foundation
June 2012
SICK IN MASSACHUSETTS: Views on Health Care Costs and Quality

This poll examines the views of sick adults in Massachusetts regarding the cost and quality of health care in the state as well as their perceptions about their own health care in the past year. "Sick" adults in Massachusetts (27% of adults) are defined as those who said they had a serious illness, medical condition, injury, or disability requiring a lot of medical care or had been hospitalized overnight in the previous 12 months. Focusing on the experiences and opinions of those who have had significant recent medical care yields special insight into the current problems and opportunities facing Massachusetts' health care system.

Today most sick adults in Massachusetts see the cost of health care as a serious problem for the state, and they view the problem as having gotten worse over the past five years. Sick adults are more troubled by costs than they are by quality.

Although Massachusetts has nearly universal health insurance coverage, the costs of health care are a serious financial problem for many sick adults and their families. Some sick adults report having been refused medical care for financial or insurance reasons. Additionally, some sick adults say they did not get needed medial care because they could not afford it. Taken together, these finding suggest that insurance coverage does not protect some Massachusetts residents against the financial hardships of illness, likely reflecting recent trends in higher deductibles and co-payments.

http://www.scribd.com/doc/96682782/Sick-in-Massachusetts


Comment: This survey is particularly important because it provides the real life health care financing experiences of patients who have serious medical problems - precisely those for whom the system should be designed to serve.

In Massachusetts, "Forty percent of sick adults in the state said the out-of-pocket costs of medical care are a 'very serious' (16%) or 'somewhat serious' (24%) problem for them." Obviously the financing system is not serving well those individuals with major medical needs.

Another significant finding: "About a quarter of sick adults (24%) who have been insured at any time during the past year say they have had a problem with their insurance paying a hospital, doctor, or other health care provider in the past 12 months." Thus the insurers are not doing their job either.

Since the Affordable Care Act uses a financing design similar to that of Massachusetts, we can anticipate the same miserable performance for the nation, or more likely even worse because of other design flaws in ACA.

At a minimum, we should expect the health care financing system to work well for those with serious problems. The ACA design won't cut it. We really do need a single payer national health program that would work well for all of us.

[Doc]

CDC
Division of Health Interview Statistics, National Center for Health Statistics
June 2012
Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2011
By Robin A. Cohen, Ph.D., and Michael E. Martinez, M.P.H., M.H.S.A.

The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is releasing selected estimates of health insurance coverage for the civilian noninstitutionalized U.S. population based on data from the 2011 National Health Interview Survey (NHIS).

* In 2011, 46.3 million persons of all ages (15.1%) were uninsured at the time of interview, 58.7 million (19.2%) had been uninsured for at least part of the year prior to interview, and 34.2 million (11.2%) had been uninsured for more than a year at the time of interview.

* In 2011, the percentage of children under age 18 years who were uninsured at the time of interview was 7.0%.

* Among adults aged 19–25, the percentage uninsured at the time of interview decreased from 33.9% (10 million persons) in 2010 to 27.9% (8.4 million) in 2011.

* Among adults aged 19–25, 56.2% were covered by a private plan in 2011, an increase from 2010 (51.0%).

Estimates of enrollment in HDHPs and CDHPs

Based on data from the 2011 NHIS, 29.0% of persons under age 65 with private health insurance were enrolled in an HDHP (high-deductible health plan), including 9.2% who were enrolled in a CDHP (consumer-directed health plan) and 19.9% who were enrolled in an HDHP without a health savings account (HSA). Enrollment in HDHPs increased from 25.3% in 2010 to 29.0% in 2011. There was a significant increase in enrollment in HDHPs without HSAs, and in CDHPs, between 2007 (when NHIS started collecting this information) and 2011.

Based on data from 2011, among persons under age 65 with private health insurance, 26.9% with employment-based coverage were enrolled in an HDHP, compared with 52.4% of those with a private plan that was directly purchased or obtained through means other than employment. The percentage of persons covered by employment-based private plans who were enrolled in HDHPs increased from 15.6% in 2007 to 26.9% in 2011. The percentage of persons covered by directly purchased private health plans who were enrolled in HDHPs increased from 39.2% in 2007 to 52.4% in 2011.

Insurance coverage by poverty status

The percentage of poor children who were uninsured at the time of interview decreased from 1997 through 2011. During the same period, the percentage of poor adults who were uninsured remained relatively stable.

Among children, all poverty status groups experienced an increase in public coverage between 1997 and 2011. However, the largest increase was seen among near poor children, for whom coverage by a public plan increased by 36.5 percentage points during the same period.

