Shumlin administration gears up for the nitty-gritty of single payer
By Andrew Stein
Vtdigger.org, July 29, 2013
Gov. Peter Shumlin put Vermont on a path to creating the nation’s first single payer health care system when he signed Act 48 in 2011. But since then, his administration has made little progress up that mountain, drawing questions and accusations from the far political left and right about the governor’s sincerity.
Now, Shumlin and his team are beginning to shift gears, planning the implementation of a publicly funded, universal health care system. In the past two months, the administration has moved two of its policy heavyweights to the fifth floor Office of Health Care Reform — right around the corner from where the governor sits.
Michael Costa, former policy director at the Tax Department, took the elevator up to his new office at the beginning of June. He is charged with figuring out how to finance a single payer system with tax dollars.
David Reynolds, a co-architect of the Affordable Care Act and a former health policy adviser to Sen. Bernie Sanders, joined the team in July. He is tasked with bringing the moving parts of a single payer system together.
Costa and Reynolds join Robin Lunge, director of Health Care Reform, who helped craft the single payer legislation and has overseen the administration’s health care policy initiatives since July 2011.
“This shows that we’re serious,” said Secretary of Administration Jeb Spaulding. “But that’s not why we’re doing this. We’re doing this because we are serious.”
Shumlin doesn’t flinch when questioned about the proposal’s vulnerable points, like shifting more than a billion dollars in health insurance dollars to the tax sector.
“I am bound and determined to pass the first sensible single payer health care system in the country, and that’s going to be the most ambitious policy lift in Vermont history,” Shumlin said on Monday. “So, obviously, we’re going to gear up our staff and engage Vermonters from all walks of life.”
Maine exchange insurance rates due, but with snag
1:00 AMThe coverage plans for individuals are so different from existing ones in Maine that comparing the costs of new and old may be impossible.
By Joe Lawlor jlawlor@pressherald.com
Staff Writer
Staff Writer
Let the spinning begin.
Maine residents intending to buy insurance on the new health insurance exchange will find out Wednesday what rates they will pay.
In other states, including California and New York, release of the rates led to furious numbers wars. Liberal and conservative commentators – using the same data sets – simultaneously declared that individual insurance rates would be declining dramatically or spiking upward.
The self-employed or people who otherwise don't have health benefits through an employer will be buying subsidized insurance on the exchange or paying a penalty. Less than 10 percent of people in the entire health insurance market will be buying insurance on the exchange, according to the Maine Bureau of Insurance.
Starting Oct. 1, individuals and small groups can buy health insurance on the exchange for coverage to begin in 2014, a key provision under the Affordable Care Act.
But while partisan battles between Republican Gov. Paul LePage and Democrats in the Legislature were waged over the Affordable Care Act, including an unsuccessful attempt to expand Medicaid, the rates may not create as much of a stir.
That's because in Maine, a health care expert said, it will be nearly impossible to compare the new rates with current rates that people pay on the individual market.
An Obamacare scorecard Part 1: What's gone, what's on hold, and what's still in place
By Trudy Lieberman
For all the controversy about the Affordable Care Act, confusion and lack of knowledge among the public is still widespread. Meanwhile, it keeps changing, as portions are altered, fixed, or dropped. After all those changes, what is Obamacare, exactly? What is out, what is on hold, and what is still standing in this large and controversial law? What are Obamacare's plusses and minuses so far? Part 1 of a two-part scorecard.
For all that has been written, spoken, screamed, and whispered about the Affordable Care Act, there is still a lot of confusion and lack of knowledge among the public. No wonder, I suppose. Republicans continue to attack it as if it were a scourge from hell. Democrats are desperate to tout it. Meanwhile, it keeps changing, as portions are altered, fixed, or dropped. Maybe it's a good moment to take stock. For starters, after all those changes, what is Obamacare, exactly? What is out, what is on hold, and what is still standing in this large and controversial law? And what have been Obamacare's plusses and minuses so far? Here's the first of a two-part scorecard.
The individual mandate.
This is the heart of the law--the requirement that everyone carry insurance or face penalties, and it is still scheduled to take effect January 1, with enrollment in the state health exchanges beginning October 1. Most Americans--about 160 million of them--are insured through their workplace, but some 50 million have no insurance at all. Many of those who have no coverage now will be able to shop in the state exchanges set up by the ACA and, depending on their income, receive a subsidy to help pay the premiums. Those with incomes up to 150 percent of the poverty level ($17,235 for individuals and $35,325 for a family of four) will get further help by having their out-of-pocket costs cut by as much as two-thirds. And if people have pre-existing conditions, they won't be turned down for coverage.
