William Rivers Pitt | Worse Than the Mob: The Insurance Industry Is Organized Crime
By William Rivers Pitt, Truthout | Op-Ed
Nothing so thoroughly dominated the American political landscape over the last year more than the Republican assault on the Affordable Care Act, colloquially known now as "Obamacare." The GOP's eternal refrain that "Government is the problem" was used as a battering ram against the law, and House Republicans have voted to repeal or denude it exactly fifty times as of today. Ted Cruz and his cohort of wreckers shut down the government over it, and the Tea Party base broke out their Sharpies to make gloriously stupid protest signs that read "Government Keep Your Hands Off My Medicare."
Amusing as all this was, the dark underbelly of it all is dangerously wrong. Yes, the ACA exchange website rollout was a train wreck, and yes, a small segment of the population has had problems with the new law. This is not in dispute. Websites can be fixed, however, and problems can be solved. None of this holds a candle to the awesome misery and financial pain inflicted upon the populace by the holy and sainted world of private business, known in this instance as the insurance industry.
My own saga with these broad-daylight thieves began in late summer, when I moved my family to New Hampshire. We were living in Boston before the move, and had health insurance through my wife's employer. My wife has Multiple Sclerosis, and one of the big reasons we felt comfortable about moving was that, if she changed jobs after the move, she could not be denied health insurance due to her pre-existing condition, thanks to the ACA.
We made the move, and my wife's employer transferred her to their location in Concord, more than an hour's drive away from our new home. She worked full-time to keep the health insurance, but after three months of ten-hour days combined with almost three hours on the road getting to and from work, it became clear that the situation was untenable. She was exhausted all the time - fatigue is the #1 danger zone for people with MS; it leaves you wide open for an attack - and worse, she felt like she was missing out on raising our daughter because she was gone more than thirteen hours a day.
On top of that, winter was coming, and the last thing she wanted to deal with was driving one-lane roads at night in a snowstorm, which would have happened more than a dozen times given the severity of this winter. After careful consideration, she asked her employer to transfer her to a location only 20 minutes away from home. The price of that transfer: going from full-time to part-time, and losing our insurance.
We looked into the insurance available through my employer, but came to the conclusion - based on the information provided on the Healthcare.gov website - that going through the exchange was our best option. So we went to the website, and shopped for new insurance. The website was klunky, to be sure, but when I reached a point where it didn't seem to be making sense any more, I called the 800-number provided and spent a couple of hours talking to a tremendously nice woman with a near-parody Wisconsin accent - "Ooh yah, dearie me" - who was amazingly helpful, and got me the rest of the way through the process. Given the fact of my wife's MS, our process was particularly complicated, and this person did everything necessary to make sure we were taken care of.
That's when my dealings with the government ended, and my dealings with the insurance industry began, and it has been downhill at speed ever since.
There is exactly one insurance company in New Hampshire peddling plans through the ACA: Anthem BlueCross BlueShield. After completing the enrollment process through the exchange, the next step was to deal directly with Anthem, which quickly came to be about as fruitful as trying to batter down a brick wall with my daughter's teething ring. First it was two weeks of phone calls, involving serial hours listening to on-hold music that could easily have come straight out of a bad porn movie soundtrack, just to establish that Anthem actually recognized Multiple Sclerosis as a real disease. Then it was another week of porn-flick hold-music to get a straight answer on the location and availability of MS doctors that were "in the network," and thus covered.
Consumers Allowed to Keep Health Plans for Two More Years
WASHINGTON — The Obama administration, grappling with continued political fallout over its health care law, said Wednesday that it would allow consumers to renew health insurance policies that did not comply with the new law for two more years, pushing the issue well beyond this fall’s midterm elections.
The reprieve was the latest in a series of waivers, deadline extensions and unilateral actions by the administration that have drawn criticism from the law’s opponents and supporters, many saying President Obama was testing the limits of his powers.
The action reflects the difficulties Mr. Obama has faced in trying to build support for the Affordable Care Act and the uproar over his promise — which he later acknowledged had been overstated — that people who liked their insurance plans could keep them, no matter what.
Under pressure from Democratic candidates, who are struggling to defend the president’s signature domestic policy, Mr. Obama in November announced a one-year reprieve for insurance plans that did not meet the minimum coverage requirements of the 2010 health care law.
