Sunday, June 28, 2015

Health Care Reform Articles - June 28, 2015

America’s health care system is still broken: Why single-payer is the only thing that will ever fix it

The final triumph of Obamacare was great news for Americans depending on it -- but it still isn't enough

 Medicare at 50: Strengths to Build On

By John Geyman, M.D.
The Huffington Post, June 22, 2015
Traditional, or Original, Medicare turns 50 on July 30, having had many challenges and achievements from the days of its passage to today. It is time to celebrate its many successes, note some of its current challenges and threats to its future, and briefly discuss how it gives us a strong foundation upon which to build still-needed health care reform.
When it was enacted in 1965, about one-half of seniors in the U.S. lacked health insurance, and many could not afford necessary health care. When it was passed with strong bipartisan support (313-116 in the House, and 70-24 in the Senate), 20 million Americans age 65 and older gained health insurance.1
From the start, Medicare was a political football raising strong arguments for and against any kind of universal health insurance, quite similar to those we hear today, including from the American Medical Association, hospitals, and the health insurance industry. But a "corporate compromise" was struck in 1965 whereby private insurers were relieved of their worse health risks, hospitals could expect assured payments for their costs of serving a previously disadvantaged population, and physicians gained a permissive "usual, customary, and reasonable" reimbursement policy.2 Claims processing and bill auditing were contracted out by the government to private fiscal intermediaries, especially Blue Cross and Blue Shield plans.3
From the beginning, Medicare has provided a broad set of benefits, defined by law, protecting all seniors, many of whom could not afford health insurance in the private market. Part A provides hospital insurance, while Part B provides supplementary medical insurance for 80 percent of physician services (initially with a $50 deductible and 20 percent coinsurance), X-ray and laboratory tests, and some home health and outpatient and mental health services. Some additional benefits were added in later years to this basic program, including coverage for the disabled and patients with end-stage renal disease in 1972 and partial coverage for prescription drugs in 2003 (Part D). Medicare's benefits have always been considered an earned right, not an entitlement, since all beneficiaries pay into the program through mandatory contributions from individuals and/or employers.4
Today, Medicare is a very large program, covering more than 55 million Americans, including all seniors and 9 million people with permanent disabilities under age 65. It accounted for 14 percent of the federal budget in 2014 and about 20 percent of total personal health expenditures in 2013.5 Since the 1990s, we have seen an increasing trend toward privatized Medicare plans (Part C), starting with Medicare + Choice HMOs in the 1990s and their sequel, Medicare Advantage (MA) since 2003. These plans have been promoted by conservative policymakers and think tanks with a goal to replace Medicare as an "entitlement program" with private market plans, health savings accounts and vouchers. Almost one-third of seniors are now enrolled in MA plans.
The Many Strengths of Traditional Medicare over 50 Years
Traditional Medicare has performed much better over the years than any of these private plans, which operate with the goal of profits more than service. Table 1 summarizes the major differences between traditional Medicare and privatized plans.6

Source: Adapted from Geyman, JP. Shredding the Social Contract: The Privatization of Medicare. Monroe, ME. Common Courage Press, 2006, p. 206.
These comparisons are supported by many studies over the years. As just four examples:
A literature review by the Kaiser Family Foundation of 40 studies since 2000 found that beneficiaries rated access and quality of care better in traditional Medicare than in Medicare Advantage, especially by those who were sick.7
An analysis by the Urban Institute over three decades found that private Medicare plans cost the government more than fee-for-service traditional Medicare, which contained costs better than private plans over those years.8
Traditional Medicare operates with an administrative overhead of 2 percent, compared to overhead of Medicare Advantage about seven times higher.9
The Centers for Medicare and Medicaid Services (CMS) took 35 enforcement actions against Medicare Advantage plans and Medicare Part D plans in 2014, particularly for inappropriate denials of care and requiring unnecessary preauthorization of services and medications that resulted in more cost shifting to beneficiaries.10
Some Major Challenges Facing Medicare Today
As in 1965, Medicare remains a lightning rod for intense political debates over its future. Despite its proven track record for efficiency, reliability, and responsible service over these last 50 years and widespread public support, Republicans are united in their attempts to dismember it, convert it to a voucher program, and shift patients to the private marketplace, all under the guise of reining in federal spending and austerity. Some Democrats are amenable to raising the eligibility age for Medicare and increasing cost sharing. These ideas are a complete disconnect with the needs of our aging society in a time of increasing inequality of incomes. More than 25 million seniors and people with disabilities live on annual incomes of $23,500 or less, many of whom cannot afford premiums and cost-sharing in either traditional or privatized Medicare. And as our population ages, pensions that in the past assured defined benefits are shifting to defined benefit pensions, without such assurances.11 There are still many gaps in coverage, even within traditional Medicare, including for long-term care and dental care.
Future funding for Medicare is seriously threatened and murky at best. The Obama administration has told us that the Affordable Care Act (ACA) will be financed in part by $716 billion in Medicare cuts over 10 years, with the unbelievable claim that these cuts will not result in reduction of services. The recently passed H. R. 2, the "doc fix" bill, has provisions in it that will require new deductibles in first-dollar supplemental Medigap plans (held by 40 percent of Medicare beneficiaries) and expand means-testing for Medicare Part D, both of which will increase costs for seniors and further undermine traditional Medicare.
Just as the future of Medicare is unclear, so is that of our entire health care system. The U. S. Supreme Court is expected to rule in coming days on the legality of subsidies under the ACA. A negative ruling will be a serious blow to the ACA and call into question where we should go next. Republicans in Congress will push for repeal or defunding parts of the ACA. As the debate heats up, the leading alternatives will likely be: (1) continuation of the ACA as it unravels, (2) some GOP "plan" based on patients having "more skin in the game" that further threatens access and affordability of care; (3) revival of the "public option" idea, hardly an effective fix as merely adding one more payer to our dysfunctional multi-payer financing system; and (4) long-overdue consideration of single-payer national health insurance that would cover all Americans in a large risk pool with more benefits, less cost, more reliability and equity in a sustainable way, as described in my recent book, How Obamacare Is Unsustainable: Why We Need a Single-Payer Solution for All Americans.11
Traditional Medicare has proven its superiority over any private, market-based alternatives for the last 50 years. It is time to build on this social insurance model as the health care debate continues.