An important wrinkle : Workers with employer coverage who pay more than 9.5 percent of their income for that insurance can shop in the exchange and receive subsidies for themselves or their families. But because of the way the Treasury Department has interpreted this provision, if the worker's contribution to an individual policy is less than 9.5 percent of income but the contribution to a family policy is more than that, family members are out of luck when it comes to getting subsidies.
Medicaid expansion.
One of the pillars of reform, Medicaid expansion, is sort of in and sort of out, thanks to the Supreme Court and several reluctant GOP-led states. Obamacare was supposed to bring coverage to some 15 million people through the expansion by raising the eligibility limit to 138 percent of the federal poverty level--or to about $32,500 for a family of four and $15,000 for a single person. The Supreme Court ruled that states had the option of dropping out of his expansion, however. By early July 19 states said they would not expand their Medicaid programs, 23 plus the District of Columbia said yes they would, while five were undecided and three were considering another kind of expansion. As a result, people with incomes below the poverty line --the poorest of the poor--are stuck if they live in states that have chosen not to expand. These people have almost no coverage options. They have little money to buy insurance on their own, and because of the way the law was written, they are barred from shopping in the exchanges and receiving subsidies.
Hospital penalties and bonuses.
These carrots and sticks aimed at encouraging better care remain in effect--despite grumbles and complaints from hospital officials. Medicare now penalizes hospitals for readmitting too many patients, though there have been fits and starts implementing the program. Medicare made some mistakes in calculating penalties and had to reduce them a bit, but so far has penalized about 2,200 hospitals. Hospitals also get bonuses or penalties if they meet or don't meet certain targets that measure quality of care. One example of good care: giving beta blockers to patients who've had heart surgery. Hospitals scoring the highest were not necessarily the ones with brand name reputations.
WHAT'S OUT?
The CLASS Act
Short for the Community Living Assistance Services and Support Act, the CLASS Act was supposed to be a down payment on a national program to pay for long-term care, a big shortcoming in the US health system. It was a voluntary effort in which people could join a government plan and pre-fund their long-term care needs. When they needed care, they would get a daily cash benefit to pay for services. The program was none too popular with many politicians. In the end the government found it unsustainable. Because it was voluntary (meaning there was no mandate to buy here), lots of people had to sign up to make it viable. If they didn't, premiums would rise, and very few people could afford them. There was no way, the government decided, to make the program actuarially sound over 75 years.
Co-op insurance companies.
These are gone, too. About $6 billion in federal start-up money for co-ops was supposed to spur their development as a lower-priced alternative to big insurance carriers; it was sort of a sop to the public option advocates. Twenty-four co-ops were funded even though the government had begun to reduce funding. Then came the New Year's surprise. In final negotiations over the fiscal cliff deal, Congress killed the remaining funding for 40 more co-ops whose applications were in the pipeline. Insurers, it seems, were not keen on the new competition.
WHAT'S BEEN DELAYED?
The employer mandate .
This is in the big one in this bucket. In early July the Obama administration announced a one-year postponement until 2015 of the employer mandate, the requirement that businesses with more than 50 full-time employees had to provide health insurance or pay a penalty. The idea was to prod employers that did not provide coverage to do so. Again business complained about the record keeping and reporting requirements.
The law said they had to provide coverage to full-time employees working 30 hours a week. That was tough for firms whose workers' hours fluctuated. Who was a full-time worker? Who was part-time? Many firms were threatening to cut worker hours to avoid the requirements. The delay means that workers in firms that don't provide coverage might be offered so-called "skinny plans." Such plans might cover some drugs and preventive services, but not hospital care or surgeries, for example. There's little protection for catastrophic illness, but the premiums are cheap for employers and workers. The employee's share may be as little as $40 or $50 a month.
SHOP exchanges.
These marketplaces for small businesses to buy insurance for employees, will offer only one plan in 2014 instead of an array of choices the law envisioned. The administration said there were "operational challenges," and the choice option would be available in 2015. Most small businesses offer only one choice now, so the exchange won't be of much value unless more carriers can sell their products.