Wednesday’s action goes much further, essentially stalling for two more years one of the central tenets of the much-debated law, which was supposed to eliminate what White House officials called substandard insurance and junk policies.
The extension could help Democrats in tight midterm election races because it may avoid the cancellation of policies that would otherwise have occurred at the height of the political campaign season this fall.
In announcing the new transition policy, the Department of Health and Human Services said it had been devised “in close consultation with members of Congress,” and it gave credit to a number of Democrats in competitive races, including Senators Mary L. Landrieu of Louisiana, Jeanne Shaheen of New Hampshire and Mark Udall of Colorado.
Kathleen Sebelius, the secretary of health and human services, said Mr. Obama was trying to “smooth the transition” to a new system, using flexibility that exists under the law.
In Health Care, Choice Is Overrated
LAST spring, a 48-year-old mother of two young girls in Colorado discovered that she had colon cancer. Her surgeon and oncologist disagreed about whether she neededchemotherapy. So a friend recommended she go to MD Anderson Cancer Center in Houston for a second opinion. Just before she booked her plane ticket, a representative from MD Anderson called, informing her that its oncologists were outside her insurance company’s network and that she should bring $10,000 for the consultation.
Many Americans can relate to this. Last year, a Kaiser survey reported that almost all individuals and families with employer-sponsored health insurance have policies that come with at least some network restrictions. These plans steer us toward certain providers and away from others.
This saves a lot of money. Insurance companies can negotiate with in-network physicians and hospitals to accept lower payments in exchange for more patients. They can include in their networks only physicians who are more efficient — who order fewer unnecessary tests, use more generic drugs and tend to keep patients healthier and out of the hospital. As a result, they can ensure that they, and their customers, get more bang for the buck.
Despite the fact that so many Americans are already in selective networks, they are nervous that the Affordable Care Act, which I helped design as an adviser to the Obama administration, will further restrict their choice of doctors or make them pay higher out-of-network charges. There was a similar backlash in the 1990s, when managed care was on the rise.
UPDATED MARCH 5, 2014 8:44 PM
When the Doctor Is No Longer the Boss
INTRODUCTION
The Affordable Care Act seems to have accelerated doctors’ flight from private practice into large physician groups and hospital networks.
Do those systems’ economies of scale benefit all involved? Or are there downsides for patients, physicians or others?
Boston Medical Center consolidating campuses
Boston Medical Center is preparing to break ground soon on a $270 million construction and renovation project that it says will consolidate the hospital’s two South End campuses and eliminate 60 beds while maintaining the same level of services.
The project, expected to be completed in 2017, is a belated culmination of the 1996 merger of Boston City Hospital and University Hospital, which created Boston Medical. While the hospitals have integrated departments over the past 18 years, and closed one of the two emergency rooms in 2010, they have continued to offer medical care at both campuses, often shuttling patients admitted at one to specialists at the other — a two-block ambulance ride.
That would end under the consolidationplan. It has been approved by Boston Medical’s directors and the Boston Redevelopment Authority but awaits a “determination of need” certificate from the state Department of Public Health.health care,” said Dr. Ravin Davidoff, chief medical officer at Boston Medical. “We’re creating a patient-centered clinical campus.”
The plan calls for eight additional operating rooms and about 70 single rooms on the former Boston City Hospital site, expanding outpatient facilities and the gastroenterology department, and creating an updated, consistent feel throughout a sprawling campus dotted with aging buildings. It would also expand by a third Boston Medical’s congested emergency department, the busiest in Massachusetts with nearly 130,000 patient visits last year.
But it will also mean closing the Newton Pavilion on the former University Hospital campus. Those two adjoining buildings will be sold.
Proceeds from the sale, along with money raised through philanthropy and bond financing, will bankroll construction and renovations at the Menino, Yawkey, and Moakley buildings on the remaining campus, plus a transport bridge that will ferry patients from a helipad over Albany Street to the medical center.
Maine lawmakers vote to cancel LePage consultant’s contract
The Alexander Group won a $925,000 no-bid contract to look at a number of issues, with its first report recommending against Medicaid expansion.