The rate of private coverage among near poor children was 25.1 percentage points lower in 2011 than in 1997. Among near poor children the percentage without health insurance and the percentage with private health insurance coverage have declined since 1997, while public coverage has increased. Private coverage generally decreased among near poor adults aged 18–64, from 52.6% in 1997 to 35.4% in 2011, so that the uninsured rate is now higher than the private coverage rate for this population. Private coverage among not poor adults aged 18–64 generally decreased from 1997 through 2011.

http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201206.pdf


Comment: The good news is that the percentage of individuals uninsured at the time of the National Health Interview Survey declined from 16.0% in 2010 to 15.1% in 2011. The improvements were primarily due to an increase in enrollment of children in public programs, and an increase in enrollment of young adults in their parents' private insurance plans.

If the Affordable Care Act is upheld, we can anticipate a further increase in enrollment in Medicaid. If not, at least public coverage for low-income children should be maintained.

The more alarming news in this report is the increase in high-deductible health plans, both those acquired through employment and especially those purchased in the individual market. The increase in private coverage made possible through the establishment of state insurance exchanges will be in lower-actuarial value plans - primarily high-deductible plans. Also employers are expected to shift more of their plans to high-deductible coverage.

High-deductible plans equate with underinsurance. These plans leave people with health care needs vulnerable to financial barriers to care. With this report, once again we see that underinsurance is becoming the new standard in America. That wouldn't occur if we were to adopt an improved Medicare for all.

[Doc]

Families USA
June 2012
Dying for Coverage:
The Deadly Consequences of Being Uninsured

Key Findings

* Across the nation, 26,100 people between the ages of 25 and 64 died prematurely due to a lack of health coverage in 2010.

* Between 2005 and 2010, the number of people who died prematurely each year due to a lack of health coverage rose from 20,350 to 26,100.

* Between 2005 and 2010, the total number of people who died prematurely due to a lack of health coverage was 134,120.

Why Insurance Matters

* The uninsured are less likely to have a usual source of care outside of the emergency room.

* The uninsured often go without screenings and preventive care.

* The uninsured often delay or forgo needed medical care.

* Uninsured Americans are sicker and die earlier than those who have insurance.

* The uninsured pay more for medical care.

http://familiesusa2.org/assets/pdfs/Dying-for-Coverage.pdf


Comment: In 2010, about 26,000 of the nearly 50 million people without health insurance died due to the lack of that insurance. At best, about 26 million people will remain uninsured if the Affordable Care act is upheld by the Supreme Court. That means that we will continue to accept about 13,000 deaths per year as a consequence of our failure to enact a single payer national health program.

It is one thing to accept inordinate financial waste in our system in order to cater to the private insurance industry, but it is quite another to accept so much suffering and death. The former reflects on our illogical willingness to accept social injustices in order to cater to the moneyed class, but to knowingly accept the latter reflects on the most basic moral fiber of our society.

Is it that people don't understand? Or are we really that animalistic?

[Doc]

Health Care: Give the People What They Want

The nutty thing about the health care debate that will play a prominent role in the next election is that most Americans want pretty much the same outcome: to control costs without sacrificing quality. And that's not what either major-party candidate is offering. Few think that Obamacare, a Romneycare descendant that contains the same kind of individual mandate the then-governor of Massachusetts signed into law, will get us to that desired goal. Nor would Mitt Romney, who has been reborn as a celebrant of the old, pre-Obama system with a few nips and tucks.

As the nation awaits a Supreme Court ruling on the constitutionality of the Obama health care approach, a new Associated Press-GfK poll suggests that the vast majority of Americans want Congress to come up with a better plan. They know that the current system is unsustainable. Only a third of those polled favored the law President Barack Obama signed, but according to the AP, "whatever people think of the law, they don't want a Supreme Court ruling against it to be the last word on health care reform." The article continued, "More than three-fourths of Americans want their political leaders to undertake a new effort, rather than leave the health care system alone if the court rules against the law, according to the poll."

That sentiment underscores the opportunity missed by Obama, who limited his ambition to what Big Pharma and the insurance giants would accept as "reform" in a system that they had so successfully exploited. Obamacare is a faux reform born of opportunism, as was Romney's original version: Play ball with those who have profited most from the run-up of medical costs and expect them to make it more affordable.

Two dynamics doomed the experiment. First, the new Democratic president wanted to launch a bold progressive program, but rather than channel the spirit of Franklin Delano Roosevelt to address the economic crisis that he inherited, he continued the bailouts begun under George W. Bush and fixed on health-care reform instead of the financial pain being suffered by average Americans.

The second dynamic that undercut the health care bill was an over-eagerness on the part of the new White House operatives to collaborate with the profiteers in the very industry targeted by reform.