Rules requiring smokers to pay more for their coverage. During debate there was little doubt that insurers would be able to charge smokers more money, because they present greater health risks and more potential costs for insurance companies. But now smoking penalties applied to policies sold through the exchanges are delayed a year because of what the administration described as a "system limitation." The law says insurers cannot charge older people more than three times it charges a younger person, and it allows carriers to charge smokers 50 percent more. The problem, discovered a few months ago: the system cannot process a premium for a 65-year-old smoker that is more than three times the premium for a 21-year old smoker.
Scaling back verification requirements for insurance exchanges. Because about 60 percent of people buying in the exchange probably will be eligible for subsidies, exchange officials needed a way to verify if they were indeed eligible; that is their income was low enough and they had no other insurance coverage. But the administration says that they have now encountered "legislative and operational barriers." The upshot: the government will rely on the honor system to make sure applicants for insurance are telling the truth about their income and insurance status. The government will do a check when people file their income tax returns in 2015. If income and insurance status change during the year, a family could end up with a tax liability or a tax refund, depending on the subsidy they got and whether their incomes went up or down during the year.
WHAT'S IN LIMBOLAND?
The Independent Payment Advisory Board.
The law called for this 15-member board appointed by the president to advise Congress on actions Medicare could take to reduce the growth of healthcare spending. Congress could take an up or down vote on the recommended measures. The board, however, cannot recommend changes in premiums, benefits, eligibility, or taxes, or other changes that would result in "rationing" of care to Medicare beneficiaries. Nevertheless, it has become something of a political football, with Republicans charging that the board could lead to death panels and rationing, because seniors wouldn't be able to get treatments, especially the costly ones.
The board is in virtually inactive right now. Members have not been appointed, but more relevant is that Medicare's costs have slowed somewhat, and in April Medicare's chief actuary declared that that medical cost inflation would not be high enough to trigger the work of the IPAB. It may not see action for a few years, and then what it does will depend on the political winds and the pace of medical inflation.
The National Health Care Workforce Commission.
The Affordable Care Act set up this 15-member body to prepare for the increased demand in primary care needed by all the newly insured people buying in the shopping exchanges. It's no secret that the US has a shortage of primary care doctors. The commission was to examine such issues as the right mix of primary care docs and specialists, and whether pharmacists could help coordinate care. The administration requested $3 million for the commission to begin its work, but Congress has not appropriated the money. Federal officials have told commission members they cannot even meet to discuss its work. The stalemate is not about money; $3 million dollars is a droplet in the federal budget. The commission is tied up in the Beltway's larger political struggle.
Next: Obamacare Scorecard Part 2--The hits and misses and mixed reviews of the Affordable Care Act.
Revealing a Health Care Secret: The Price
By TINA ROSENBERG
The Surgery Center of Oklahoma is an ambulatory surgical center in Oklahoma City owned by its roughly 40 surgeons and anesthesiologists. What makes it different from every other such facility in America is this: If you need an anterior cruciate ligament reconstruction, you will know beforehand — because it’s on their Web site — that it costs $6,990 if you self-pay in advance. If you need a tonsillectomy, that’s $3,600. Repair of a simple closed nasal fracture: $1,900. These prices are all-inclusive.
Keith Smith, the co-founder of the center, said that it had been posting prices for the last 4 of its 16 years. He knew something was happening, he said, when people started coming from Canada. “They could pay $3,740 for arthroscopic surgery of the knee and not have to wait for three years,” he said. Then he began getting patients from elsewhere in the United States and began to find out — “I get 8 or 10 e-mails a week” — that he was having an effect on prices far away. “Patients are holding plane tickets to Oklahoma City and printing out our prices, and leveraging better deals in their local markets.”
The Oklahoma City TV station KFOR, which ran a story on the Surgery Center on July 8, said that several other medical facilities in Oklahoma are now posting their prices as well.
KFOR’s story has been picked up by news outlets around the United States. Clearly what the Surgery Center has done is resonating.
On NewChoiceHealth.com, which compares prices offered by different facilities in the same city, Smith’s prices are consistently the cheapest or near it in Oklahoma City. Several hospitals charge $17,200 for laparoscopic hernia repair — for which Smith charges $3,975. A gallbladder removal is $24,000 at some hospitals in the city; it’s $3,200 at the Surgery Center. His prices are better in part because ambulatory surgical centers are cheaper than hospitals (for many reasons), but also there’s a virtuous circle here. He can post his prices because they are good ones. And they are good because he’s chosen to compete on price.
What’s remarkable is that this is remarkable. Why should a business become the subject of news stories simply because it tells people the cost of its services?
Medicare has proved itself after 48 years
By Rob Stone, M.D.