AUGUSTA — Lawmakers on the Legislature’s Health and Human Services committee sniped at one another Wednesday over a controversial $925,000 no-bid contract for an evaluation of public assistance programs, and then voted along party lines in favor of a bill that would cancel it.
Democrats prevailed as the committee voted 7-5 to cancel the contract with Rhode Island-based The Alexander Group, which was hired to evaluate the programs. The bill will now go to the full Legislature, but even if approved, it faces an almost-certain veto from Gov. Paul LePage, whose administration hired the consultant.
About 1/3 of the $925,000 has already been paid to the Alexander Group, which has completed one report that recommends against expanding Medicaid, called MaineCare in Maine.
Rep. Deb Sanderson, R-Chelsea, said that she hasn’t always agreed with consultants’ reports over the years, but it’s not the Legislature’s role to cancel contracts.
“This is inserting ourselves into the executive branch’s right to form a contract,” Sanderson said. “We are being very far-reaching and overstepping our bounds.”
But Rep. Drew Gattine, D-Westbrook, said it’s the Legislature’s job to rein in irresponsible spending. He said he considers The Alexander Group’s report to be partisan and the LePage campaign should have paid for it. The governor is seeking re-election this year in a three-way race against Democratic U.S. Rep. Mike Michaud and independent candidate Eliot Cutler.
“I don’t think taxpayers in the state of Maine should be paying for this report, and I don’t think they should have to pay another penny for it,” Gattine said.
Republican-controlled New Hampshire Senate expected to pass Medicaid expansion today
Maine Politics, National, Other
The New Physician, January-February 2014
In medical school, we are taught that practicing good medicine means first asking a good history. Gathering relevant information guides the review of the patient’s body systems, physical examination, and ultimately the assessment and plan that leads to an effective medical intervention. With experience, the doctor learns to recognize patterns which help guide clinical judgment. We are at the beginning of this process, but some patterns have already begun to emerge.
There’s the 40-year-old woman who can’t afford the premiums and deductibles on the insurance offered through her workplace. She suffers from depression and has to take the generic form of her preferred antidepressant, with significant psychiatric side-effects. There’s the 58-year-old man with musculoskeletal issues. The attending physician acknowledged that his workup and treatment would be different had he been insured. He might otherwise have received an MRI of his back and treatment of his right leg problems, correcting his posture. Then there’s the 27-year-old who can’t afford insurance covering the suboxone treatment for his opiate addiction, forcing him to buy it on the street.
The Patient Protection and Affordable Care Act (ACA) was signed into law by President Barack Obama on March 23, 2010, with the goal of reducing the number of uninsured Americans by making health care more affordable to Americans. It achieves this through mandates, subsidies and insurance exchanges. But a May 14, 2013, report by the Congressional Budget Office projected that the number of American who will remain uninsured in 2023 will be 31 million, revised upward from a previous projection of 30 million.
The patients we described above are just a few of those millions of Americans struggling with the effects of being uninsured. But additionally, we have an epidemic of inadequate coverage among Americans who are insured. Without solving the latter, we won’t adequately help the former even if we managed to insure every man, woman and child in the country. Getting everyone on board with health insurance is an initial step, but if everyone is on board a vessel which is slowly sinking, we haven’t gone far enough. In theory, paying for insurance should result in adequate, affordable health care. In reality, it doesn’t. And that brings our entire approach to financing health care into question.
Massachusetts implemented a policy of universal health coverage in 2006, four years prior to the ACA’s passage. A study published in the American Journal of Medicine showed that the amount of bankruptcies in the state due to illness and medical bills were reduced, but not significantly: dropping 59 percent to 52 percent from 2007 to 2009. Furthermore, the study states that “in 2009, 89 percent of debtors had health insurance at the time of filing.” It seems antithetical to us that the provision of health care necessary to ensure an adequate quality of life should result in financial ruin. Medicine is complicated enough without having to consider whether even the insured patients can afford the care they need to live healthy, productive lives.
The insurance exchanges offer plans of various cost, and the most expensive plan, dubbed “Platinum,” will pay 90 percent of essential health benefits. It is the responsibility of the patient to pay the other 10 percent of health care expenditures out-of-pocket, in addition to added costs associated with care received by providers deemed out of network. A June 2013 study published in the journal Health Services Research found that among those who pay for out-of-network services, 58 percent of inpatient services and 13 percent of outpatient services were paid involuntarily. An individual navigating our highly fragmented system will pay for the health care most immediately available to them in times of need, in or out of network. This demonstrates a pitfall of a system that expects individuals to make rational economic choices when purchasing health care in situations that are often medical emergencies.