The email trail of cave-ins to the medical industry heavyweights is startlingly clear, and it is difficult to quarrel with the headline on a Wall Street Journal story: "Emails Reveal How the White House Bought Big Pharma." Except, as a related editorial in the WSJ makes clear, it was the pharmaceutical industry that did the buying, with "a $150 million advertising campaign coordinated with the White House political shop."
What the industry bought was an end to the notion of a health care "public option," and a guarantee of no serious restrictions on drug prices, arranged by then White House chief of staff Rahm Emanuel, who was in close communication with the lobbyists involved. The Journal article pointed to the cynical language of the emails exchanged, quoting one incriminating note from a lobbyist: "Rahm asked for Harry and Louise ads thru third party. We've already contacted the agent."

The American Medical Association and others also were in on the fix, yet with all of that power being exercised the public wasn't conned. As the WSJ editorialized (it galls me to agree with that newspaper's editorialists), "The miracle is that despite this collusion of big government and big business, Obamacare has received the public scorn that it deserves."

But scorn for an individual mandate that compels consumers to purchase something they don't want does not translate into a rational alternative to the current mess. Californian Gary Hess, a retired school administrator and a Republican, is quoted in the AP story about the new poll as saying that he wants the Supreme Court to reject the entire Obama plan but that he still wants the government to retain the requirement that insurance companies cover people regardless of their prior medical conditions. "There needs to be compromise on both sides," he said. Clearly, any good compromise must include both control on costs and the availability of health care to the needy in places other than the very expensive emergency room.

Let me humbly suggest that as an alternative to a mandatory system rejected by the majority, we return to the idea of covering most people by attracting them to quality public and private programs through consumer choice, and that one of those choices be a version of the public option we now offer seniors. It's called Medicare and it works splendidly.

[Doc]

Jill Stein: (Presumptive) 2012 Green Party Presidential Nominee


Jill Stein is a physician and activist from Massachusetts. She's a Harvard graduate and a teacher of Internal Medicine. She calls her platform the Green New Deal, and it has four major components.


The first plank of this platform is to guarantee economic rights for all Americans. This entails the right to a job at a living wage for every American willing and able to work. It also entails the right to quality education, health care, utilities, and housing as well as the right to unionize, to fair taxation and to fair trade.


Dr. Stein has what she calls a Full Employment Program which will create 16 million jobs through a community-based direct employment initiative that is nationally funded, locally controlled and democratically protected.

There are many rights Dr. Stein wants to honor, include a right to quality healthcare through an improved Medicare for All program and a right to tuition-free, quality public education from pre-school through college at public institutions (Jill Stein would forgive student loan debt left over from the current era of unaffordable college education and couple this debt forgiveness with a tuition-free higher education based on the model of the post World War II GI Bill).

Jill Stein believes that it is necessary to halt all foreclosures and evictions and then to create a federal bank with local branches which would take over homes with distressed mortgages. These mortgages could either be restructured to affordable levels, or, if the occupants cannot afford a mortgage, then the homes will be rented to the occupants.


Being an activist for the way the health of the environment affects the health of the person, and being a (presumably, the) Green Party candidate, Dr. Stein as president would redirect research money from fossil fuels and other 'dead-end' industries toward research in wind, solar and geothermal. Along with this, she would invest in research in sustainable, nontoxic materials, closed-loop cycles that eliminate waste and pollution, as well as organic agriculture, permaculture, and sustainable forestry.

Addressing the financial sector, Jill Stein would restore Glass-Steagall, establish a 90% tax on bonuses for bailed out bankers, regulate financial derivatives, break up the big banks that are 'too big to fail' and nationalize the Federal Reserve.

She would also put in place a Voter's Bill of Rights that would guarantee us a voter-marked paper ballot for all voting and require that all votes are counted before election results are released. It would also replace partisan oversight of elections with non-partisan election commissions, make Election Day a national holiday and bring simplified, safe same-day voter registration to the nation.

With concern to the military and homeland security, Dr. Stein would repeal the PATRIOT Act and the parts of the NDAA that violate civil liberties. She would also call for a 50% reduction in military spending that includes the withdrawal of U.S. military bases from the over 140 countries in which our military is now located.

[Doc]

JAMA Forum
June 21, 2012
How Medicare Solves Private Plans’ Problems and Vice Versa
By Austin Frakt, PhD

In a new article in the Annual Review of Economics, Katherine Baicker, Amitabh Chandra, and Jon Skinner point out some of the ways Medicare has helped solve a coordination problem among private plans:

"It is natural to ask why private providers have not adopted ACOs [Accountable Care Organizations, groups that give coordinated health care and for whom payment is tied to achieving health care quality outcomes and goals that can lead to cost savings] or more bundled payments on their own. This remains a puzzle. One explanation is that it is a coordination problem—all insurers may want to adopt larger bundled payments, but no single insurer can make the transition. This is certainly consistent with the historical record on the adoption of prospective payment for hospital care. Once it was introduced in Medicare, private plans were quick to adopt it. Similarly, private hospitals were quick to use the federal government’s efforts to measure quality of care even though nothing stopped them from forming consortiums to measure quality before these federal efforts."