The Herald-Times (Bloomington, Ind.), July 30, 2013
Who is the most popular health insurer in America? Not Anthem Blue Cross. It’s Medicare. And what insurer is the most efficient? Medicare again, operating at only 1.4 percent overhead, while the private insurers strain to meet the Affordable Care Act maximum overhead of 20 percent.
While the Affordable Care Act struggles to be born, it’s worth looking again at how well Medicare works. Last year the respected journal Health Affairs published a study showing how Medicare performs better than private health insurance plans.
According to the report, “Medicare beneficiaries are less likely to have cost-related access problems, high premium and out-of-pocket health care expenses as a share of income, and financial problems because of medical bills. And compared to non-elderly adults with employer-based coverage, Medicare beneficiaries are more likely to have access to a medical home – a primary care provider who knows their medical history well, is accessible, and helps coordinate their care,” and are “far more likely to report excellent quality of care.”
Medicare is not perfect and needs improvement, but it performs far better than the best of the private plans – the employer-sponsored health plans. Individual and small group plans have even worse performance. The Health Affairs article concluded, “Medicare is doing a better job than employer-sponsored plans at fulfilling the two main purposes of health insurance: ensuring access to care and providing financial protection.”
In my work as a physician I see it every day – patients under the Medicare eligibility age of 65 struggling to find affordable insurance, or fighting with their insurance company when they try to make a claim, or driven to bankruptcy by impossibly high deductible payments. But if they can hang on until they reach Medicare age, then they can finally get the care they need, without the hassles. “Pre-existing conditions” are not an issue. You can pick the hospital and doctor of your choice.
We need to celebrate and protect Medicare, a uniquely American approach to health care. Somehow Congress in their infinite wisdom decided 48 years ago that we should have a universal health care system for everyone over 65, but that the rest of us were on our own.
http://www.pnhp.org/print/news/2013/july/medicare-has-proved-itself-after-48-years
The Herald-Times (Bloomington, Ind.), July 30, 2013
Who is the most popular health insurer in America? Not Anthem Blue Cross. It’s Medicare. And what insurer is the most efficient? Medicare again, operating at only 1.4 percent overhead, while the private insurers strain to meet the Affordable Care Act maximum overhead of 20 percent.
While the Affordable Care Act struggles to be born, it’s worth looking again at how well Medicare works. Last year the respected journal Health Affairs published a study showing how Medicare performs better than private health insurance plans.
According to the report, “Medicare beneficiaries are less likely to have cost-related access problems, high premium and out-of-pocket health care expenses as a share of income, and financial problems because of medical bills. And compared to non-elderly adults with employer-based coverage, Medicare beneficiaries are more likely to have access to a medical home – a primary care provider who knows their medical history well, is accessible, and helps coordinate their care,” and are “far more likely to report excellent quality of care.”
Medicare is not perfect and needs improvement, but it performs far better than the best of the private plans – the employer-sponsored health plans. Individual and small group plans have even worse performance. The Health Affairs article concluded, “Medicare is doing a better job than employer-sponsored plans at fulfilling the two main purposes of health insurance: ensuring access to care and providing financial protection.”
In my work as a physician I see it every day – patients under the Medicare eligibility age of 65 struggling to find affordable insurance, or fighting with their insurance company when they try to make a claim, or driven to bankruptcy by impossibly high deductible payments. But if they can hang on until they reach Medicare age, then they can finally get the care they need, without the hassles. “Pre-existing conditions” are not an issue. You can pick the hospital and doctor of your choice.
We need to celebrate and protect Medicare, a uniquely American approach to health care. Somehow Congress in their infinite wisdom decided 48 years ago that we should have a universal health care system for everyone over 65, but that the rest of us were on our own.
http://www.pnhp.org/print/news/2013/july/medicare-has-proved-itself-after-48-years
Treat health care as a social need, not a commodity
By Elizabeth R. Rosenthal, M.D.
The Journal News (Westchester, N.Y.), July 25, 2013
The 48th birthday of Medicare on Tuesday reminds us that the birth of the Affordable Care Act has not and will not fix our broken health-care system.
Health care is simply unaffordable for too many of us. In October, the last phase of the reform act known as “Obamacare” will begin with the opening of the health-care exchanges (now known as “the marketplace”). Here many more people will be able to buy more affordable health insurance.
However, by continuing to rely on our for-profit, market-based system, we are wasting billions of dollars on inflated administrative costs. These dollars should instead be going to pay for actual health care.