We believe that health care reform has to go beyond tethering more Americans to our current, dysfunctional system. But the only way that we can evolve toward a better system is to transcend the scope of the current debate that has dominated mainstream discussion. One of the effects of the battle to pass, preserve and implement the ACA has been the way it has framed this debate as a simple dichotomy between the law’s articulated vision and the status quo.
http://www.pnhp.org/print/news/2014/march/not-far-enough
After getting together in multiple meetings to negotiate, Republican and Democratic leaders in the Granite Stateagreed on a compromise to expand Medicaid.
Today the Republican-controlled Senate is expected to pass the bill.
New Hampshire’s Democratic governor backs it, and the Democratic-controlled House is also seen as likely to support it.
People in New Hampshire support expansion by a 2-1 margin. To be more precise, 66% support, 25% oppose, and the rest were not sure.
Now, most Maine legislators and most Maine people support expansion as well.
But in the Pine Tree state, passing Medicaid expansion requires getting past the veto of Gov. Paul LePage.
The governor has had no interest in any form of expansion, not even the “private option” variant that 75% or more of Arkansas legislators in each legislative body just endorsed for the second year in the row. (New Hampshire’s plan has some elements in common with the Arkansas approach.)
So even though majorities in the Maine Hose and Senate have and will again support Medicaid expansion, Gov. Page will veto it. He opposes the expansion plan that includes cost controls, which was developed by two respected moderate Republicans, Senators Katz and Saviello.
The Katz-Saviello plan would also fund services for people on waiting lists, something Medicaid expansion opponents say is a priority yet have never proposed a plan with funding to cover them.
It’s unclear right now if there will be enough votes in the Maine Legislature to overturn a veto.
Swing Republican legislators are under enormous pressure from their party’s leadership and they are also hearing from citizens who need health coverage. (Intra-party tensions have also spilled over to current and former Republican staffers.)
If LePage’s promised veto isn’t overturned, about 20% of Maine’s uninsured will have no way of obtaining coverage and many more poor working people will have choices they will find very difficult to afford.
And if Medicaid isn’t expanded in Maine, it looks like the Pine Tree State will be the only state in New England not to do so. Maine will instead take its place with states like Mississippi, Texas and Alabama, non-expansion states which have high rates of infant mortality and preventible deaths.
Not far enough?
Health care for everyone isn’t a question of realism – it’s a moral necessity
By Gabriel Edwards and David MealieaThe New Physician, January-February 2014
In medical school, we are taught that practicing good medicine means first asking a good history. Gathering relevant information guides the review of the patient’s body systems, physical examination, and ultimately the assessment and plan that leads to an effective medical intervention. With experience, the doctor learns to recognize patterns which help guide clinical judgment. We are at the beginning of this process, but some patterns have already begun to emerge.
There’s the 40-year-old woman who can’t afford the premiums and deductibles on the insurance offered through her workplace. She suffers from depression and has to take the generic form of her preferred antidepressant, with significant psychiatric side-effects. There’s the 58-year-old man with musculoskeletal issues. The attending physician acknowledged that his workup and treatment would be different had he been insured. He might otherwise have received an MRI of his back and treatment of his right leg problems, correcting his posture. Then there’s the 27-year-old who can’t afford insurance covering the suboxone treatment for his opiate addiction, forcing him to buy it on the street.
The Patient Protection and Affordable Care Act (ACA) was signed into law by President Barack Obama on March 23, 2010, with the goal of reducing the number of uninsured Americans by making health care more affordable to Americans. It achieves this through mandates, subsidies and insurance exchanges. But a May 14, 2013, report by the Congressional Budget Office projected that the number of American who will remain uninsured in 2023 will be 31 million, revised upward from a previous projection of 30 million.