Their points are generally valid in that it’s common for private plans to adopt certain types of payment reforms and quality monitoring after these measures are introduced in Medicare but not before. Nevertheless, there are some examples of ACO-like contracts made by private plans ahead of the Medicare counterparts. And that doesn’t count the failed attempts at capitation (establishing a dollar amount to cover the cost of health care services provided for an individual during a specified length of time) by private insurers and provider groups in the 1990s. I don’t think this invalidates the general point the authors make. It seems Medicare has solved a coordination problem among private insurers.

Indeed, some of the things Medicare will do are properly viewed as public goods. All but a handful of large, dominant health plans cannot convince large hospital systems to accept a new form of payment system. But Medicare can. What health plan will do its own comparative effectiveness analysis to determine which interventions work best for managing a condition? Medicare will or could. The results of both of these types of innovations, and others, will be public information and can benefit all plans and all consumers.

History shows that Medicare has done some things private plans seem unable to do, and then private plans voluntarily copy Medicare. But it goes the other way too.

For example, private plans have innovated in ways that traditional Medicare has not. Managed care, consumer-directed health plans, prescription drug benefits, and catastrophic coverage all exist or existed in the commercial market before adoption by Medicare (if ever). In some cases, the Medicare program, though not the traditional fee-for-service arm of Medicare itself, followed private plans’ lead, adding managed care plans (Medicare Advantage) and a prescription drug benefit (Part D), for example.

There does seem to be a coordination problem among private plans that Medicare solves. Likewise, the private sector sometimes does a better job of designing health plan options. That both plan types, private and government, play a worthwhile role needn’t be shocking or blasphemous. The fact that they both play worthwhile roles ought to be widely acknowledged. Naturally, it often isn’t—least of all, it seems, in our politically charged health policy debates.

http://newsatjama.jama.com/2012/06/21/jama-forum-how-medicare-solves-private-plans-problems-and-vice-versa/


Comment: Austin Frakt makes the point that both Medicare and the private health insurers have each independently introduced innovations that then can help the other when these innovations are shared. But when you look at the respective innovations, it becomes obvious which innovator it is that truly serves the interests of patients.

Medicare attempts to create greater value when using taxpayer and premium dollars for the payment of health care services. Thus you see innovations such as the adoption of prospective payment for hospital care. We benefit both as taxpayers and as patients.

Look at the innovations of private insurers that Frakt mentions: managed care, consumer-directed health plans, and prescription drug benefit plans. These designs take away choice of health care professionals and institutions, choice of drug benefits, and also erect financial barriers between the patient and health care. Here the process of innovation is not used to benefit patients, but rather is designed to enhance the business model of the intermediary intruder - the private insurance plans.

Frakt points out that these private innovations are being used by Medicare in the private Medicare Advantage plans and in the private Part D Medicare drug benefit. True, but these are terrible innovations to introduce into Medicare because they waste funds and reduce choice while increasing administrative complexity. Medicare's adoption of private innovations has been a bad thing, not a good thing.

Coordinated care is certainly beneficial and should be expected regardless of whether Medicare or private insurers are paying the bills. There may be instances where bundling of payment would be appropriate, just as capitation has been appropriate in selected circumstances. If it benefits both taxpayers and patients, it would be appropriate. The risk is that the business mind of the private insurers will most likely morph accountable care organizations into intermediary intruders designed to benefit third party payers, likely at a cost to patients. That is not a desirable innovation.

Frakt does make the important point that Medicare does not provide catastrophic coverage, whereas some private plans do. Medicare certainly should as well. But that's not really a private plan innovation; it's merely a benefit that should have been included in Medicare in the first place. That is one more reason why we advocate for an improved Medicare for all, rather than merely for a universal expansion of the existing Medicare program.

Government can do it. In fact, it is leading on the catastrophic coverage benefit by making it a requirement through the Affordable Care Act. Innovation in the private sector benefits the private sector. Innovation in the government serves the public interest. Trading public and private innovation is not in our interest when we come out the losers.

[Tom]

Jill Stein: (Presumptive) 2012 Green Party Presidential Nominee


Here is a link to that story


http://longhairedpoet.blogspot.com/2012/06/jill-stein-presumptive-2012-green-party.html
_________________
Conservatism is a pale horse, and the riders should be called DEATH.