We need to follow Medicare’s lead — with greatly reduced administrative costs — and treat health care as a social need instead of as a commodity, as an opportunity for profit-making.
Original Medicare, born July 30, 1965, brought affordable health care to the elderly, lifting most of them out of poverty. It has been working well for 48 years and is one of the most popular government programs. In recent years, efforts have been made to privatize it: The Part D drug program and the Medicare Advantage plans are both private. This has led to higher costs.
Although original Medicare’s costs are rising, they are rising more slowly than overall health-care costs. Lowering the costs to government by shifting more of the costs onto patients (e.g., through higher deductibles) does nothing to lower the total health-care expenditure. Even with the arrival of the Affordable Care Act’s insurance exchange, 2,000 New Yorkers will die each year for lack of health care.
We can do better. New York can adopt a publicly funded, privately delivered single-payer plan for all New Yorkers. We can pass the New York Health Bill (A5389/S2078) that provides such a plan. This will save New York billions of dollars and lift the burden from municipalities and companies of providing health care for their workers.
New York could show the nation that access to health care should not depend on one’s ability to pay. By doing so, we would also boost support for national legislation, the Expanded and Improved Medicare for All Act, H.R. 676, which would assure that every resident of the United States has access to high-quality care.
It is immoral to leave so many to suffer and die due to lack of health care. We can, with an improved and expanded Medicare for all, bring health justice to all.
http://www.pnhp.org/print/news/2013/july/treat-health-care-as-a-social-need-not-a-commodity
The Journal News (Westchester, N.Y.), July 25, 2013
The 48th birthday of Medicare on Tuesday reminds us that the birth of the Affordable Care Act has not and will not fix our broken health-care system.
Health care is simply unaffordable for too many of us. In October, the last phase of the reform act known as “Obamacare” will begin with the opening of the health-care exchanges (now known as “the marketplace”). Here many more people will be able to buy more affordable health insurance.
However, by continuing to rely on our for-profit, market-based system, we are wasting billions of dollars on inflated administrative costs. These dollars should instead be going to pay for actual health care.
We need to follow Medicare’s lead — with greatly reduced administrative costs — and treat health care as a social need instead of as a commodity, as an opportunity for profit-making.
Original Medicare, born July 30, 1965, brought affordable health care to the elderly, lifting most of them out of poverty. It has been working well for 48 years and is one of the most popular government programs. In recent years, efforts have been made to privatize it: The Part D drug program and the Medicare Advantage plans are both private. This has led to higher costs.
Although original Medicare’s costs are rising, they are rising more slowly than overall health-care costs. Lowering the costs to government by shifting more of the costs onto patients (e.g., through higher deductibles) does nothing to lower the total health-care expenditure. Even with the arrival of the Affordable Care Act’s insurance exchange, 2,000 New Yorkers will die each year for lack of health care.
We can do better. New York can adopt a publicly funded, privately delivered single-payer plan for all New Yorkers. We can pass the New York Health Bill (A5389/S2078) that provides such a plan. This will save New York billions of dollars and lift the burden from municipalities and companies of providing health care for their workers.
New York could show the nation that access to health care should not depend on one’s ability to pay. By doing so, we would also boost support for national legislation, the Expanded and Improved Medicare for All Act, H.R. 676, which would assure that every resident of the United States has access to high-quality care.
It is immoral to leave so many to suffer and die due to lack of health care. We can, with an improved and expanded Medicare for all, bring health justice to all.
http://www.pnhp.org/print/news/2013/july/treat-health-care-as-a-social-need-not-a-commodity
Tom Coburn seeks answers on Hill staff health coverage
| |
| Sen. Tom Coburn has placed a hold on the nominee to lead the Office of Personnel Management because of the agency’s silence over an Obamacare provision that essentially requires Hill staffers and members of Congress get their health coverage in the new exchanges in 2014. Coburn told POLITICO he wants to know how the agency will rule on the provision because he wants time to possibly pursue a legislative fix, if necessary, to ensure the federal government would still be able to pay for a portion of Hill staffers’ health insurance premiums. The provision was drafted in a way that moves most of them into the exchanges without the employer contribution that other federal workers will still receive. “I don’t care what the answer is — give us an answer so that if we want to do a legislative fix to take care of the people who actually work for us,” the Oklahoma Republican told POLITICO. “I mean, they’re going to be the only set of federal employees that actually get paid by the federal government that have to go in the exchange.” |
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