The patients we described above are just a few of those millions of Americans struggling with the effects of being uninsured. But additionally, we have an epidemic of inadequate coverage among Americans who are insured. Without solving the latter, we won’t adequately help the former even if we managed to insure every man, woman and child in the country. Getting everyone on board with health insurance is an initial step, but if everyone is on board a vessel which is slowly sinking, we haven’t gone far enough. In theory, paying for insurance should result in adequate, affordable health care. In reality, it doesn’t. And that brings our entire approach to financing health care into question.
Massachusetts implemented a policy of universal health coverage in 2006, four years prior to the ACA’s passage. A study published in the American Journal of Medicine showed that the amount of bankruptcies in the state due to illness and medical bills were reduced, but not significantly: dropping 59 percent to 52 percent from 2007 to 2009. Furthermore, the study states that “in 2009, 89 percent of debtors had health insurance at the time of filing.” It seems antithetical to us that the provision of health care necessary to ensure an adequate quality of life should result in financial ruin. Medicine is complicated enough without having to consider whether even the insured patients can afford the care they need to live healthy, productive lives.
The insurance exchanges offer plans of various cost, and the most expensive plan, dubbed “Platinum,” will pay 90 percent of essential health benefits. It is the responsibility of the patient to pay the other 10 percent of health care expenditures out-of-pocket, in addition to added costs associated with care received by providers deemed out of network. A June 2013 study published in the journal Health Services Research found that among those who pay for out-of-network services, 58 percent of inpatient services and 13 percent of outpatient services were paid involuntarily. An individual navigating our highly fragmented system will pay for the health care most immediately available to them in times of need, in or out of network. This demonstrates a pitfall of a system that expects individuals to make rational economic choices when purchasing health care in situations that are often medical emergencies.
We believe that health care reform has to go beyond tethering more Americans to our current, dysfunctional system. But the only way that we can evolve toward a better system is to transcend the scope of the current debate that has dominated mainstream discussion. One of the effects of the battle to pass, preserve and implement the ACA has been the way it has framed this debate as a simple dichotomy between the law’s articulated vision and the status quo.
http://www.pnhp.org/print/news/2014/march/not-far-enough
Pitfalls Seen in a Turn to Privately Run Long-Term Care
Growth in long-term-care programs managed by Medicaid
Users, by state
Texas
71,239
70,000
New York
67,683
60,000
Arizona
52,251
50,000
Michigan
41,272
40,000
Wisconsin
37,010
Minnesota
32,693
Tennessee
31,200
30,000
Florida
19,283
20,000
Mass.
15,568
N. Carolina
6,874
10,000
Hawaii
6,830
Delaware
4,800
New Mexico
4,699
2004
2012
Other states with programs: California, Pennsylvania, Washington
Users, by state
Texas
71,239
70,000
New York
67,683
60,000
Arizona
52,251
50,000
Michigan
41,272
40,000
Wisconsin
37,010
Minnesota
32,693
Tennessee
31,200
30,000
Florida
19,283
20,000
Mass.
15,568
N. Carolina
6,874
10,000
Hawaii
6,830
Delaware
4,800
New Mexico
4,699
2004
2012
Other states with programs: California, Pennsylvania, Washington
But a closer look at Tennessee, widely cited as a model, reveals hidden pitfalls as the system of caring for the frail comes under the twin pressures of cost containment and profit motive. In many cases, care was denied after needs grew costlier — including care that people would have received under the old system.
“The notion of prevention saving money in the long run only works if you actually provide care in the long run,” said Gordon Bonnyman, former director of the Tennessee Justice Center, a patient advocacy group. “Tennessee is probably as good as it gets in terms of oversight and financial regulation, and thus I think it is a cautionary tale.”
Like many advocates, he originally supported managed long-term care, seeing it as a way to break the stranglehold of nursing home lobbies that opposed shifting more Medicaid money to home and community-based care. But now he says too high a price is being paid by very debilitated people denied care when they need it most — people like Billy Scarlett II, who was 33 in 2005 when he sustained severe brain injuries in an A.T.V. accident, and Glenn McClanahan, who is 79.
Mr. McClanahan’s case illustrates both the appeal and the perils of the new system. Once a high school quarterback, a successful car salesman and a ladies’ man, he was living alone on Social Security, already hobbled by arthritis and emphysema, when at 75 he abruptly lost nearly all of his sight. For years, Tennessee residents like him had to move to nursing homes, with Medicaid paying the bills from a mix of state and federal money.
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