[Doc]

Kaiser Family Foundation
Health Reform Subsidy Calculator

Based on the Patient Protection and Affordable Care Act (including subsequent amendments in the Health Care and Education Reconciliation Act of 2010), as signed by the President.

The premiums are illustrative examples in 2014 dollars derived from estimates of average premiums for 2016 from the Congressional Budget Office.

Premium subsidies are based on a silver plan (with an actuarial value of 70%), so all premiums shown are for silver coverage. People may be able to pay a lower premium for less comprehensive coverage (i.e., a bronze plan, with an actuarial value of 60%). The tables showing results by age and income also reflect premiums for silver coverage, though the minimum insurance that people would be required to obtain would be bronze coverage.

The actual premium calculated is adjusted for family type, and for age (within the three to one limit specified in the proposal). Subsidized people can enroll in more expensive plans, but must pay the full difference in the premium.

Health Reform Subsidy Calculator:
http://healthreform.kff.org/SubsidyCalculator.aspx#incomeAgeTables


Comment: On June 28, the Supreme Court will release its ruling on the constitutionality of the Affordable Care Act. If the full Act is repealed, individuals who would have purchased plans in the state insurance exchanges will receive neither their premium subsidies nor their tax credits for out-of-pocket expenses. What precisely would they be losing?

Let's use the Health Reform Subsidy Calculator to check a few examples. In each example, we will assume that the policyholder is 45, has a family of four, and does not have employer coverage available. For this family living in a region with a medium cost factor, the predicted premium for the silver plan (70% actuarial value) is $14,245. In the examples, we will change only the income level.

Income: $31,155 (133% of poverty)
Premium payment: None - covered by Medicaid
Maximum out-of-pocket costs: None - covered by Medicaid

Income: $31,156 (133% of poverty plus $1)
Premium payment: $935
Maximum out-of-pocket costs: $4,167

Note that at this level, one additional dollar of income results in the family losing the more comprehensive benefits of the Medicaid program, and mandates that they pay a premium of $935 plus potential out-of-pocket expenses of $4,167, for a total exposure of $5,202. That's a staggering amount at this income level. Compliance surely would be a problem, not by lack of will but simply by inability to pay.

Income: $93,700 (400% of poverty)
Premium payment: $8,901
Maximum out-of-pocket costs: $8,333

Income: $93,701 (400% of poverty plus $1)
Premium payment: $14,245
Maximum out-of-pocket costs: $12,500

So at an income of $93,700, the premium would be $8,901 and the potential out-of-pocket costs would be $8,333, for a total exposure of $17,234. That is quite a dent for a family that is trying to save for two college educations, a retirement fund, and maybe for replacement of the broken-down family automobile. But add just one more dollar of income and the premium shoots up to $14,245 and potential out-of-pocket expenses to $12,500, for a total of $26,745. Then what are you going to cut out of the family budget? And isn't the $9,511 increase quite a "tax" to pay on that one dollar of additional income?

Just the premium increase alone might cause this family to downgrade their coverage from silver (70% actuarial value) to bronze (60%) in order to save on the premium. If so, this family literally would be placing a bet that none of them would develop a serious medical problem, and it would lose the bet if any of them did so. Should we really be forcing a family to gamble on its health care coverage?

If the Affordable Care Act is repealed, all of this goes away, and many more would remain with no coverage at all. That would be tragic. But even if the Act is upheld, this coverage is still far from satisfactory, and should be unacceptable as a standard for our nation. Regardless of the Supreme Court decision, we should replace the Affordable Care Act with a program that really does work: a single payer, improved Medicare for all.

[Doc]

JAMA
June 26, 2012
Duplicate Federal Payments for Dual Enrollees in Medicare Advantage Plans and the Veterans Affairs Health Care System
By Amal N. Trivedi, MD, MPH; Regina C. Grebla, MGA, MPH, PhD; Lan Jiang, MS; Jean Yoon, PhD; Jent Mor, PhD; Kenneth W. Kizer, MD, MPH

Abstract

Context: Some veterans are eligible to enroll simultaneously in a Medicare Advantage (MA) plan and the Veterans Affairs health care system (VA). This scenario produces the potential for redundant federal spending because MA plans would receive payments to insure veterans who receive care from the VA, another taxpayer-funded health plan.

Objective: To quantify the prevalence of dual enrollment in VA and MA, the concurrent use of health services in each setting, and the estimated costs of VA care provided to MA enrollees.

Design: Retrospective analysis of 1 245 657 veterans simultaneously enrolled in the VA and an MA plan between 2004-2009.

Main Outcome Measures: Use of health services and inflation-adjusted estimated VA health care costs.