Obamacare and Reagan

Legal Challenges Remain for Health Law 

Friday, June 26, 2015

Health Care Reform Articles - June 26, 2015

Supreme Court upholds Obamacare tax subsidies

By Lawrence Hurley,  Reuters

WASHINGTON — The U.S. Supreme Court handed President Barack Obama a major victory on Thursday by upholding tax subsidies crucial to his signature health care law, with Chief Justice John Roberts saying Congress clearly intended for them to be available in all 50 states.
The court ruled on a 6-3 vote that the 2010 Affordable Care Act, widely known as Obamacare, did not restrict the subsidies to states that establish their own online health care exchanges. It marked the second time in three years the high court ruled against a major challenge to the law brought by conservatives seeking to gut it.
“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” Roberts wrote in the court’s decision, adding that nationwide availability of the credits is required to “avoid the type of calamitous result that Congress plainly meant to avoid.”
Roberts was joined by fellow conservative Justice Anthony Kennedy and the court’s four liberal members in the majority.
Shares of hospital operators, health services providers and insurers rallied broadly following the court’s decision to uphold the subsidies. Top gainers included hospital companies Tenet Healthcare Corp., up 8.8 percent, and Community Health Systems Inc., up 8.5 percent.
The decision means the subsidies will remain not just in the 13 states that have set up their own exchanges and the three states that have state-federal hybrid exchanges, but also in the 34 states, including Maine, that use the exchange run by the federal government.
The case centered on the tax subsidies offered under the law, passed by Obama’s fellow Democrats in Congress in 2010 over unified Republican opposition, that help low- and moderate-income people buy private health insurance. The exchanges are online marketplaces that allow consumers to shop among competing insurance plans.
In Maine, nearly 90 percent of the 68,000 residents who enrolled in health insurance under the law received subsidies to help them afford their monthly premiums. Without the financial leg up, the average premium would have shot up nearly 400 percent, from $88 to $425 per month, according to an analysis by the Kaiser Family Foundation.
“This is a tremendous victory for all of us. We are thrilled that Mainers will continue to have access to subsidies to make health insurance more affordable and accessible” Emily Brostek, executive director of the advocacy group Consumers for Affordable Health Care, said in a statement. “Tens of thousands of hard working Mainers will be helped by this decision. Without the subsidies, monthly insurance premiums are just too expensive for many people.”

Supreme Court Allows Nationwide Health Care Subsidies 

The Supreme Court Saves Obamacare, Again

Obama Gains Vindication and Secures Legacy With Health Care Ruling

Obamacare Ruling May Have Just Killed State-Based Exchanges

by Margot Sanger-Katz

Now that the Supreme Court has ruled that health insurance consumers can receive federal subsidies regardless of their state’s role in running their insurance market, fewer states may stay in the game.
When the Affordable Care Act passed in 2010, most people expected that each state would want to run its own health insurance marketplace. That never really happened, as many states opted to let the federal system,, do the work for them. Many of those states that did try running their own marketplaces are starting to think twice.
Now, with the Supreme Court ensuring that every state’s consumers will have equal access to federal subsidies, it is becoming clear that more of those states will revert to a federal system for enrolling people in health insurance.
“There may be a little bit of buyers’ remorse going on in some state capitals right now,” said Sabrina Corlette, the director of the Center on Health Insurance Reforms at Georgetown University. She said states underestimated the difficulty and expense of building and maintaining state marketplaces. Now, she said, many officials are asking: “What did we get ourselves into?”

Hooray for Obamacare

Measuring the Success of Health Insurance Subsidies

Bad Neighborhoods May Be Bad for Your DNA

by Nicholas Bakalar - NYT - June 24, 2015

Why Don’t the Poor Rise Up?