Results: Among individuals who were eligible to enroll in the VA and in an MA plan, the number of persons dually enrolled increased from 485 651 in 2004 to 924 792 in 2009. In 2009, 8.3% of the MA population was enrolled in the VA and 5.0% of MA beneficiaries were VA users. The estimated VA health care costs for MA enrollees totaled $13.0 billion over 6 years, increasing from $1.3 billion in 2004 to $3.2 billion in 2009. Among dual enrollees, 10% exclusively used the VA for outpatient and acute inpatient services, 35% exclusively used the MA plan, 50% used both the VA and MA, and 4% received no services during the calendar year. The VA financed 44% of all outpatient visits (n = 21 353 841), 15% of all acute medical and surgical admissions (n = 177 663), and 18% of all acute medical and surgical inpatient days (n = 1 106 284) for this dually enrolled population. In 2009, the VA billed private insurers $52.3 million to reimburse care provided to MA enrollees and collected $9.4 million (18% of the billed amount; 0.3% of the total cost of care).

Conclusions: The federal government spends a substantial and increasing amount of potentially duplicative funds in 2 separate managed care programs for the care of same individuals.

http://jama.jamanetwork.com/article.aspx?articleid=1197014#AuthorInformation


Comment: Most veterans who are eligible for enrollment in the Veterans Administration health care system are also eligible for enrollment in Medicare when they turn 65. Many of these veterans elect to enroll in the publicly-financed but private Medicare Advantage plans. This study shows that these private plans benefit greatly by receiving full capitation payments for all care in spite of the fact that they avoid the costs of the care that is actually delivered in our publicly-financed VA system. Thus taxpayers are paying twice for the same care - real care in the VA system and phantom care under the Medicare Advantage plans.

The authors suggest that rules could be changed to rectify this. Either the VA could be authorized to bill the private Medicare Advantage plans for care delivered by the VA (currently prohibited by federal law - a law dating back to before private Medicare plans were available), or the capitation payments to the Medicare Advantage plans could be adjusted downward to reflect the use of VA facilities.

There is a far better choice. The traditional Medicare program could be improved by expanding benefits and eliminating out-of-pocket cost sharing. Then we could get rid of the private Medicare Advantage plans with their profound administrative waste and the restrictions in health care choices that they inflict upon their patients. The VA-eligible patient would be able to choose either Medicare or the VA system, but regardless, we would be paying for the care only once, instead of twice like we are now.

In fact, the improved Medicare system would be so effective that we should all be able to have it as participants in a single payer national health program. Providing veterans with the choice of the VA system would not be much different from providing the rest of us with the choice of an integrated health care delivery system such as Kaiser Permanente. It would be just another health care delivery option under an improved Medicare for all.

[Doc]

Health Affairs Blog
June 26, 2012
Private Insurance Is Bankrupting Americans: Is Congress Paying Attention?
By Diane Archer

Over the last decade, health insurance costs doubled for the average family of four, and health costs ate away at real income, eliminating any wage gains that occurred.

Health insurance premiums (for both employers and workers) now amount to one-quarter of median family income and are projected to rise to 35 percent in the next decade. And these higher premiums are buying thinner and thinner coverage: We are paying more and more every time we go to the doctor or hospital – deductibles and copays have risen rapidly over the last decade. The share of workers paying a deductible greater than $1,000 has risen from 10 percent to over 30 percent since 2006.

Costs are rising for employers as well, and the share of workers who even receive insurance from their employer is plummeting, having fallen from more than 69 percent to 61 percent in the last 10 years. Meanwhile, fewer large employers continue to offer supplemental coverage to retirees. Since the early 1990s, the percentage of large employers offering retiree coverage has fallen from 40 percent to only 21 percent.

Shifting Americans with Medicare into private pools is not a serious solution to the rising cost of health care, given the far higher costs in the private sector. Privatizing Medicare, or even raising the age of eligibility and forcing more of our parents and grandparents into the commercial market, would actually raise overall costs, and it would only save the government money by forcing more of the cost burden onto people who cannot afford it.

http://healthaffairs.org/blog/2012/06/26/private-insurance-is-bankrupting-americans-is-congress-paying-attention/


Comment: Regardless of tomorrow's Supreme Court decision on the fate of the Affordable Care Act, the status quo is dependent on private insurance and the Affordable Care Act model is dependent on private insurance, yet private insurance has been a miserable failure.

You don't have to wait until tomorrow to decide what approach should be taken in response to the Supreme Court decision. You can start immediately with efforts to replace the private insurers with an improved Medicare for all.

[Doc]

Public Option Advocates To Push Medicare For All If Supreme Court Strikes ‘Obamacare’
Brian Beutler June 26, 2012, 8:13 AM 14995



The progressive activists who put the public option at the heart of the health care reform debate in 2009 and 2010 will return in 2012 to press Democrats to back a single-payer system if the Supreme Court throws out the Affordable Care Act on Thursday.

For progressives, Medicare for all — or a similar approach — was always the ideal way to address the soaring costs and widespread un- and underinsurance that defined the country’s broken health care system. But Democratic leaders believed an approach along the lines of Mitt Romney’s reforms in Massachusetts would stand a better chance of attracting Republican and conservative Democratic support in Congress, and foreclosed on the single-payer model without giving it any legislative consideration.

To keep single-payer supporters in their coalition, though, Democrats pledged to fight for a Medicare-like public option that would allow consumers the opportunity to buy insurance directly from the government. They ultimately abandoned that idea as well.

That’s why the same disappointed activists aren’t sweating Thursday’s Supreme Court ruling. If the health care law fails, they believe it will open up a whole new set of political and substantive opportunities for liberals.

“The right fought [the Affordable Care Act] just as bitterly as they would have fought if it was single payer,” said Chuck Idelson, spokesman for National Nurses United — a union and trade association of registered nurses that has consistently supported Medicare for all.

“Medicare continues to be an extremely popular reform — it’s one of the most popular reforms in U.S. history,” said Idelson.

NNU will host medical screenings and town halls and other events in the run up to the Court’s decision to push single payer as a preferable alternative to the health care law.

Expanding Medicare to all Americans would be an enormously heavy legislative lift. But supporters of the approach believe President Obama and Democrats will have an immediate political incentive to turn to the idea if the Court wipes their signature achievement off the books.

“Medicare For All was the right solution in 2009, is the right solution now, and is the ultimate destiny at which our nation will arrive. The only question is whether Democratic leaders are strategic enough to start the process of marching through that door as it opens,” said Adam Green, co-founder of the Progressive Change Campaign Committee. “If the Supreme Court is so political that it overturns the Affordable Care Act despite clear legal precedent, that illegitimate ruling would call for outrage — but it also would blow the door to Medicare For All wide open. The march to Medicare For All would be a marathon, not a sprint, but an absurd ruling this Thursday would be the opportunity for Democrats to start marching.”

Moreover, the argument goes, it would create for Democrats a useful tool to bring Mitt Romney’s radical plans for Medicare into sharper focus.

“If the Supreme Court opens the door for Democrats to campaign in 2012 on Medicare For All and Republicans are left campaigning on Paul Ryan’s plan to end Medicare, that clean contrast could be the game changer that gives Democrats a clean sweep in November,” Green said.

Obama kept these more aggressive reformers at arms length during the year-long fight over the Affordable Care Act. But in the run up to an election, and if the conservative Supreme Court deals a death blow to Obama’s signature legislation, the calculus could change.

“We would certainly encourage him … to say, ‘OK the court didn’t like the way this law was drawn up, ok then let’s go back to square one, let’s do a law that has no constitutional problem — Medicare,’” Idelson said. “And they could probably do this in one page.”

[Doc]

How to Fix Health Care Without the Mandate
Wednesday, 27 June 2012 09:09 By Sarah van Gelder, Yes! Magazine | Op-Ed



Why truly affordable care means single-payer.

What happens if the Supreme Court strikes down the “individual mandate” in the health care reform law?

Commentators ranging from former Labor Secretary Robert Reich to Forbes Magazine columnist Rick Ungar agree: Such a decision could open the door to single-payer health care—perhaps even make it inevitable.

This may be the best news about health care in years. Because ever since Republicans convinced the Obama administration to drop the “public option” in the Affordable Care Act, health reform has been in trouble. True, most Americans favor many of the provisions of Affordable Care Act. But the overall plan rests on forcing you and me to buy insurance from the same companies that have been driving up the costs of health care all along—the same companies that have been finding creative ways to avoid covering needed care, shifting costs on to patients, and endlessly increasing premiums and out-of-pocket expenses for all of us.

Forcing all Americans into a failed system is bad policy, and it’s not just President Obama’s opponents who say so.

What the Doctors Ordered

When the Supreme Court agreed to hear a challenge to the Affordable Care Act brought by 26 state attorneys general, one of the supporting briefs came from an unexpected source—a group of 50 doctors who believe that single-payer health care is the way to cover everyone and contain costs. As a model for a revamped health care system, they point to Medicare, which covers millions of seniors while devoting just 2 percent of expenditures to overhead (compared to as much as 16 percent for private insurers).

In spite of all the fear about government involvement in health care, Medicare is enormously popular; in a recent poll, two-thirds of Americans oppose changing Medicare to something more like private insurance. In the Medicare model, as in Canada’s single-payer system, health care providers are in private practice, but the government acts as insurer, covering everyone. The money for the program comes from payroll taxes.

This model is just one of a variety of ways that industrialized countries provide universal coverage; only the United States does not yet offer universal coverage at all, and the impact of our fragmented, privatized approach ripples throughout the economy and into the lives of families that face bankruptcy and exclusion from needed treatment.

While we in the United States spend far more on health care, per person, than any other nation, we’re way behind other wealthy countries when it comes to our actual health. The residents of 25 other countries—all of which spend less on health care than we do—can expect to live longer, on average, than U.S. residents. In a recent study of 19 industrialized countries, the United States came in last when it came to averting preventable death. Researchers say that amounts to more than a 100,000 avoidable deaths each year.

We devote 15 percent of our economy (by GDP) to paying for health care (or $6,402 per person each year), and still leave millions without coverage. In contrast, the French spend 11 percent of GDP on health care (or $3,374 per person) and cover everyone; the French live two years longer, on average, than Americans, and have better health by all key measures.

Follow the Money

If we’re spending so much for poor results, where is all the extra money going? Private, for-profit health insurance companies spend big on overhead: covering the paperwork and arguments about who will cover what, finding ways to avoid covering people who might require costly services, disputing charges from health care providers. They spend money on marketing and on lobbying Congress, federal regulators, and state lawmakers. They pay dividends to shareholders and they pay executives six- or seven-figure compensation packages. No wonder premiums keep rising.

None of these costs are incurred by Medicare or other national insurance programs.

Some argue that patients are better off with competing insurance companies because that gives them a choice. Perhaps this is true of a patient who spends many hours required to read the small print in competing insurance plans, producing spreadsheets to track the multiple variables, guessing what sort of coverage they and their family will need in years to come, and hoping that they made the right choice when an unexpected accident or illness means their life depends on the bet they made. On the other side, insurance companies have battalions of lawyers and adjusters making bets about coverage, co-pays, and deductibles—coming up with ways to cover less.

Asking each of us to choose among competing plans is like playing against the house in a casino—it might seem as though you’re getting choices among slot machines, but really, the odds are stacked against you whatever choice you make.

Where choice really matters to most people is in choosing health care providers. In France, where public financing of health care is the rule, patients actually have more choices among doctors than do Americans, who must choose among health care providers preferred by their insurance company.

So the doctors who are calling on the Supreme Court to strike down the individual mandate are on to something. Instead of locking us in even more tightly to an inefficient private insurance system, which has built-in incentives to take more of our money and do less for us, they argue we should switch gears. We’re spending $200 billion more per year than we would need to under a single-payer system, they say. We pay more out-of-pocket than other countries, and the Obama Affordable Care Act wouldn’t fix that.

What do Americans Want?

In poll after poll, a majority of Americans have expressed support for single-payer health care or national health insurance. This is true in spite of the near media blackout on this topic, and the failure of most national politicians to even consider single-payer as an option (the Obama administration and Democratic leadership in Congress excluded single-payer advocates from the key summits and hearings leading up to the passage of the health care bill).

In Massachusetts, which has had time to try out policies very similar to those in the Affordable Care Act, over 5 percent of the population remains uninsured. And, according to the doctors’ brief, local initiatives calling for single-payer health care passed by wide majorities in all the Massachusetts districts where they were on the ballot.

Vermont has adopted a single-payer health care plan, and the California Assembly twice passed single-payer, only to have it vetoed by the governor.

Single-payer health care, in short, is far more popular than the political establishment likes to admit—while requiring individuals to purchase health coverage from private insurance companies is wildly unpopular across the political spectrum. According to a recent poll, only a third of Americans favor the individual mandate, but 70 percent favor expanding the existing Medicaid program to cover more low-income, uninsured adults.

Here’s something to ask yourself: If you’re on Medicare now, would you give it up to move to a private insurance plan? If you’re not now covered and you could sign up for Medicare today, would you?

Medicare for All

That contrast offers a good starting point. We don’t need to assume that our health care policy must be designed to maintain the health-industrial complex and their lobbyists in the manner to which they have become accustomed. Instead, we can expand Medicare to cover more and more age groups, until everyone is covered. We could all then have access to a program that keeps overhead low, is wildly popular among its clients, and is similar to programs in Europe, Canada, Japan, and elsewhere that have excellent records of cost containment, universal coverage, and great health outcomes.

So what happens if the Supreme Court overturns the individual mandate or—as now seems possible—rejects the entire package? Such a move could turn out to be a great boon to those who doubt the wisdom of relying on private, profit-focused insurance companies to cover us when we get sick. It could offer us the opportunity to get the sort of proven universal coverage we can count on.